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

Excision of the primary tumour in patients with metastatic breast cancer: a clinical dilemma

BACKGROUND

Approximately 10% of new breast cancer patients will present with overt synchronous metastatic disease. The optimal local management of those patients is controversial. Several series suggest that removal of the primary tumour is associated with a survival benefit, but the retrospective nature of those studies raises considerable methodologic challenges. We evaluated our clinical experience with the management of such patients and, more specifically, the impact of surgery in patients with synchronous metastasis.

METHODS

We reviewed patients with primary breast cancer and concurrent distant metastases seen at our centre between 2005 and 2007. Demographic and treatment data were collected. Study endpoints included overall survival and symptomatic local progression rates.

RESULTS

The 111 patients identified had a median follow-up of 40 months (range: 0.6-71 months). We allocated the patients to one ot two groups: a nonsurgical group (those who did not have breast surgery, n = 63) and a surgical group (those who did have surgery, n = 48, 29 of whom had surgery before the metastatic diagnosis). When compared with patients in the nonsurgical group, patients in the surgical group were less likely to present with T4 tumours (23% vs. 35%), N3 nodal disease (8% vs. 19%), and visceral metastasis (67% vs. 73%). Patients in the surgical group experienced longer overall survival (49 months vs. 33 months, p = 0.01) and lower rates of symptomatic local progression (14% vs. 44%, p < 0.001).

CONCLUSIONS

In our study, improved overall survival and symptomatic local control were demonstrated in the surgically treated patients; however, this group had less aggressive disease at presentation. The optimal local management of patients with metastatic breast cancer remains unknown. An ongoing phase iii trial, E2108, has been designed to assess the effect of breast surgery in metastatic patients responding to first-line systemic therapy. If excision of the primary tumour is associated with a survival benefit, then the preselected subgroup of patients who have responded to initial systemic therapy is the desired population in which to put this hypothesis to the test.

Surgery of primary tumors in stage IV breast cancer: an updated meta-analysis of published studies with meta-regression

Systemic therapy is the mainstream treatment of stage IV breast cancer. Surgical excision of the primary breast cancer tumor in the presence of synchronous metastatic disease is debated, but a shared indication is not proposed by current guidelines. The purpose of this analysis is to aggregate the published survival data of surgery of an intact primary tumor in stage IV disease. The authors searched PubMed for publications reporting data about the survival benefit of surgery of the primary tumor in patients with metastatic breast cancer. Hazard ratios for survival when reported after multivariate analysis (with 95 % confidence intervals) were obtained from publications and pooled in a meta-analysis. A meta-regression weighted for the extent of disease, ER/HER2 status, age, visceral or bone disease, rate of radiotherapy, and systemic therapies offered was performed. A total of 15 publications were included in this meta-analysis. Surgery of the primary tumor appeared to be an independent factor for an improved survival in the multivariate analyses from the individual studies, with an HR of 0.69 (p < 0.00001). According to meta-regression, the survival benefit was independent of age, extent, site of the metastatic disease, and HER2 status, but was directly proportional to the rate of patients exposed to systemic therapies and radiotherapy and inversely correlated with the ER+ status of the population included. Surgery of the primary tumor in stage IV breast cancer seems to offer a survival benefit in metastatic patients, in particular when it is offered in a multimodality treatment program.

Limited M1 disease: a significant prognostic factor for stage IV breast cancer

PURPOSE

The prognosis of patients with breast cancer presenting with distant metastasis can vary depending on disease extent. This study evaluates a definition of limited M1 disease in association with survival in a cohort of women presenting with metastatic breast cancer.

METHODS

The study cohort comprised 692 women referred to the BC Cancer Agency between 1996 and 2005 with M1 breast cancer at presentation. Limited M1 disease was defined as <5 metastatic lesions confined to one anatomic subsite. Extensive M1 disease was defined as ≥ 5 lesions or disease in more than one subsite. Clinicopathologic and treatment characteristics and overall survival (OS) were compared between subjects with limited (n = 233) versus extensive (n = 459) M1 disease. Multivariable analysis was performed by Cox regression modeling.

