Hepatic resection in metastatic breast cancer: results and prognostic factors

Liver resection for breast cancer metastasis: does it improve survival?

PURPOSE

To assess the outcome and prognostic factors of liver surgery for breast cancer metastasis.

METHODS

We retrospectively examined 16 patients who underwent partial liver resection for breast cancer liver metastasis (BCLM). All patients had been treated with chemotherapy or hormonotherapy, or both, before referral for surgery. We confirmed by preoperative radiological examinations that metastasis was confined to the liver. The survival curve was estimated using the Kaplan-Meier method. Univariate and multivariate analysis were conducted to evaluate the role of the known factors of breast cancer survival.

RESULTS

The median age of the patients was 54 years (range 38-68) and the median disease-free interval between the diagnoses of breast cancer and liver metastasis was 54 months (range 7-120). Nine major and 7 minor hepatectomies were performed. There was no postoperative death. The overall 1-, 3-, and 5-year survival rates were 94%, 61%, and 33%, respectively. The median survival rate was 42 months. Univariate analysis revealed that hormone receptor status, number of metastases, a major hepatectomy, and a younger age were associated with a poorer prognosis. The survival rate was not influenced by the disease-free interval, grade or stage of breast cancer, or intraoperative blood transfusions. The number of liver metastases was identified as a significant independent factor of survival according to the Cox proportional hazard model (P = 0.04).

CONCLUSIONS

Liver resection, when done in combination with adjuvant therapy, can improve the prognosis of selected patients with BCLM.

Resection of liver metastases from non-colorectal non-endocrine primary tumours

Despite the greater number of hepatectomies for non-colorectal non-endocrine liver metastases, its benefits and its indications remain unclear because most of the patient series are small with heterogeneous primary tumours. After analyzing the literature including a large recent series (1451 patients), we can conclude that liver resection of non-colorectal non-endocrine metastases is feasible, safe, and improves survival. Better selection of patients according to their tumour biology (a long interval between the primary and liver metastases), the histologic type (non epithelial) and tumour chemosensitivity should improve long-term disease-free and overall survival, as we observed after resection of liver metastases from colorectal cancer.

Radiofrequency ablation in the management of liver metastases from breast cancer

OBJECTIVE

Systemic chemotherapy remains the standard treatment for patients with breast cancer hepatic metastases. Resection of metastases has survival advantages in a small percentage of selected patients. Radiofrequency ablation has been used in small numbers of selected patients. This small series was undertaken to review our experience with radiofrequency ablation in the management of patients with breast cancer hepatic metastases.

CONCLUSION

Radiofrequency ablation of breast cancer hepatic metastases is safe and may be used to control hepatic deposits in patients with stable or no extrahepatic disease.

Surgical therapy of liver metastases

The liver is the most common site of metastatic disease from both gastrointestinal and extra-intestinal malignancies. Historically, only a minority of patients with colorectal liver metastases were candidates for resection. However, over the past several decades, liver resection has evolved as a safe and potentially curative treatment for hepatic colorectal metastases. The development of active chemotherapy and molecular targeted therapies, together with newer modalities like radiofrequency ablation, have expanded the indications for hepatic resection and improved survival. Selected patients with isolated liver metastases from neuroendocrine tumors, germ cell cancers, ocular melanoma, gastrointestinal stromal tumors (GIST), and breast cancer also may be considered for hepatic surgery.

[Role of surgery in metastases from breast cancer]

Patients with distant metastases from breast cancer have always been considered terminally ill and as such candidates for palliative treatment only. However, due to new therapeutic modalities in oncology, survival in these patients has improved. Furthermore, in 5% of patients, metastasis from breast cancer is limited to a single solid organ (oligometastatic state). Because of these two factors, surgery is now being performed as a component of multidisciplinary treatment for hepatic, lung and bone metastases from a primary breast tumor. In the present article, we review the different published series, focussing discussion on two issues: selecting candidates for liver, lung or bone resection, and identifying prognostic factors for recurrence and/or survival following surgical excision of metastases to these sites.

Radiofrequency ablation (RFA) as a cytoreductive strategy for hepatic metastasis from breast cancer

INTRODUCTION

Patients with liver metastasis from breast cancer have a poor prognosis, although this may be improved by hepatectomy in a selected group with disease confined to the liver. We evaluate the effectiveness of radiofrequency ablation (RFA) as a cytoreductive strategy in the management of liver metastasis from primary breast cancer.

