Surgical resection of the primary tumor is associated with increased long-term survival in patients with stage IV breast cancer after controlling for site of metastasis

Survival Benefit of Surgical Removal of Primary Tumor in Patients With Stage IV Breast Cancer

BACKGROUND

Several studies have suggested that primary tumor removal improved overall survival for patients with stage IV breast cancer. However, the survival benefit of local treatment remains controversial. The purpose of the present study was to determine whether surgical removal of the primary tumor provides survival benefits to patients with stage IV breast cancer.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 155 patients with an initial diagnosis of stage IV breast cancer at Seoul National University Bundang Hospital from 2003 to 2014. Kaplan-Meier analysis was used to estimate the median survival. The log-rank test was used to compare differences in patient and tumor characteristics. Multivariate Cox regression analysis for survival was used, controlling for potential confounding variables.

RESULTS

Of 155 patients with stage IV breast cancer, 95 (61%) underwent surgical removal of the primary tumor. The median follow-up period was 59 months (95% confidence interval [CI], 45-73 months). The median survival was longer for the patients with a better response to chemotherapy (70 vs. 47 months; P = .010) and for those who had undergone surgery (118 vs. 28 months; P < .001) than for those who without a better chemotherapy response or surgery. The median survival of the patients who received radiotherapy was better than that of the patients who did not (65 vs. 39 months; P = .004). Patients with luminal A cancer had a median survival of 118 months, the longest compared with those with other subtypes (P = .001). In addition, patients with distant metastasis at a single site had a longer median survival than did those with multiple metastatic sites. The multivariate Cox regression analysis revealed that fewer distant metastases, surgery of the primary tumor, a better response to chemotherapy, and luminal A subtype were significant independent predictors of survival.

CONCLUSION

Our results showed that primary tumor removal was independently associated with improvement in survival. Therefore, surgical management for the primary tumor could be considered more actively in patients with stage IV breast cancer.

Randomized Trial Comparing Resection of Primary Tumor with No Surgery in Stage IV Breast Cancer at Presentation: Protocol MF07-01

BACKGROUND

The MF07-01 trial is a multicenter, phase III, randomized, controlled study comparing locoregional treatment (LRT) followed by systemic therapy (ST) with ST alone for treatment-naïve stage IV breast cancer (BC) patients.

METHODS

At initial diagnosis, patients were randomized 1:1 to either the LRT or ST group. All the patients were given ST either immediately after randomization or after surgical resection of the intact primary tumor.

RESULTS

The trial enrolled 274 patients: 138 in the LRT group and 136 in the ST group. Hazard of death was 34% lower in the LRT group than in the ST group (hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.49-0.88; p = 0.005). Unplanned subgroup analyses showed that the risk of death was statistically lower in the LRT group than in the ST group with respect to estrogen receptor (ER)/progesterone receptor (PR)(+) (HR 0.64; 95% CI 0.46-0.91; p = 0.01), human epidermal growth factor 2 (HER2)/neu(-) (HR 0.64; 95% CI 0.45-0.91; p = 0.01), patients younger than 55 years (HR 0.57; 95% CI 0.38-0.86; p = 0.007), and patients with solitary bone-only metastases (HR 0.47; 95% CI 0.23-0.98; p = 0.04).

CONCLUSION

In the current trial, improvement in 36-month survival was not observed with upfront surgery for stage IV breast cancer patients. However, a longer follow-up study (median, 40 months) showed statistically significant improvement in median survival. When locoregional treatment in de novo stage IV BC is discussed with the patient as an option, practitioners must consider age, performance status, comorbidities, tumor type, and metastatic disease burden.

Breast surgery for metastatic breast cancer

BACKGROUND

Metastatic breast cancer is not a curable disease, but women with metastatic disease are living longer. Surgery to remove the primary tumour is associated with an increased survival in other types of metastatic cancer. Breast surgery is not standard treatment for metastatic disease, however several recent retrospective studies have suggested that breast surgery could increase the women's survival. These studies have methodological limitations including selection bias. A systematic review mapping all randomised controlled trials addressing the benefits and potential harms of breast surgery is ideal to answer this question.

OBJECTIVES

To assess the effects of breast surgery in women with metastatic breast cancer.

SEARCH METHODS

We conducted searches using the MeSH terms 'breast neoplasms', 'mastectomy', and 'analysis, survival' in the following databases: the Cochrane Breast Cancer Specialised Register, CENTRAL, MEDLINE (by PubMed) and Embase (by OvidSP) on 22 February 2016. We also searched ClinicalTrials.gov (22 February 2016) and the WHO International Clinical Trials Registry Platform (24 February 2016). We conducted an additional search in the American Society of Clinical Oncology (ASCO) conference proceedings in July 2016 that included reference checking, citation searching, and contacting study authors to identify additional studies.

SELECTION CRITERIA

The inclusion criteria were randomised controlled trials of women with metastatic breast cancer at initial diagnosis comparing breast surgery plus systemic therapy versus systemic therapy alone. The primary outcomes were overall survival and quality of life. Secondary outcomes were progression-free survival (local and distant control), breast cancer-specific survival, and toxicity from local therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted trial selection, data extraction, and 'Risk of bias' assessment (using Cochrane's 'Risk of bias' tool), which a third review author checked. We used the GRADE tool to assess the quality of the body of evidence. We used the risk ratio (RR) to measure the effect of treatment for dichotomous outcomes and the hazard ratio (HR) for time-to-event outcomes. We calculated 95% confidence intervals (CI) for these measures. We used the random-effects model, as we expected clinical or methodological heterogeneity, or both, among the included studies.

MAIN RESULTS

We included two trials enrolling 624 women in the review. It is uncertain whether breast surgery improves overall survival as the quality of the evidence has been assessed as very low (HR 0.83, 95% CI 0.53 to 1.31; 2 studies; 624 women). The two studies did not report quality of life. Breast surgery may improve local progression-free survival (HR 0.22, 95% CI 0.08 to 0.57; 2 studies; 607 women; low-quality evidence), while it probably worsened distant progression-free survival (HR 1.42, 95% CI 1.08 to 1.86; 1 study; 350 women; moderate-quality evidence). The two included studies did not measure breast cancer-specific survival. Toxicity from local therapy was reported by 30-day mortality and did not appear to differ between the two groups (RR 0.99, 95% CI 0.14 to 6.90; 1 study; 274 women; low-quality evidence).