RESULTS

Median follow-up time was 1.9 years. Five-year Kaplan-Meier OS was significantly higher in patients with limited compared to extensive M1 disease (29.7 vs. 13.1 %, p < 0.001). In the multivariable Cox regression analysis, limited M1 disease was significantly associated with OS (hazard ratio 0.51, 95 % confidence interval 0.40-0.66, p < 0.001). The only patient subsets with limited M1 disease with poor 5-year OS <15 % were patients with Eastern Cooperative Oncology Group performance status of ≥ 2 or estrogen receptor-negative status.

CONCLUSIONS

Limited M1 disease, defined as <5 metastatic lesions confined to one anatomic subsite, is a relevant favorable prognostic factor in patients with stage IV breast cancer. This definition may be used in conjunction with other clinicopathologic factors to select patients for more aggressive systemic and locoregional treatments.

SUBMIT: Systemic therapy with or without up front surgery of the primary tumor in breast cancer patients with distant metastases at initial presentation

BACKGROUND

Five percent of all patients with breast cancer have distant metastatic disease at initial presentation. Because metastatic breast cancer is considered to be an incurable disease, it is generally treated with a palliative intent. Recent non-randomized studies have demonstrated that (complete) resection of the primary tumor is associated with a significant improvement of the survival of patients with primary metastatic breast cancer. However, other studies have suggested that the claimed survival benefit by surgery may be caused by selection bias. Therefore, a randomized controlled trial will be performed to assess whether breast surgery in patients with primary distant metastatic breast cancer will improve the prognosis.

DESIGN

Randomization will take place after the diagnosis of primary distant metastatic breast cancer. Patients will either be randomized to up front surgery of the breast tumor followed by systemic therapy or to systemic therapy, followed by delayed local treatment of the breast tumor if clinically indicated.Patients with primary distant metastatic breast cancer, with no prior treatment of the breast cancer, who are 18 years or older and fit enough to undergo surgery and systemic therapy are eligible. Important exclusion criteria are: prior invasive breast cancer, surgical treatment or radiotherapy of this breast tumor before randomization, irresectable T4 tumor and synchronous bilateral breast cancer. The primary endpoint is 2-year survival. Quality of life and local tumor control are among the secondary endpoints.Based on the results of prior research it was calculated that 258 patients are needed in each treatment arm, assuming a power of 80%. Total accrual time is expected to take 60 months. An interim analysis will be performed to assess any clinically significant safety concerns and to determine whether there is evidence that up front surgery is clinically or statistically inferior to systemic therapy with respect to the primary endpoint.

DISCUSSION

The SUBMIT study is a randomized controlled trial that will provide evidence on whether or not surgery of the primary tumor in breast cancer patients with metastatic disease at initial presentation results in an improved survival.

TRIAL REGISTRATION

NCT01392586.

A debate on locoregional treatment of the primary tumor in patients presenting with stage IV breast cancer

Approximately 5-10% of patients with breast cancer present with distant metastasis (stage IV disease) at diagnosis. Systemic therapy is usually the main treatment for these patients. Other than in the context of palliation, the use of radical locoregional therapy, such as surgery or radiotherapy, is controversial. Recent studies have suggested that definitive locoregional treatment of the primary breast tumor can improve survival for patients presenting with metastatic breast cancer. This article reviews available literature pertaining to the benefits and disadvantages of locoregional treatment, focusing on data from institutional and registry studies. The effect of locoregional treatment on outcome for patients with stage IV breast cancer and related key issues will be discussed. Information on ongoing prospective randomized trials designed to address this issue will be provided.

The role of surgery in metastatic breast cancer

Some of the patients who present with breast cancer already have distant metastatic disease. According to recent literature, these patients may benefit from resection of the breast tumour. One explanation for the effect of this resection is that reducing the tumour load influences metastatic growth. Results of future randomised controlled trials should indicate whether surgery of the breast tumour truly improves survival. Selected patients could even benefit from metastasectomy of liver and lung metastases; survival seems to improve and these procedures seldom lead to major complications. When metastasectomy is not possible, minimally invasive techniques can be used in selected patients for the treatment of breast cancer liver metastases, radiofrequency ablation (RFA) being discussed most in the literature. Patients with locally advanced breast cancer are treated multidisciplinarily and with curative intent. Part of the treatment is surgery to reduce tumour load. Regarding treatment of the axilla, in a clinically negative axilla sentinel node biopsy is advised before neoadjuvant treatment; an axillary lymph node dissection is not warranted. In local recurrence, surgery is the primary treatment. Axillary staging can be done in patients with a previous negative sentinel node biopsy. Regional recurrence after breast-conserving surgery or mastectomy is treated with surgery followed by radiotherapy.