PATIENTS AND METHODS

Nineteen patients with hepatic metastasis from primary breast cancer underwent RFA of their liver lesions between April 1998 and August 2004.

RESULTS

The median age of the patients was 52 years (range, 32-69 years), 8 had disease confined to the liver, with 11 having stable extrahepatic disease in addition. Seven patients with disease confined to the liver at presentation are alive, as are 6 with extrahepatic disease, median follow-up after RFA was 15 months (range, 0-77 months). Survival at 30 months was 41.6%. In addition, 7 patients followed up for a median of 14 months (range, 2-29 months) remain alive and disease-free. RFA failed to control hepatic disease in 3 patients. RFA was not associated with any mortality or major morbidity.

CONCLUSIONS

Control of hepatic metastasis from breast cancer is possible using RFA and may lead to a survival benefit, particularly in those patients with disease confined to the liver.

MR-Guided Laser Ablation

MR-guided LITT is a safe and effective treatment modality that improves survival in well-selected patients who have liver metastases. A major advantage of MR-guided LITT is that it can be easily performed under local anesthesia in an outpatient setting with a low complication rate.

Treatment for liver metastases from breast cancer: Results and prognostic factors

AIM: Liver metastases from breast cancer (BCLM) are associated with poor prognosis. Cytotoxic chemotherapy can result in regression of tumor lesions and a decrease in symptoms. Available data, in the literature, also suggest a subgroup of patients may benefit from surgery, but few talked about transcatheter arterial chemoembolization (TACE). We report the results of TACE and systemic chemotherapy for patients with liver metastases from breast cancer and evaluate the prognostic factors.

METHODS: Forty-eight patients with liver metastases, from proved breast primary cancer were treated with TACE or systemic chemotherapy between January 1995 and December 2000. Treatment results were assessed according to WHO criteria, along with analysis of prognostic factors for survival using Cox regression model.

RESULTS: The median follow-up was 28 mo (1-72 mo). Response rates were calculated for the TACE group and chemotherapy group, being 35.7% and 7.1%, respectively. The difference was significant. The one-, two- and three-year Survival rates for the TACE group were 63.04%, 30.35%, and 13.01%, and those for the systemic chemotherapy group were 33.88%, 11.29%, and 0%. According to univariate analysis, variables significantly associated with survival were the lymph node status of the primary cancer, the clinical stage of liver metastases, the Child-Pugh grade, loss of weight. Other factors such as age, the intervals between the primary to the metastases, the maximal diameter of the liver metastases, the number of liver metastases, extrahepatic metastasis showed no prognostic significances. These factors mentioned above such as the lymph node status of the primary cancer, the clinical stage of liver metastases, the Child-Pugh grade, loss of weight were also independent factors in multivariate analysis.

CONCLUSION: TACE treatment of liver metastases from breast cancer may prolong survival in certain patients. This approach offers new promise for the curative treatment of the patients with metastatic breast cancer.

Hepatic Resection for Metastatic Breast Cancer: Prognostic Analysis of 34 Patients

Liver metastasis of breast cancer is considered a generalized disease, and surgical treatment is rarely discussed. Thirty-four patients who underwent 35 hepatectomies for liver metastases of breast cancer between 1985 and 2003 were analyzed. The median interval between the breast surgery and relapse in the liver was 1.9 years (0-20 years). The liver was the first site of recurrence in 25 patients. Fifteen clinicopathologic factors were evaluated using univariate and multivariate analyses to predict survival after hepatic resection. No patients died because of the surgery. The median survival was 36 months (1 month to 20 years). The overall and disease-free 5-year survival rates after hepatectomy for breast metastases were 21% and 16%, respectively. Four patients survived more than 5 years. The presence of extrahepatic recurrence prior to hepatectomy was the only significant prognostic factor according to the analyses, and the 5-year survival rate of patients without extrahepatic disease was 31%. No patient who had hilar lymph node metastasis survived more than 5 years. In the absence of extrahepatic recurrence, surgical resection of liver metastasis from breast cancer can offer an acceptable prognosis and should not be avoided in selected patients.