AUTHORS' CONCLUSIONS

Based on existing evidence from two randomised clinical trials, it is not possible to make definitive conclusions on the benefits and risks of breast surgery associated with systemic treatment for women diagnosed with metastatic breast cancer. Until the ongoing clinical trials are finalised, the decision to perform breast surgery in these women should be individualised and shared between the physician and the patient considering the potential risks, benefits, and costs of each intervention.

Factors associated with improved outcomes for metastatic inflammatory breast cancer patients

PURPOSE

Controversy exists regarding the role of locoregional therapy for stage IV inflammatory breast cancer (IBC). This study aims to determine indicators of prognosis, including primary tumor resection, for stage IV IBC patients.

METHODS

Using the National Cancer Data Base, female patients diagnosed 2010-2013 with unilateral a priori metastatic T4d invasive adenocarcinoma of the breast were identified. We conducted propensity score matched analysis to balance confounders of surgery versus no-surgery. Stratified log-rank test and double-robust estimation under the Cox model were used to assess the effect of surgery, and margins, on overall survival (OS) in the propensity score matched cohort.

RESULTS

Of 1266 patients, 41% underwent surgery. In the unmatched cohort, median OS of the surgery and no-surgery groups was 36 and 20 months, respectively (p < 0.001). In the matched cohort (n = 588), the median OS of surgery and no-surgery groups was 29 and 27 months, respectively (p = 0.052). Patients with negative margin surgery (p = 0.024), hormone receptor-positive (p = 0.019), HER2-positive disease (p < 0.0001), treated with chemotherapy (p < 0.0001) and hormonal therapy (p < 0.0001), had better survival. Those with brain metastases had increased risk of death (p < 0.0001).

CONCLUSION

This study represents the largest cohort of metastatic IBC patients, and identified negative margin surgery, systemic therapy, hormone receptor and HER2-positive disease as factors associated with improved outcomes. While these findings should be interpreted cautiously, they may be used to guide further investigations into local control and quality of life in this patient population with limited treatment options.

Readdressing the Role of Surgery of the Primary Tumor in de Novo Stage IV Breast Cancer

The impressive advances in breast cancer treatment observed in recent years also apply to the metastatic setting, where a subset of patients with favorable metastatic disease enjoy long-term survival with systemic therapy. In patients with distant disease, the primary tumor in the breast has not classically been though to merit specific locoregional therapy. However, about 6% of Stage IV patients in the USA and up to 20% in limited resource environments present with synchronous distant metastases at the time of initial diagnosis. For this group, who have an intact primary tumor, retrospective studies suggest that local therapy for the primary site may be beneficial. However, these retrospective analyses are biased in that women receiving local therapy to the primary site were younger and had biologically favorable tumors and lower volume metastatic disease. Two completed randomized clinical trials have shown conflicting results, and others are ongoing. In this chapter, we discuss the results of these studies through the present day and summarize their conclusions and their implications for clinical management.

The impact of surgical excision of the primary tumor in stage IV breast cancer on survival: a meta-analysis

Introduction

Approximately 5% of primary breast cancer patients present de novo stage IV breast cancer, for whom systematic therapy is the mainstream treatment. The role of surgical excision of the primary tumor has been controversial due to inconsistent results of relevant studies. Recently, with the reports of some relevant preclinical data, retrospective studies and randomized clinical trials, we've got more evidence to reexamine the issue. Based on those above, a literature review and meta-analysis was performed to determine whether surgery of the primary tumor could improve overall survival in the setting of stage IV breast cancer.

Materials and Methods

A comprehensive search of PubMed, OVID, American Society of Clinical Oncology (ASCO) symposium documents, European Society for Medical Oncology (ESMO) symposium documents and San Antonio Breast Cancer Symposium (SABCS) symposium documents was performed to identify published literature that evaluated survival benefits from excision of the primary tumor in the setting of stage IV breast cancer. Data were extracted in review of appropriate studies by the authors independently. The primary endpoint was overall survival following surgical removal of the primary tumor. Secondary endpoints were the impacts of surgery on progression free survival (PFS) and time to progression (TTP).

Results

Data from 19 retrospective studies showed a pooled hazard ratio of 0.65 (95% confidence interval (95% CI), 0.60-0.71, P < 0.01= for overall survival (OS), indicating a 35% reduction in risk of mortality in patients who underwent surgical excision of the primary tumor. Nevertheless, the analysis of 3 randomized clinical trials revealed a pooled hazard ratio of 0.85 (95% CI, 0.59–1.21, P = 0.359) for OS in the surgical group. According to the meta-regression, the survival benefit was independent of age, tumor size, site of the metastases, and PR or HER-2 status, acceptance of systematic therapies and radiotherapy and inversely correlated with the ER+ status of the population included.

Conclusions

This is the first meta-analysis that includes both retrospective and prospective studies regarding the impact of surgery of the primary tumor on survival in stage IV breast cancer patients. According to the analytical results, we do not recommend surgery of the primary tumor as routine therapy for stage IV breast cancer. However, for those who are supposed to have long life expectancy, physicians could discuss it with these patients, put forward surgery as a therapy choice and perform the operation under deliberation.

Improved Survival After Primary Tumor Surgery in Metastatic Breast Cancer: A Propensity-adjusted, Population-based SEER Trend Analysis

BACKGROUND

There is ongoing debate about nonpalliative primary tumor surgery in metastatic breast cancer patients. This issue has become even more relevant with the introduction of increasingly sensitive imaging modalities.

METHODS

Metastatic breast cancer patients were identified in the SEER registry between 1998 and 2009. The effect of primary tumor surgery on overall and cancer-specific mortality using risk-adjusted Cox proportional hazard regression modeling and stratified propensity score matching was assessed.