Primary tumor excision in stage IV breast cancer at diagnosis without influence on survival: a retrospective analysis and review of the literature

BACKGROUND

Patients with synchronous metastastic breast cancer and intact primary tumor traditionally undergo systemic treatment. Surgical intervention at the primary site is typically reserved for palliation and often replaceable by radiation. Nevertheless, local surgery in metastatic breast cancer has become an issue of great controversy since retrospective studies published during the recent years suggested a slight benefit from an operative procedure. We evaluated the effect of surgery on long-term survival and progression-free survival in synchronous stage IV breast cancer.

METHODS

We retrospectively reviewed the records of all breast cancer patients treated at our institution between 1986 and 2007. Information recorded for each patient included age, tumor characteristics, metastasis characteristics, therapy, progression-free survival, and overall survival. Survival data were compared between surgical and nonsurgical patients.

RESULTS

61 patients with synchronous metastastic breast cancer and intact primary tumor were analyzed. 26 patients (43%) received no primary site surgery and 35 (57%) patients had surgery. Overall survival and progression-free survival determined via the Kaplan-Meier method showed no significant difference between the surgery and the non-surgery group.

CONCLUSION

In patients with metastatic breast cancer, the operation of the primary tumor did not influence overall survival or progression-free survival.

Osteopoikilosis masquerading as osseous metastases in breast cancer

Osteopoikilosis (OPK) is a rare, congenital bone disorder characterised by multiple round or ovoid radio densities appearing throughout the axial and appendicular skeleton. It is usually an asymptomatic condition diagnosed incidentally on radiological imaging, and may mimic other bone disorders, including osseous metastases. In this case report, we present a patient with lobular breast cancer whose computed tomography findings were thought to be consistent with osseous cancer metastases. Radionuclide bone scintigraphy plays a key role in distinguishing OPK from osteoblastic bone metastases. This case demonstrates the importance of a clinical awareness of OPK to ensure that patients with potentially curable disease are properly diagnosed.

Impact of breast surgery on survival in women presenting with metastatic breast cancer

BACKGROUND

Advanced breast cancer is common in less affluent parts of Asia. The impact of breast surgery on survival of women presenting with metastatic breast cancer in this setting was investigated.

METHODS

Women presenting with metastatic breast cancer at the initial diagnosis at the University Malaya Medical Centre (Malaysia) between 1993 and 2008 were included in the study. Mortality of patients who had primary breast surgery was compared with that of those without surgery, and adjusted for possible confounders by means of a propensity score.

RESULTS

Of 3689 patients, 375 (10·2 per cent) presented with metastatic disease. One hundred and thirty-nine patients (37·1 per cent) underwent surgery. A total of 330 deaths occurred during 6814 person-months of follow-up. The 2-year survival rate was 21·2 (95 per cent confidence interval (c.i.) 15·9 to 26·5) per cent in women who did not have surgery and 46·3 (37·7 to 54·9) per cent in those who had breast surgery. Breast surgery was associated with a 28 per cent lower risk of death (hazard ratio 0·72, 95 per cent c.i. 0·56 to 0·94), after adjustment for patient and tumour characteristics, metastatic profile and treatment.

CONCLUSION

Surgical resection of the primary breast tumour was independently associated with a survival advantage in patients presenting with metastatic breast cancer.