High-dose chemotherapy with autologous stem cell transplantation in patients with oligometastatic breast cancer

The purpose of this prospective trial was to study a combined-modality treatment including local consolidation by surgery or radiotherapy and high-dose chemotherapy (HDC) followed by peripheral-blood stem-cell (PBSC) transplantation. In all, 48 patients with oligometastatic breast cancer amenable to local treatment after induction chemotherapy with epirubicin and cyclophosphamide or paclitaxel and cisplatin, depending on prior adjuvant chemotherapy, were enrolled. The median follow-up was 41 months (range, 7-85 months). PBSC were collected in 47 patients, and 40 received one or two courses of HDC. Local therapy was given in 37 patients. No treatment-related deaths occurred. Of 47 evaluable patients, 36 (75% of intention-to-treat population) had no evidence of disease or complete remission after completion of therapy. Six patients (12.5%) had partial response, two patients (4%) no change, and three patients (6%) progressive disease. The median time to progression and overall survival was 17.5 (95% confidence interval (CI), 14-21 months) and 42.2 months (95% CI, 33-52 months), respectively, and 27% of patients were progression free after 5 years. In conclusion, patients with oligometastatic breast cancer can be treated safely with this combined modality protocol with promising relapse-free survivals.

Breast cancer metastases in liver: laser-induced interstitial thermotherapy--local tumor control rate and survival data

PURPOSE

To evaluate the local tumor control rate and survival data for magnetic resonance (MR) imaging-guided laser ablation of breast cancer liver metastases by using laser-induced interstitial thermotherapy (LITT).

MATERIALS AND METHODS

MR-guided LITT was performed in 232 female patients with 578 liver metastases from breast cancer. Survival rates were calculated with the Kaplan-Meier method. Indications for the procedure were defined for patients with no more than five metastases, none of which were larger than 5 cm in diameter, as follows: recurrent liver metastases after partial liver resection (8.2%), metastases in both liver lobes (45.2%), locally nonresectable tumors (19%), general contraindications for surgery (2.6%), or refusal to undergo surgical resection (25%).

RESULTS

Local recurrence rate at 6-month follow-up after LITT was 2.3% (five of 213) for metastases up to 2 cm in diameter, 4.3% (seven of 162) for metastases 2-3 cm in diameter, 3.2% (two of 63) for metastases 3-4 cm in diameter, and 1.9% (one of 52) for metastases larger than 4 cm in diameter. No additional local tumor progression was observed beyond 6 months. The mean survival rate for all treated patients, with calculation started on the date of diagnosis of the metastases treated with LITT, was 4.9 years (95% confidence interval: 4.3, 5.4). The median survival was 4.3 years; 1-year survival, 96%; 2-year survival, 80%; 3-year survival, 63%; and 5-year survival, 41%. The mean survival after the first LITT treatment was 4.2 years (95% confidence interval: 3.6, 4.8).

CONCLUSION

MR-guided LITT yields high local tumor control and survival rates in patients with liver metastases from breast cancer.

Long-term Survival After An Aggressive Surgical Approach in Patients With Breast Cancer Hepatic Metastases

BACKGROUND

Metastatic breast cancer is generally believed to be associated with a poor prognosis. Therapeutic advances over the past two decades, however, have resulted in improved outcomes for selected patients with limited metastatic disease.

METHODS

Between March 1991 and October 2002, 31 patients had hepatic resection for breast cancer metastases limited to the liver. Clinical and pathologic data were collected prospectively from breast and hepatobiliary databases.

RESULTS

Median age of patients was 46 years (range, 31 to 70). Liver metastases were solitary in 20 patients and multiple in 11 patients. Median size of the largest liver metastasis was 2.9 cm (range, 1 to 8). Major liver resections (three or more segments resected) were performed in 14 patients, whereas minor resections (fewer than three segments resected) with or without radiofrequency ablation (RFA) were performed in 17 patients. No postoperative mortality occurred. Of the 31 patients, 27 (87%) received either preoperative or postoperative systemic therapy as treatment for metastatic disease. The median survival was 63 months; a single patient died within 12 months of hepatic resection. The overall 2- and 5-year survival rates were 86% and 61%, respectively, whereas the 2- and 5-year disease-free survival rates were 39% and 31%, respectively. No treatment- or patient-specific variables were found to correlate with survival rates.