RESULTS

Overall, 16,247 women with metastatic breast cancer were included. Of those 7600 women underwent primary tumor surgery although 8647 did not have any surgery at all. Primary tumor surgery decreased from 62.0% in 1998 to 39.1% in 2009 (P < 0.001). Primary tumor surgery was associated with decreased overall mortality (hazard ratio (HR) = 0.53, 95% CI 0.50-0.55, P < 0.001) and cancer-specific mortality (HR = 0.51, 95% CI 0.48-0.54, P < 0.001) in the propensity score-matched model. The benefit of primary tumor surgery increased from 1998 to 2009 for overall mortality (1998: HR = 0.72, 95% CI 0.59-0.89, 2009: HR = 0.42, 95% CI 0.35-0.50) and cancer-specific mortality (1998: HR = 0.72, 95% CI 0.58-0.89, 2009: HR = 0.40, 95% CI 0.33-0.48).

CONCLUSIONS

The present study-the first population-based analysis using propensity score methods-provides evidence of a favorable impact of primary tumor surgery on mortality in metastatic breast cancer patients. Most importantly, the benefit of primary tumor surgery increased over time from 1998 to 2009. Although the final results of ongoing randomized studies are awaited, currently available evidence should be discussed with metastatic breast cancer patients.

Therapeutic role of axillary lymph node dissection in patients with stage IV breast cancer: a population-based analysis

PURPOSE

To assess the clinical value of axillary lymph node (ALN) dissection in stage IV breast cancer.

METHODS

Patients with a diagnosis of stage IV breast cancer from 1990 to 2010 were identified using the Surveillance, Epidemiology, and End Results database. Univariate and multivariate Cox regression analyses were performed to analyze the effect of ALN dissection and ALN status on breast cancer-specific survival (BCSS) and overall survival (OS).

RESULTS

A total of 11,645 patients were identified. Of these, 7358 (63.2%) patients underwent ALN dissection, and 6168 (83.8%) patients showed nodal positivity. During this time, the rate of ALN dissection increased. Patients with delayed diagnosis, age <50 years, poorly/undifferentiated disease, larger tumor size (>2 cm), and married women were more likely to undergo ALN dissection. ALN dissection was associated with improved BCSS and OS in multivariate analysis. ALN dissection improved the survival in patients with bone and liver metastasis, and patients with single site of distant metastasis also had survival benefit by ALN dissection. Lymph node staging based on the number of positive lymph nodes was the independent prognostic factor for BCSS and OS in multivariate analysis; patients with advanced lymph node staging had a poor survival.

CONCLUSIONS

ALN dissection may improve survival in patients with stage IV breast cancer who received primary tumor surgery, especially in patients with bone, liver, and single site of distant metastasis. The lymph node staging was also the prognostic factor in patients with stage IV breast cancer.

Modest overall survival improvements from 1998 to 2009 in metastatic gastric cancer patients: a population-based SEER analysis

BACKGROUND

An increasing fraction of gastric cancer patients present with distant metastases at diagnosis. The objective of the present 11-year population-based trend analysis was to assess the survival rates in patients who underwent and in patients who did not undergo palliative gastrectomy.

METHODS

Patients with metastatic gastric cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 1998 and 2009. Time trend and impact of palliative gastrectomy on survival were assessed by both a multivariate Cox proportional hazards model and propensity score matching.

RESULTS

We identified 8249 patients with stage IV gastric cancer. The rate of metastatic disease increased from 31.0 % in 1998 to 37.5 % in 2009 (P < 0.001). The palliative gastrectomy rate dropped from 18.8 to 10.2 % (P = 0.004). The median survival for patients who underwent palliative gastrectomy (N = 1445, 17.4 %) and for patients who did not undergo palliative gastrectomy (N = 6804, 82.4 %) was 7 and 3 months, respectively. There was an increase in median overall survival from 2 months (1998) to 3 months (2009) in the no-gastrectomy group, and from 6.5 to 8 months in the gastrectomy group. The 3-year cancer-specific survival rates were 2.1 % (95 % confidence interval 1.7-2.5 %) for patients who did not undergo palliative gastrectomy and 9.4 % (95 % confidence interval 7.8-11.2 %) for patients who underwent palliative gastrectomy (P < 0.001). Palliative gastrectomy was associated with an increased cancer-specific survival in propensity-score-adjusted Cox regression analyses (hazard ratio 0.50, 95 % confidence interval 0.46-0.55, P < 0.001).

CONCLUSION

On a population-based level, only modest improvements in prognosis for metastatic gastric cancer were observed in patients who underwent and in patients who did not undergo palliative gastrectomy. Considering the low rate of midterm survivors in both groups, only a small subgroup of patients benefits from palliative gastrectomy.

The role and indications of aggressive locoregional therapy in metastatic inflammatory breast cancer

We seek to confirm the effect and explore the indications of aggressive locoregional management in patients with metastatic inflammatory breast cancer (IBC). Between 2003 and 2014, we reviewed the records of 156 patients with metastatic IBC from five large centers of Breast Surgery in the region of central south of China. Clinicopathologic data were collected to access overall survival (OS), prognostic factors and the indications for locoregional treatment. 75 (48%) patients underwent aggressive locoregional therapy. Patients in locoregional therapy group had a median OS of 24 months compared with 17 months of those in no locoregional therapy group. 2-year OS rate of these two groups was 52% and 32%, separately. Locoregional therapy (HR = 0.556; 95% CI 0.385–0.803; p = 0.002) was confirmed to be an independent prognostic factor, which could significantly improve OS of patients with metastatic IBC. For locoregional therapy group, statistical differences were observed in all subgroups stratified by the factors that were significant in univariate analysis except in the subgroups of stable disease, Charlson comorbidity index ≥3 and cerebral metastasis. Therefore, systemic therapy efficacy, Charlson comorbidity index and cerebral metastasis status appeared to be important indexes for choice of locoregional therapy in different individuals.