Surgery of the primary tumor does not improve survival in stage IV breast cancer

We sought to evaluate the survival of patients who received breast surgery prior to any other breast cancer therapy following a metastatic diagnosis. Standard treatment for stage IV breast cancer is systemic therapy without resection of the primary tumor. Registry-based studies suggest that resection of the primary tumor may improve survival in stage IV cancer. We performed a retrospective analysis using data from the National Comprehensive Cancer Network (NCCN) Breast Cancer Outcomes Database. Patients were eligible if they had a metastatic breast cancer diagnosis at presentation with disease at a distant site and either received surgery prior to any systemic therapy or received systemic therapy only. Eligible patients who did not receive surgery were matched to those who received surgery based on age at diagnosis, ER, HER2, and number of metastatic sites. To determine whether estimates from the matched analysis were consistent with estimates that could be obtained without matching univariate and multivariable analyses of the unmatched sample were also conducted. There were 1,048 patients in the NCCN database diagnosed with stage IV breast cancer from 1997 to 2007. 609 metastatic breast cancer patients were identified as eligible for the study. Among the 551 patients who had data available for matching, 236 patients who did not receive surgery were matched to 54 patients who received surgery. Survival was similar between the groups with a median of 3.4 years in the nonsurgery group and 3.5 years in the surgery group. The groups were similar after adjusting for the presence of lung metastases and use of trastuzumab therapy (HR=0.94, CI 0.83-1.08, P=0.38). When matching for the variables associated with a survival benefit in previous studies, surgery was not shown to improve survival in the stage IV setting for this subset.

Improvement of survival and prospect of cure in patients with metastatic breast cancer

Patients with metastatic breast cancer have traditionally been considered incurable with conventional treatment. However, 5-10% of those patients survive more than 5 years, and 2-5% survive more than 10 years. Recent studies suggest that the survival of patients with metastatic breast cancer has been slowly improving. In this review, we examine the possible curative approach for a certain group of patients with metastatic breast cancer. We identify that patients most likely to benefit from such an aggressive approach are young and have good performance status, adequate body functional reserve, long disease-free interval before recurrence, oligometastatic disease, and low systemic tumor load. An aggressive multidisciplinary approach including both local treatment of macroscopic disease and systemic treatment of microscopic disease can result in prolonged disease control in certain patients with metastatic breast cancer. Whether patients with prolonged disease control are "cured" remains controversial.

Exclusive and adjuvant radiotherapy in breast cancer patients with synchronous metastases

Background

Data from the Surveillance, Epidemiology, and End Results program and the European Concerted Action on survival and Care of Cancer Patients (EUROCARE) project indicate that about 6% of women newly diagnosed with breast cancer have stage IV disease, representing about 12 600 new cases per year in the United States in 2005. Historically, local therapy of the primary tumor in this setting has been aimed solely at symptom palliation. However, several studies suggest that surgical excision of the primary tumor can prolong these patients' survival.

Discussion

Exclusive locoregional radiotherapy is an alternative form of locoregional treatment in this setting and may represent an effective alternative to surgery in this setting. Here we discuss current issues regarding exclusive and adjuvant locoregional radiotherapy in breast cancer patients with synchronous metastases.

Summary

Several studies suggest that surgery or exclusive irradiation of the primary tumor is associated with better survival in breast cancer patients with synchronous metastases and that exclusive locoregional radiotherapy may represent an effective alternative to surgery in this setting. Results of well-designed prospective studies are needed to re-evaluate treatment of the primary breast tumor in patients with metastases at diagnosis, and to identify those patients who are most likely to benefit.

Metastasectomy and surgical resection of the primary tumor in patients with stage IV breast cancer: time for a second look?

Patients with metastatic or stage IV breast cancer have limited therapeutic options, and the mainstay of treatment remains systemic chemotherapy. Traditionally, the role of surgery has been confined to strict palliation. Improvements in the efficacy of chemotherapeutic regimens, coupled with the use of hormonal and targeted therapy, have resulted in an expansion of surgical resection beyond simple palliation. Several single-institution studies have reported improved survival and even long-term cures after surgical resection for oligometastatic stage IV breast cancer. Similarly, provocative new data suggest that removal of the primary tumor in some patients may confer a survival advantage. The aim of this review is to summarize studies in the medical literature pertaining to the use of surgical resection in patients with stage IV breast cancer. We believe there is enough evidence to challenge conventional thinking about the role of surgery in stage IV breast cancer and to consider a new multimodality treatment paradigm to optimize patient outcomes. It is time to conduct a carefully designed randomized trial to see whether surgery in stage IV breast cancer does indeed warrant a second look.