CONCLUSIONS

In selected patients with liver metastases from breast cancer, an aggressive surgical approach is associated with favorable long-term survival. Hepatic resection should be considered a component of multimodality treatment of breast cancer in these patients.

Superiority of combined chemo-embolization and portal infusion with 5-fluorouracil over locoregional infusion concepts in Novikoff hepatoma-bearing rats

The aim of this study was to investigate experimentally whether there is a superior effect of the combination of hepatic artery chemo-embolization with portal vein infusion over either of the two treatment modalities alone. Novikoff hepatoma cells transplanted under the liver capsule of Sprague Dawley rats were used as a model. Tumor growth was assessed at 7 and 21 days after tumor inoculation. The prolamine solution Ethibloc was employed for embolization, and 5-fluorouracil was used as a chemotherapeutic agent for both infusion and chemo-embolization. All arterial treatment modalities were administered in a super-selective manner. There was no intolerable toxicity after dosages of 55 to 125 mg 5-fluorouracil/kg body weight. With regard to therapeutic efficacy the results show that embolization is an effective therapeutic means for inducing tumor necrosis in selected liver areas. As a consequence, the ranking of all treatment modalities was based on the combined evaluation of tumor size and extent of tumor necrosis. According to this evaluation, hepatic artery chemo-embolization was superior to the respective type of infusion (P<0.01). In addition, the combination of both modalities in the form of hepatic artery chemo-embolization and portal vein infusion was effective in destroying more than 97% of vital tumor tissue (P<0.01). These results suggest the need for a comparative clinical study.

Prognostic factors for patients with hepatic metastases from breast cancer

Median survival from liver metastases secondary to breast cancer is only a few months, with very rare 5-year survival. This study reviewed 145 patients with liver metastases from breast cancer to determine factors that may influence survival. Data were analysed using Kaplan-Meier survival curves, univariate and multivariate analysis. Median survival was 4.23 months (range 0.16-51), with a 27.6% 1-year survival. Factors that significantly predicted a poor prognosis on univariate analysis included symptomatic liver disease, deranged liver function tests, the presence of ascites, histological grade 3 disease at primary presentation, advanced age, oestrogen receptor (ER) negative tumours, carcinoembryonic antigen of over 1000 ng ml(-1) and multiple vs single liver metastases. Response to treatment was also a significant predictor of survival with patients responding to chemo- or endocrine therapy surviving for a median of 13 and 13.9 months, respectively. Multivariate analysis of pretreatment variables identified a low albumin, advanced age and ER negativity as independent predictors of poor survival. The time interval between primary and metastatic disease, metastases at extrahepatic sites, histological subtype and nodal stage at primary presentation did not predict prognosis. Awareness of the prognostic implications of the above factors may assist in selecting the most appropriate treatment for these patients.British Journal of Cancer (2003) 89, 284-290. doi:10.1038/sj.bjc.6601038 www.bjcancer.com

Surgical treatment of hepatic and pulmonary metastases from non-colorectal and non-neuroendocrine carcinoma

BACKGROUND

Surgical resection is standard treatment for colorectal and neuroendocrine liver metases provided the tumor can be removed completely. The same is true for isolated pulmonary metastases. To date, only few reports have addressed the value of surgical resection of organ metastases from other solid tumors.

METHODS

The literature was searched by Medline, conference proceedings and cross-referencing of published articles for information pertaining to the long-term results of surgical treatment of non-colorectal and non-neuroendocrine (NCNN) liver or lung metastases.

RESULTS

Resection of hepatic and pulmonary metastases is increasingly performed in non-colorectal and non-neuroendocrine malignancies. Mortality and morbidity of hepatic and pulmonary resection are low and 5 year survival can be expected to reach some 20-30 percent, irrespective of the histological type of the primary tumor.

CONCLUSION

Resection of hepatic or pulmonary metastasis should be considered in all patients with low operative risk provided that complete resection is possible.