Surgical treatment of the primary tumour improves the overall survival in patients with metastatic breast cancer: A systematic review and meta-analysis

Traditionally, stage IV metastatic breast cancer has been treated with systemic therapy and/or radiotherapy in order to decrease cancer-associated symptoms, maintain quality of life and control disease burden. Previous research suggests that surgical treatment of the primary tumour may prolong survival, as well achieve local control of disease. Using the PubMed and Ovid SP databases, a literature review and meta-analysis was performed in order to assess whether surgical resection of the primary tumour in metastatic breast cancer prolongs survival. In this meta-analysis, a pooled hazard ratio of 0.63 (95% confidence interval, 0.58-0.7; P<0.0001) was revealed, equating to a 37% reduction in risk of mortality in patients that underwent surgical resection of the primary tumour. Therefore, it was concluded that surgery of the primary tumour in stage IV breast cancer appears to offer a survival benefit in metastatic patients.

Liver Ablation: Best Practice

Tumor ablation in the liver has evolved to become a well-accepted tool in the management of increasing complex oncologic patients. At present, percutaneous ablation is considered first-line therapy for very early and early hepatocellular carcinoma and second-line therapy for colorectal carcinoma liver metastasis. Because thermal ablation is a treatment option for other primary and secondary liver tumors, an understanding of the underlying tumor biology is important when weighing the potential benefits of ablation. This article reviews ablation modalities, indications, patient selection, and imaging surveillance, and emphasizes technique-specific considerations for the performance of percutaneous ablation.

Locoregional treatment versus no treatment of the primary tumour in metastatic breast cancer: an open-label randomised controlled trial

BACKGROUND

The role of locoregional treatment in women with metastatic breast cancer at first presentation is unclear. Preclinical evidence suggests that such treatment might help the growth of metastatic disease, whereas many retrospective analyses in clinical cohorts have suggested a favourable effect of locoregional treatment in these patients. We aimed to compare the effect of locoregional treatment with no treatment on outcome in women with metastatic breast cancer at initial presentation.

METHODS

In this open-label, randomised controlled trial, we recruited previously untreated patients (≤65 years of age with an estimated remaining life expectancy of at least 1 year) presenting with de-novo metastatic breast cancer from Tata Memorial Centre, Mumbai, India. Patients were randomly assigned (1:1) to receive locoregional treatment directed at their primary breast tumour and axillary lymph nodes, or no locoregional treatment, by a computer-generated block randomisation sequence (block size of four). Randomisation was stratified by site of distant metastases, number of metastatic lesions, and hormone receptor status. Patients with resectable primary tumour in the breast that could be treated with endocrine therapy were randomly assigned upfront, whereas those with an unresectable primary tumour were planned for chemotherapy before randomisation. Of the patients who had chemotherapy before randomisation, we randomly assigned patients who had an objective tumour response after six to eight cycles of chemotherapy. The primary endpoint was overall survival analysed by intention to treat. This study is registered with ClinicalTrials.gov, NCT00193778.

FINDINGS

Between Feb 7, 2005, and Jan 18, 2013, of the 716 women presenting with de-novo metastatic breast cancer, we randomly assigned 350 patients: 173 to locoregional treatment and 177 to no locoregional treatment. At data cut-off of Nov 1, 2013, median follow-up was 23 months (IQR 12·2-38·7) with 235 deaths (locoregional treatment n=118, no locoregional treatment n=117). Median overall survival was 19·2 months (95% CI 15·98-22·46) in the locoregional treatment group and 20·5 months (16·96-23·98) in the no-locoregional treatment group (HR 1·04, 95% CI 0·81-1·34; p=0·79), and the corresponding 2-year overall survival was 41·9% (95% CI 33·9-49·7) in the locoregional treatment group and 43·0% (35·2-50·8) in the no locoregional treatment group. The only adverse event noted was wound infection related to surgery in one patient in the locoregional treatment group.

INTERPRETATION

There is no evidence to suggest that locoregional treatment of the primary tumour affects overall survival in patients with metastatic breast cancer at initial presentation who have responded to front-line chemotherapy, and this procedure should not be part of routine practice.

Surgical Management of de novo Stage IV Breast Cancer

The natural history of stage IV breast cancer is changing, with diagnosis when the disease burden is lower and better drugs translating into longer survival. Nevertheless, a small but constant fraction of women present with de novo stage IV disease and an intact primary tumor. The management of the primary site in this setting has classically been determined by the presence of symptoms, but this approach has been questioned based on multiple retrospective reviews reported over the past decade that suggested a survival advantage for women whose intact primary tumor is resected. These reviews are necessarily biased, as younger women with lower disease burden and more favorable biological features were offered surgery, but they led to several randomized trials to test the value of local therapy for the primary tumor in the face of distant disease. Preliminary results from 2 of these do not support a significant survival benefit, although local control benefits may exist. Completion of ongoing trials is needed to reach a definitive conclusion regarding the merit of primary tumor resection for local control and survival. Until unbiased data are available, local therapy for asymptomatic primary tumors cannot be recommended in the expectation of a survival benefit.

DEGRO practical guidelines for radiotherapy of breast cancer V: Therapy for locally advanced and inflammatory breast cancer, as well as local therapy in cases with synchronous distant metastases

AIM

The purpose of this work is to give practical guidelines for radiotherapy of locally advanced, inflammatory and metastatic breast cancer at first presentation.

METHODS

A comprehensive survey of the literature using the search phrases "locally advanced breast cancer", "inflammatory breast cancer", "breast cancer and synchronous metastases", "de novo stage IV and breast cancer", and "metastatic breast cancer" and "at first presentation" restricted to "clinical trials", "randomized trials", "meta-analysis", "systematic review", and "guideline" was performed and supplemented by using references of the respective publications. Based on the German interdisciplinary S3 guidelines, updated in 2012, this publication addresses indications, sequence to other therapies, target volumes, dose, and fractionation of radiotherapy.

RESULTS

International and national guidelines are in agreement that locally advanced, at least if regarded primarily unresectable and inflammatory breast cancer should receive neoadjuvant systemic therapy first, followed by surgery and radiotherapy. If surgery is not amenable after systemic therapy, radiotherapy is the treatment of choice followed by surgery, if possible. Surgery and radiotherapy should be administered independent of response to neoadjuvant systemic treatment. In patients with a de novo diagnosis of breast cancer with synchronous distant metastases, surgery and radiotherapy result in considerably better locoregional tumor control. An improvement in survival has not been consistently proven, but may exist in subgroups of patients.