Treatment of the primary tumor in breast cancer patients with synchronous metastases

Data from the Surveillance, Epidemiology, and End Results program and the European Concerted Action on survival and Care of Cancer Patients (EUROCARE) project indicate that approximately 6% of women newly diagnosed with breast cancer have stage IV disease, representing approximately 12 600 new cases per year in the United States in 2005. Historically, local therapy of the primary tumor in this setting has been aimed solely at symptom palliation. However, several studies suggest that surgical excision or exclusive irradiation of the primary tumor can prolong these patients' survival. In contrast, the impact of surgical dissection of regional lymph nodes and postoperative radiotherapy is poorly documented, and the patient subgroups most likely to benefit from treatment of the primary tumor remain to be identified. Two prospective studies are currently examining the benefits of locoregional therapy compared with systemic therapy alone in this setting. Here, we discuss current issues regarding treatment of the primary tumor in breast cancer patients with synchronous metastases.

International guidelines for management of metastatic breast cancer: can metastatic breast cancer be cured?

A distinctive subset of metastatic breast cancer (MBC) is oligometastatic disease, which is characterized by single or few detectable metastatic lesions. The existing treatment guidelines for patients with localized MBC include surgery, radiotherapy, and regional chemotherapy. The European School of Oncology-Metastatic Breast Cancer Task Force addressed the management of these patients in its first consensus recommendations published in 2007. The Task Force endorsed the possibility of a more aggressive and multidisciplinary approach for patients with oligometastatic disease, stressing also the need for clinical trials in this patient population. At the sixth European Breast Cancer Conference, held in Berlin in March 2008, the second public session on MBC guidelines addressed the controversial issue of whether MBC can be cured. In this commentary, we summarize the discussion and related recommendations regarding the available therapeutic options that are possibly associated with cure in these patients. In particular, data on local (surgery and radiotherapy) and chemotherapy options are discussed. Large retrospective series show an association between surgical removal of the primary tumor or of lung metastases and improved long-term outcome in patients with oligometastatic disease. In the absence of data from prospective randomized studies, removal of the primary tumor or isolated metastatic lesions may be an attractive therapeutic strategy in this subset of patients, offering rapid disease control and potential for survival benefit. Some improvement in outcome may also be achieved with optimization of systemic therapies, possibly in combination with optimal local treatment.

Stage IV breast cancer in the era of targeted therapy: does surgery of the primary tumor matter?

BACKGROUND

Multiple studies have suggested that resection of the primary tumor improves survival in patients with stage IV breast cancer, yet in the era of targeted therapy, the relation between surgery and tumor molecular subtype is unknown. The objective of the current study was to identify subsets of patients who may benefit from primary tumor treatment and assess the frequency of local disease progression.

METHODS

Patients presenting with stage IV breast cancer and intact primary tumors (n = 186) were identified from a prospectively maintained clinical database (2000-2004) and clinical data were abstracted (grading determined according to the American Joint Committee on Cancer staging system).

RESULTS

Surgery was performed in 69 (37%) patients: 34 (49%) patients with unknown metastatic disease at the time of surgery, 15 (22%) patients for local control, 14 (20%) patients for palliation, and in 6 (9%) patients to obtain tissue. Surgical patients were more likely to be HER-2/neu negative (P = .001), and to have smaller tumors (P = .05) and solitary metastasis (P <.001). Local therapy included axillary lymph node clearance in 33 (48%) patients and postoperative radiotherapy in 9 (13%) patients. The median survival was 35 months. Cox regression analysis identified estrogen receptor (ER) positivity (hazard ratio [HR], 0.47; 95% confidence interval [95% CI], 0.29-0.76), progesterone receptor (PR) positivity (HR, 0.57; 95% CI, 0.36-0.90), and HER-2/neu amplification (HR, 0.51; 95% CI, 0.34-0.77) as being predictive of improved survival. There was a trend toward improved survival with surgery (HR, 0.71; 95% CI, 0.47-1.06). On exploratory analyses, surgery was found to be associated with improved survival in patients with ER/PR positive or HER-2/neu-amplified disease (P = .004). No survival benefit was observed in patients with triple-negative disease.

CONCLUSIONS

Although a trend toward improved survival with surgery was observed, it was noted most strongly in patients with ER/PR positive and/or HER-2/neu-amplified disease. This suggests that the impact of local control is greatest in the presence of effective targeted therapy, and supports the need for further study to define patient subsets that will benefit most.