Liver resection for metastatic non-colorectal non-neuroendocrine hepatic neoplasms

AIMS

Major liver surgery can be performed safely and hepatic resection for metastatic disease is increasingly carried out. However, the role of liver resection for hepatic metastases from non-colorectal, non-neuroendocrine (NCNN) cancers is unknown. Our aim was to evaluate our experience from hepatectomies for NCNN metastases. A retrospective study of 170 patients with liver resection performed the last 8 years was performed in two liver units in affiliated university hospitals.

METHODS

Eighteen patients underwent liver resection for NCNN tumours. Origins included kidney (n=6), breast (n=4), gastric tumours (n=4), intestinal leiomyosarcoma (n=2) and malignant melanoma and in one patient a metastatic papillary of unknown origin was found. Eleven patients underwent a hepatic lobectomy and seven had local resections. Ten hepatectomies were performed at the same time with the primary tumour resection (synchronous resections) with five of those in an en bloc fashion with the primary tumour.

RESULTS

There were no post-operative deaths and the peri-operative morbidity was minimal. During a median follow-up time of 3.2 years, 14 patients are alive with one of them having developed pulmonary metastases.

CONCLUSION

In carefully selected patients with NCNN liver metastasis, liver resection can prolong survival as well and improve quality of life.

Metastasectomy for liver metastases of non-colorectal primaries

BACKGROUND

Resection of liver metastases of non-colorectal primary malignancies has been reported to prolong survival. We studied the results in our hospital and compared the survival data with that described in the literature.

PATIENTS AND METHODS

Since 1991, a prospective database has been kept at The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital of patients undergoing hepatic surgery (n=180). Between 1991 and 1999, 32 patients underwent laparotomy for hepatic metastases of non-colorectal primaries. This study evaluates the operative technical aspects and determines morbidity, mortality, disease-free and overall survival.

RESULTS

There were 11 males and 21 females with a median age of 52 (25-69) years. Histology of the primary tumour were various carcinomas (n=22), melanomas (n=4) and sarcomas (n=6). Resection was performed in 28 patients; four patients appeared to be irresectable. There was no perioperative mortality. Morbidity was 23%. One re-operation was necessary because of haemorrhage. The median disease-free survival for the 28 patients was 12 months with an actuarial 5-year disease-free survival of 20% (Kaplan-Meier). The 5-year overall survival was 35% with a median survival of 21 months.

CONCLUSION

Liver metastasectomy for selected types of non-colorectal primary tumours is relatively safe and shows in selected patients long-term survival comparable to that of metastasectomies for colorectal origin.

[Hepatic resection for breast cancer metastases: results and prognosis (65 cases)]

STUDY AIM

To report results of liver resections for breast cancer liver metastasis (BCLM) and to evaluate the rate of survival and the prognostic factors.

PATIENTS AND METHOD

Between 1988 and 1999, 69 patients were operated on for BCLM and 65 who had liver resection were analyzed. The selection criteria for surgery were: normal performance status and liver function test; radiological objective response to chemotherapy (and/or hormonotherapy); in cases of non-isolated BCLM, complete response of associated metastatic site (usually bone) and no brain metastases. The mean age of the 65 patients was 47 (30-70) years. BCLM was diagnosed an average of 60 (0-205) months after the initial cancer. The BCLM was more frequently solitary (n = 44). The mean diameter was 3.8 (0-12) cm. The mean number of cycles of chemotherapy before surgery was 7.5 (3-24). Liver resections included major hepatectomy (n = 31): right n = 19, extended left n = 4, left n = 8, minor hepatectomy (n = 25) and limited resection (n = 9).

RESULTS

There was no postoperative mortality. The 18% morbidity rate included a majority of pleural effusions with two reoperations. The median follow-up was 41 months (6-100 months). The survival rate after surgery was 90% at 1 year, 71% at 3 and 46% at 4 years. Thirteen patients are alive at 4 years. The 36-month survival rate differed according to the time to onset of BCLM: 55% before versus 86% after 48 months (p = 0.01). The other studied factors were not statistically associated with survival. The recurrence rate in the remaining liver at 36 months differed according to the lymph node status of the initial breast cancer: 40% for N0-N1 versus 81% for N1b-N2 (p = 0.01) and according to the type of liver resection: 45% for minor liver resection versus 73% for major (p = 0.02).

CONCLUSION

Adjuvant liver surgery should be included in multicenter treatment protocols for medically-controlled breast cancer liver metastasis.