CONCLUSION

Radiotherapy is an important part in the treatment of locally advanced and inflammatory breast cancer that should be given to all patients regardless to the intensity and effect of neoadjuvant systemic treatment and the extent of surgery. Locoregional radiotherapy in patients with primarily distant metastatic disease should be prescribed on an individual basis.

Surgery of the primary tumor in de novo metastatic breast cancer: To do or not to do?

Approximately five percent of all breast cancer patients in developed countries present with distant metastases at initial diagnosis. Due to its incurability, metastatic breast cancer is generally treated with systemic therapies to achieve disease control and reduce tumor-related symptoms. Primary treatments for metastatic breast cancer are chemotherapy, endocrine- and biologic therapy, whereas surgery with or without radiotherapy is usually performed to treat impending wound issues. Since 2002, several retrospective non-randomized clinical studies have shown that extirpation of the primary tumor correlates with a significantly improved survival in patients with primary metastatic breast cancer. Others have argued that this survival benefit associated with surgery may be due to selection biases. Therefore, in the absence of published results from randomized controlled trials carried out in India and Turkey and completion of a trial in the United States, there is no clear conclusion on whether surgical excision of the primary breast cancer translates into a survival benefit for patients with de novo metastatic disease. Furthermore, timing and type of surgical procedure, as well as selection of patients who could benefit the most from this approach, represent additional points of uncertainty. Despite the epidemiological burden of this condition, there are no guidelines on how to manage breast cancer patients presenting with de novo metastatic breast cancer; and decisions are often left to provider and patient preferences. Here, we present a critical overview of the literature focusing on the rationale and potential role of primary tumour excision in patients with de novo metastatic breast cancer.

[Locoregional surgery for stage IV breast cancer patients]

Three to 6% of women newly diagnosed with breast cancers have stage IV disease. Overall survival was improved during the last few years (16-45 months). The treatment of stage IV breast cancer has traditionally been palliative with surgical resection reserved for symptomatic wound complications. Since 2000, several retrospective studies have compared surgery versus no local therapy in women presenting with stage IV breast cancer with an intact primary tumor. All showed a survival advantage for the surgical cohort. However, these studies are limited by the fact that it is not possible to control for biases that led to surgical resection of the primary tumor. Several prospective randomized trials have been undertaken. We have partial results for two of them and they show no survival differences between patients who benefit from local surgery and patients who did not have surgery. However, breast surgery is at low risk of complication, if not considering psychological aspect of mastectomy, and can be proposed to patients with no progression after first chemotherapy. Conservative management can be an option, but surgery must be optimal with negative margins. No benefit of axillary surgery has been shown but this treatment can lead to complications and impact quality of life of patients. Therefore, axillary node resection is not recommended for stage IV breast cancer. Finally, radiotherapy can be an alternative option of local therapy associated or no to surgery in stage IV breast cancer.

Is there a role for locoregional surgery in stage IV breast cancer?

Current guidelines do not recommend locoregional surgery for Stage IV breast cancer at presentation despite some studies suggesting a survival benefit. We aimed to assess outcomes in patients with Stage IV breast cancer who underwent surgery. In a cohort study of all Stage IV breast cancers diagnosed at our tertiary-referral specialist centre between 2006 and 2012, we assessed patient survival in the context of demographics, histopathology, metastatic burden, and type of surgery performed. One hundred and nine patients were included; 52 underwent surgery. Patients in the surgery group had longer 5-year-survival (p = 0.003). Survival was also significantly longer in those with just one site of metastatic disease (p < 0.001). Patients with axillary cytology positive for regional metastases were less likely to proceed to surgery. Locoregional surgery does confer a survival advantage in Stage IV breast cancer. Assessment of preoperative axillary cytology may preclude some patients from proceeding to potentially beneficial locoregional surgery.

Higher rate of breast surgery complications in patients with metastatic breast cancer: an analysis of the NSQIP database

BACKGROUND

Four percent of breast cancer patients present with metastatic disease. To date, no one has examined whether these patients are at higher risk of postoperative complications. The objective of this study was to determine morbidity and mortality associated with breast surgery in the metastatic setting.

METHODS

We analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, including breast cancer patients undergoing primary breast surgery from 2005 to 2012. Patients with bilateral surgery or severe comorbidities were excluded. Multivariable logistic regression was performed to determine the independent effect of metastatic breast cancer on postoperative morbidity and mortality.

RESULTS

We identified 68,316 patients who underwent breast surgery for invasive breast cancer; 1,031 (1.5 %) had metastatic disease. The 30-day unadjusted morbidity was significantly higher in the metastatic cohort (7.5 vs. 3.7 %; p < 0.001), as was the all-cause 30-day mortality (1.8 vs. 0.06 %; p < 0.001). The metastatic cohort was more likely to experience an: infectious, respiratory, thromboembolic, cardiac, or bleeding complication than non-metastatic patients. However, preoperative chemo- and radiation therapy did not contribute to an overall increased complication rate. The adjusted odds ratio for postoperative complications in the setting of metastatic disease was 1.6 (95 % confidence limit 1.2-2.1).

CONCLUSIONS

This is the first study documenting the morbidity and mortality associated with breast surgery in metastatic breast cancer. The 30-day morbidity and mortality in this population is higher than in patients with stage I-III disease. Although the complication rate is increased, operating on the primary in metastatic breast cancer is relatively safe.

Prognostic impact of definitive local therapy of the primary tumor in men with metastatic prostate cancer at diagnosis: A population-based, propensity score analysis

BACKGROUND

This study investigated whether definitive local therapy [radical prostatectomy (RP) or brachytherapy (BT)] of the primary tumor improves survival in men with metastatic prostate cancer (PrCA) at diagnosis.

METHODS

Data on newly diagnosed metastatic PrCA cases (stage IV, N=7858) were obtained from the Surveillance Epidemiology and End Results (SEER) program. Conventional multivariable survival analysis and propensity score analysis were used to estimate hazard ratios (HRs) and corresponding 95% confidence intervals (95% CI) comparing men who underwent definitive local therapy of the primary tumor to those who did not.