Impact of breast surgery on survival in patients with distant metastases at initial presentation: a systematic review of the literature

According to current treatment standards, patients with metastatic breast cancer at diagnosis receive palliative therapy. Local treatment of the breast is only recommended if the primary tumor is symptomatic. Recent studies suggest that surgical removal of the primary tumor has a favorable impact on the prognosis of patients with primary metastatic breast cancer. We performed a systematic review of the literature to weigh the evidence for and against breast surgery in this patient group. Ten retrospective studies were found in which the use of breast surgery in primary metastatic breast cancer and its impact on survival was examined. The hazard ratios of the studies were pooled to provide an estimate of the overall effect of surgery, and the results and conclusions of the studies were analyzed. A crude analysis, without adjustment for potential confounders, showed that surgical removal of the breast lesion in stage-IV disease was associated with a significantly higher overall survival rate in seven of the ten studies, and a trend toward a better survival in the three remaining studies. Surgery of the primary tumor appeared to be an independent factor for an improved survival in the multivariate analyses from the individual studies, with hazard ratios ranging from 0.47 to 0.71. The pooled hazard ratio for overall mortality was 0.65 (95% CI 0.59-0.72) in favor of the patients undergoing surgery. This systematic review of the literature suggests that surgery of the primary breast tumor in patients with stage-IV disease at initial presentation does have a positive impact on survival. In order to provide a definite answer on whether local tumor control in patients with primary metastatic disease improves survival, a randomized controlled trial comparing systemic therapy with and without breast surgery is needed.

Primary tumor resection may improve prognosis for nonoperable advanced breast cancer

Breast cancer has become a powerful killer worldwide that leads to the most global death among women, especially, the nonoperable stage IV breast cancer attracts lots of attentions for its difficulties of treatment. Recently, accumulating evidences hold a promise that resection of the primary tumor can improve the survival of patients with stage IV breast cancer. In order to explain its possible mechanisms, we took a deep insight into the existing rationales and focus on the crosstalks between them. We proposed that breast stem cell niche plays a significant role in the metastatic facilitation. On one hand, cancer stem cells in the niche can express productions making it more adhesive to the metastatic site. On the other hand, the niche has a positive effect on the cellular quiescence accelerating metastasis. Based on the cancer stem cells niche theory, we hypothesized that resection of the primary tumor may be a new avenue to improve the survival and the quality of life for advanced breast cancer patients.

Randomized trial comparing locoregional resection of primary tumor with no surgery in stage IV breast cancer at the presentation (Protocol MF07-01): a study of Turkish Federation of the National Societies for Breast Diseases

The MF07-01 trial is a phase III randomized controlled trial which compares breast cancer patients with distant metastases at presentation who receive locoregional treatment for intact primary tumor with those who do not receive such treatment. The primary objective of the study is to assess whether locoregional treatment of the primary tumor provides a better overall survival. Secondary objectives include progression-free survival, quality-of-life, and morbidity related to locoregional treatment. Locoregional treatments consist of either mastectomy or breast conserving surgery with level I-II axillary clearance in clinically or sentinel lymph node positive patients. Radiation therapy to the whole breast follows breast conserving surgery. Standard systemic therapy is given to all patients either immediately after randomization in no-locoregional treatment arm or after surgical resection of the intact primary tumor in locoregional treatment arm. The study is conducted in Turkey as a multicenter trial with central randomization. Total accrual target is 271. The trial was activated in October 2007 and authorized centers started to recruit patients since then. ClinicalTrials.gov identifier number is NCT00557986.

Surgical resection of the primary tumour is associated with improved survival in patients with distant metastatic breast cancer at diagnosis

OBJECTIVE

Recent studies indicate that removal of the primary tumour may have a beneficial effect on mortality risk of patients with primary distant metastatic breast cancer (stage IV), although most of them did not rule out confounding by the presence of co-morbidity. In this retrospective study the impact of surgical resection of the primary tumour on the survival of patients with primary distant metastatic disease is investigated, taking into account the presence of co-morbidity and other potential confounders.

METHODS

Between 1993 and 2004, 15 769 patients with breast cancer were diagnosed in the south of the Netherlands. This study included the 728 patients with distant metastatic disease at initial presentation, which was 5% of all patients. Of them, 40% had surgery of the primary tumour. Follow-up was carried out until 1 July 2006.