RESULTS

After adjusting for sociodemographic and tumor attributes, having RP after diagnosis with metastatic PrCA was associated with 73% (HR=0.27, 95% CI: 0.20-0.38) lower risk of all-cause mortality and 72% (HR=0.28, 95% CI: 0.20-0.39) reduced risk of death from PrCA. Having BT also was associated with 57% (HR=0.43, 95% CI: 0.31-0.59) and 54% (HR=0.46, 95% CI: 0.33-0.64) lower risk of all-cause and PrCA-specific mortality. Similar results were observed in propensity score-adjusted analysis as well as when stratified by age and extent of tumor metastasis.

CONCLUSIONS

These findings suggest that definitive local therapy improves survival in men with metastatic PrCA at diagnosis. Future work should consider comorbidities, diet, physical activity and smoking status.

Primary metastatic breast cancer: the impact of locoregional therapy

The impact of treatment for the primary tumor on distant metastases and survival in primary metastatic breast cancer patients is controversial. Previous retrospective studies and meta-analyses suggested a survival benefit for the removal of the primary tumor. Early follow-up data from 2 prospectively randomized trials presented at San Antonio Breast Cancer Symposium 2013 could not confirm this. Only a very small subgroup of patients with solitary bone metastases seemed to profit from surgery, while patients with multiple visceral metastases showed a worse prognosis with initial surgery. There are no studies available with the primary aim to investigate the impact of axillary lymph node surgery or locoregional radiotherapy on the survival of stage IV breast cancer patients. Based on current data, locoregional treatment in primary metastatic breast cancer should not be recommended in patients with asymptomatic primary tumor as a matter of routine. More solid conclusion of the impact of primary tumor treatment in stage IV breast cancer patients on their prognosis will be reached with the completion of the ongoing prospectively randomized trials. Until these studies are completed, locoregional therapy, which can provoke additional morbidity in a metastatic setting with limited live expectancy, is exclusively indicated for palliative reasons.

Radiotherapy in patients with distant metastatic breast cancer

Background

The study evaluates frequency of and indications for disease-related radiotherapy in the palliative breast cancer (BC) situation and analyzes in which phase of the palliative disease course radiotherapy was applied.

Patients & methods

340 patients who developed distant metastatic disease (DMD) and died (i.e. patients with completed disease courses) were analyzed.

Results

165 patients (48.5%) received palliative radiotherapy (255 series, 337 planning target volumes) as a part of palliative care. The most common sites for radiotherapy were the bone (217 volumes, 64.4% of all radiated volumes) and the brain (57 volumes, 16.9%). 127 series (49.8%) were performed in the first third of the metastatic disease survival (MDS) period; 84 series (32.8%) were performed in the last third. The median survival after radiotherapy was 10 months. Patients who had received radiation were younger compared to those who had no radiation (61 vs. 68 years, p < 0.001) and had an improved MDS (26 vs. 14 months, p < 0.001). Compared to rapidly progressive disease courses with short survival times, in cases where effective systemic therapy achieved a longer MDS (≥24 months), radiotherapy was significantly more often a part of the multimodal palliative therapy (52.1% vs. 37.1%, p = 0.006).

Conclusions

In a cohort of BC patients with DMD, nearly one half of the patients received radiotherapy during the palliative disease course. In a palliative therapy approach, which increasingly allows for treatment according to the principles of a chronic disease, radiotherapy has a clearly established role in the therapy concept.

De novo Stage IV breast cancer: breast conserving resection of the primary tumor?

Multiple retrospective reviews completed over the past decade suggest a survival advantage with resection of the intact primary tumor in women with metastatic breast cancer. However, these reviews are not without bias, and recently completed randomized trials do not support a significant survival benefit, although local control benefits may exist. Completion of ongoing trials is needed to reach a definitive conclusion regarding the merit of primary tumor resection for local control and survival.

Primary tumor resection as a component of multimodality treatment may improve local control and survival in patients with stage IV inflammatory breast cancer

BACKGROUND

To the authors' knowledge, the benefit of primary tumor resection among patients with metastatic inflammatory breast cancer (IBC) is unknown.

METHODS

The authors reviewed 172 cases of metastatic IBC. All patients received chemotherapy with or without radiotherapy and/or surgery. Patients were classified as responders or nonresponders to chemotherapy. The 5-year overall survival (OS) and distant progression-free survival (DPFS) and local control at the time of last follow-up were evaluated.

RESULTS

A total of 79 patients (46%) underwent surgery. OS and DPFS were better among patients treated with surgery versus no surgery (47% vs 10%, respectively [P<.0001] and 30% vs 3%, respectively [P<.0001]). Surgery plus radiotherapy was associated with better survival compared with treatment with surgery or radiotherapy alone (OS rate: 50% vs 25% vs 14%, respectively; DPFS rate: 32% vs 18% vs 15%, respectively [P<.0001 for both]). Surgery was associated with better survival for both responders (OS rate for surgery vs no surgery: 49% vs 23% [P<.0001] and DPFS rate for surgery vs no surgery: 31% vs 8% [P<.0001]) and nonresponders (OS rate for surgery vs no surgery: 40% vs 6% [P<.0001] and DPFS rate for surgery vs no surgery: 30% vs 0% [P<.0001]). On multivariate analysis, treatment with surgery plus radiotherapy and response to chemotherapy were found to be significant predictors of better OS and DPFS. Local control at the time of last follow-up was 4-fold more likely in patients who underwent surgery with or without radiotherapy compared with patients who received chemotherapy alone (81% vs 18%; P<.0001). Surgery and response to chemotherapy independently predicted local control on multivariate analysis.

CONCLUSIONS

The results of the current study demonstrate that for select patients with metastatic IBC, multimodality treatment including primary tumor resection may result in better local control and survival. However, a randomized trial is needed to validate these findings.

Is there value to primary tumor control in patients with stage IV breast cancer?

SUMMARY In the past decade there has been interest as to whether or not resection of the primary tumor improves survival in metastatic breast cancer. There have been multiple retrospective reviews addressing this question. The retrospective data seem to suggest that there is a survival advantage with resection of the primary tumor. However, these reviews are not without bias. In this review, we will address the biases present in the retrospective data and the potential harm in offering surgery to women with metastatic breast cancer, as well as the ongoing randomized clinical trials to answer this question.

Does removal of the primary tumor in metastatic breast cancer improve survival?

Although relative survival for breast cancer has improved in recent years, patients who present with metastatic disease have a less than 30% 5-year survival. Thus, improvements in treatment for these patients have the potential to have a significant impact on outcomes. Historically, removal of the primary breast tumor has been offered to these patients only for palliation. However, there have been recent reports that removal of the primary tumor may improve survival. Here, we review the theories and data at the center of the debate, the landmark studies that historically guided treatment, the retrospective data that revisited the role of removal of the primary tumor, as well as the latest advances in basic science and the accruing clinical studies to provide for future directions in this field. Although the definitive role of removal of the primary tumor in metastatic breast cancer is not settled, it is critical to understand the complexities of this debate in order to make further gains in breast cancer survivorship.

Caught in the act: revealing the metastatic process by live imaging

The prognosis of metastatic cancer in patients is poor. Interfering with metastatic spread is therefore important for achieving better survival from cancer. Metastatic disease is established through a series of steps, including breaching of the basement membrane, intravasation and survival in lymphatic or blood vessels, extravasation, and growth at distant sites. Yet, although we know the steps involved in metastasis, the cellular and molecular mechanisms of dissemination and colonization of distant organs are incompletely understood. Here, we review the important insights into the metastatic process that have been gained specifically through the use of imaging technologies in murine, chicken embryo and zebrafish model systems, including high-resolution two-photon microscopy and bioluminescence. We further discuss how imaging technologies are beginning to allow researchers to address the role of regional activation of specific molecular pathways in the metastatic process. These technologies are shedding light, literally, on almost every step of the metastatic process, particularly with regards to the dynamics and plasticity of the disseminating cancer cells and the active participation of the microenvironment in the processes.

Disease-related surgery in patients with distant metastatic breast cancer

INTRODUCTION

This study evaluates the frequency of and indications for disease-related surgical procedures in the palliative breast cancer (BC) situation.

PATIENTS & METHODS

Based on a cohort of women who were treated for newly diagnosed BC during a 20-year period (1990-2009), we analyzed 340 patients who developed distant metastatic disease (DMD) until 2011 and died (i.e. still ongoing palliative disease courses were not included).

RESULTS

One hundred and twenty-seven surgical procedures were performed in 100 patients (29.4% of all patients with metastatic disease). The most common site for surgery was breast (n = 60, 47.2%). The primary tumor was removed at first diagnosis of DMD in 43 patients (33.9%); sixteen operations (12.6%) were performed for local recurrence. In 37 patients, 50 surgical procedures (39.4%) were necessary to stabilize osseous structures due to metastases. Procedures were rarely performed on other common metastatic sites: lung: n = 1 (0.8%); liver: n = 1 (0.8%), brain: n = 4 (3.1%). When excluding surgery for primary breast tumors at initial diagnosis of DMD from analysis, 34 of 84 surgeries (40.4%) were performed in the first third of survival follow-up (i.e. period of metastatic disease survival); operations in the last two-thirds each totaled 29.8% (n = 25). The median survival after surgery was 16 months (range: 0.5-89 months).

CONCLUSIONS

In a cohort of BC patients who had primary or developed secondary DMD, nearly one third of the patients received disease-related surgical procedures during their palliative disease course. This high rate of operations shows that surgery has a clearly established role in the palliative therapy concept.

Liver resection in selected patients with metastatic breast cancer: a single-centre analysis and review of literature

PURPOSE

Despite the development of modern chemotherapeutics and target-specific drugs as well as improved surgical techniques, prognosis of metastatic breast cancer remains poor. Only a small number of selected patients will be eligible for liver resection and/or alternative metastatic ablation. Data on prognostic factors for patients with surgically resectable liver metastases of breast cancer are scarce at present.

METHODS

From 1997 to 2010, 50 patients with hepatic metastases of breast cancer have undergone laparotomy with the intention to undergo a curative liver resection at our institution. Data from these patients were collected in a prospectively maintained standardized liver resection data base.

RESULTS

Liver resection was performed in 34 patients. Resection margins were clear in 21 cases (R0). Nine patients lived for more than 60 months after liver resection. The observed 5-year survival rate was 21% for all 50 patients, 28% for resected patients and 38% after R0-resection. On univariate analysis, survival rates of the resected patients were statistically significantly influenced by R-classification, age, extrahepatic tumour at the time of liver resection, size of metastases and HER2 expression of liver metastases. Multivariate analysis revealed absence of HER2 expression, presence of extrahepatic tumour and patient's age ≥50 years as independent factors of poor prognosis.

CONCLUSIONS

Breast cancer patients younger than 50 years with technically resectable hepatic metastases, minimal extrahepatic tumour and positive HER2 expression appear to be suitable candidates for liver resection with curative intent. An aggressive multi-disciplinary management of those patients including surgical treatment may improve long-term survival.

Meta-analysis to determine if surgical resection of the primary tumour in the setting of stage IV breast cancer impacts on survival

INTRODUCTION

The role of primary tumor excision in patients with stage IV breast cancer is unclear. Therefore, a meta-analysis of relevant studies was performed to determine whether surgical excision of the primary tumor enhances oncological outcome in the setting of stage IV breast cancer.

METHODS

A comprehensive search for relevant published trials that evaluated outcomes following excision of the primary tumor in stage IV breast cancer was performed using MEDLINE and available data were cross-referenced. Data were extracted following review of appropriate studies by authors. The primary outcome was overall survival following surgical removal of the primary tumor.

RESULTS

Data from ten studies included 28,693 patients with stage IV disease of whom 52.8% underwent excision of the primary carcinoma. Surgical excision of the primary tumor in the setting of stage IV breast cancer was associated with a superior survival at 3 years (40% (surgery) versus 22% (no surgery) (odds ratio 2.32, 95% confidence interval 2.08-2.6, p<0.01). Subgroup analyses for selection of patients for surgery or not, favored smaller primary tumors, less competing medical comorbidities and lower metastatic burden (p<0.01). There was no statistical difference between the two groups regarding location of metastatic disease, grade of tumor, or receptor status.

CONCLUSIONS

Patients with stage IV disease undergoing surgical excision of the primary tumor achieve a superior survival rate then their nonsurgical counterparts. In the absence of robust evidence, this meta-analysis provides evidence base for primary resection in the setting of stage IV breast cancer for appropriately selected patients.

Resection of the primary tumor improves survival in metastatic breast cancer by reducing overall tumor burden

BACKGROUND

Although many retrospective studies suggest that resection of the primary tumor improves survival in metastatic breast cancer, animal studies suggest that resection induces metastasis. Moreover, there has been no critical evaluation of how well animal studies actually model metastatic breast cancer. We used our newly established orthotopic cancer implantation under direct vision model to evaluate the hypothesis that primary tumor resection improves survival in metastatic breast cancer by reducing overall tumor burden and improving immune responsiveness.

METHODS

Murine mammary adenocarcinoma 4T1-luc2 cells that can be visualized by bioluminescence were implanted orthotopically into BALB/c mice under direct vision. Resection of the primary tumors at days 6, 10, and 28 were compared to sham resection of the contralateral normal mammary gland and observation alone. Tumor burden was quantified by bioluminescence. Tumor-draining lymph nodes were identified by intradermal injection of lymphazurin, and primary tumors, lymph nodes, and lungs were examined pathologically. Kaplan-Meier survival analyses were performed. Splenocyte myeloid-derived suppressor cells (MDSCs) and CD4 or CD8 single positive T lymphocytes were quantified by flow cytometry.

RESULTS

Tumors invaded locally, metastasized to regional lymph nodes, and then metastasized to distant organs, with subsequent mortality. Surgical stress increased tumor burden only transiently without affecting survival. When primary tumor resection decreased overall tumor burden substantially, further growth of metastatic lesions did not increase the overall tumor burden compared to observation, and survival was improved, which was not the case when resection did not significantly reduce the overall tumor burden. Decreasing overall tumor burden through resection of the primary tumor resulted in decreased splenic MDSC numbers and increased CD4 and CD8 cells, suggesting the potential for an improved immunologic response to cancer.

CONCLUSION

Decreasing overall tumor burden through resection of the primary breast tumor decreased MDSCs, increased CD4 and CD8 cells, and improved survival.

Role of breast surgery in T1-3 breast cancer patients with synchronous bone metastases

The impact of breast surgery on survival of metastatic breast cancer (MBC) patients is controversial. We addressed the question in a mono-institutional series of MBC patients with synchronous bone metastases. We identified 187 consecutive women diagnosed between 2000 and 2008 with locally operable (T1-T3) MBC, synchronous bone metastases, with no other distant sites being involved. Progression-free survival (PFS) and overall survival (OS) were compared between operated and non-operated patients. Median age was 51 years; 92 % of the women had a hormone-positive tumor. At the time of diagnosis, 131 patients out of 187 (70 %) underwent surgery. Operated and non-operated patients differed in terms of number of bone metastatic sites: a single metastasis was detected in 35 (28 %) operated, and 6 (11 %) non-operated cases (P = 0.01). No other significant differences were observed. The multi-adjusted hazard ratio was 0.63 (95 % CI 0.43-0.92) for PFS and 0.64 (95 % CI 0.41-0.99) for OS in favor of surgery. The 5-year cumulative incidence of ipsilateral breast skin progressions among non-operated patients was 18 %. In this large and homogeneous series of MBC patients with synchronous bone metastases, the role of breast surgery had a favorable impact on both disease progression and mortality.

Impact of loco-regional treatment on metastatic breast cancer outcome: a review

Metastatic breast cancer (MBC) at presentation (Stage IV) is a devastating diagnosis with a poor prognosis and a 5-year overall survival rate not exceeding 20%. The treatment is palliative, and its primary aim is to improve the patient's quality of life. In this context, the benefit of local therapy, considered to have no impact on survival, was to control the local evolution of the disease in order to limit the symptoms. Several publications have challenged this paradigm. These studies, either retrospective single-center or based on population cohorts, compared locoregional treatment to exclusive systemic therapy, which is the gold standard in this situation. The outcomes, marked by inherent biases as in all retrospective studies, mainly related to prognostic factors, albeit suggesting a strong and constant association between locoregional therapy and improvement of metastatic progression-free survival and overall survival. Furthermore, the advances made in the metastatic setting using innovative systemic therapies raise more than ever the interest in locoregional treatment. However, currently we have no data to better define subgroups of patients who would benefit from a strategy that include systematic local therapy. Thus, the important ongoing randomized trials may not only answer some of these issues, but will probably change the practice for many patients with MBC at diagnosis. In this review we will focus on the biologic hypotheses that support the importance of local therapy for MBC patients, review data published in this issue and summarize the ingoing trials.

Primary tumor extirpation in breast cancer patients who present with stage IV disease is associated with improved survival

PURPOSE

Previous evaluation of our institutional experience with stage IV breast cancer patients with an intact primary tumor (IPT) did not reveal an overall survival (OS) benefit for surgery at 32.1 months median follow-up. We assessed the impact of surgery after 74.2 months median follow-up, and the effect of systemic therapy and local radiotherapy (RT).

METHODS

We reviewed the records of all patients presenting from 1997 to 2002 with stage IV disease with an IPT. Cox proportional hazards modeling was used to assess differences in survival between treatment groups.

RESULTS

Seventy-four (35.6 %) of 208 patients underwent resection of the IPT. After adjustment for covariates, surgery was associated with improved OS (p = 0.04). Multivariable analysis revealed that estrogen receptor (ER) positivity (p = 0.002) and having only a single focus of metastatic disease (p = 0.05) were also associated with improved OS. Surgery was highly associated with receipt of RT (p = 0.0003). RT was significantly associated with improved survival (p = 0.015) in an exploratory analysis.

CONCLUSIONS

Stage IV breast cancer patients with an IPT treated surgically had significantly improved OS. Radiation to the primary was also associated with improved survival, but this was evident only with adjustment for the effect of surgery. These findings may be limited by selection bias. Completion of ongoing prospective randomized trials is needed to conclusively determine whether stage IV patients with an IPT should be offered aggressive locoregional therapy.