RESULTS

Median survival of the patients who had surgery of their primary tumour was significantly longer than for the patients who did not have surgery (31 vs. 14 months). The 5-year survival rates were 24.5% and 13.1%, respectively (p < 0.0001). In a multivariable Cox regression analysis, adjusting for age, period of diagnosis, T-classification, number of metastatic sites, co-morbidity, use of loco-regional radiotherapy and use of systemic therapy, surgery appeared to be an independent prognostic factor for overall survival (HR = 0.62; 95% CI 0.51-0.76).

CONCLUSION

Removal of the primary tumour in patients with primary distant metastatic disease was associated with a reduction of the mortality risk of around 40%. The association was independent of age, presence of co-morbidity and other potential confounders, but a randomized controlled trial will be needed to rule out residual confounding.

[Ovarian metastasis of breast cancer: a case report. Role of cytoreductive surgery]

The ovaries are a common metastatic site for breast cancer. The diagnosis and treatment of ovarian masses from a metastatic breast cancer are difficult. The complete resection of these metastatic masses seems to give a benefit in terms of global survival. This benefit depends on the residual tumoral volume and on the free interval between initial breast cancer diagnosis and apparition of the metastatic ovarian masses. We discuss the treatment of a patient with ovarian metastasis as first sign of a metastatic breast cancer.

Breast cancer with synchronous metastases: survival impact of exclusive locoregional radiotherapy

PURPOSE

Several studies suggest that surgical excision of the primary tumor improves survival among patients with stage IV breast cancer at diagnosis. Exclusive locoregional radiotherapy (LRR) is an alternative form of locoregional treatment (LRT) in this setting. We retrospectively studied the impact of LRT on the survival of breast cancer patients with synchronous metastases.

PATIENTS AND METHODS

Among 18,753 breast cancer patients treated in our institution between 1980 and 2004, 598 patients (3.2%) had synchronous metastasis at diagnosis. Demographic data, tumor characteristics, metastatic sites, and treatments were prospectively recorded. The impact of LRT on overall survival (OS) was evaluated by multivariate analysis including known prognostic factors.

RESULTS

Among 581 eligible patients, 320 received LRT (group A), and 261 received no LRT (group B). LRT consisted of exclusive LRR in 249 patients (78%), surgery of the primary tumor with adjuvant LRR in 41 patients (13%), and surgery alone in 30 patients (9%). With a median follow-up time of 39 months, the 3-year OS rates were 43.4% and 26.7% in group A and group B (P =.00002), respectively. The association between LRT and improved survival was particularly marked in women with visceral metastases. LRT was an independent prognostic factor in multivariate analysis (hazard ratio [HR] = 0.70; 95% CI, 0.58 to 0.85; P = .0002). The adjusted HR for late death (>or= 1 year) was 0.76 (95% CI, 0.61 to 0.96; P = .02).

CONCLUSION

In our experience, LRT, consisting mainly of exclusive LRR, was associated with improved survival in breast cancer patients with synchronous metastases. Exclusive LRR may thus represent an active alternative to surgery.

Surgical resection of the primary tumor, chest wall control, and survival in women with metastatic breast cancer

BACKGROUND

Among women presenting with de novo stage IV breast cancer, 35% to 60% undergo local therapy, presumably to avoid uncontrolled chest wall disease. Several studies suggest that resection of the primary tumor may prolong survival, but chest wall outcome data are notably lacking. The authors reviewed chest wall status, time to first progression (TTFP), and overall survival (OS) in this group of women.

METHODS

Women presenting at the Lynn Sage Breast Center (1995-2005) with an intact primary tumor and stage IV breast cancer or postoperative diagnosis of distant metastases were identified. Logistic regression and Cox proportional hazards models, adjusted for relevant covariates, were used to examine associations between surgical treatment and chest wall status, TTFP, and OS.

RESULTS

Of 111 eligible women, 47 (42%) underwent early resection of the primary tumor. Chest wall status was available for 103 women. Local control was maintained in 36 of 44 (82%) patients in the surgical group versus 20 of 59 (34%) patients without surgery (P = .001). TTFP was prolonged in the surgical group (adjusted hazards ratio [HR], 0.493; P = .015). The adjusted HR for OS in the surgical group was 0.798 (P = .520). Chest wall control was associated with improved OS regardless of whether surgical resection of the tumor was performed (HR, 0.415; P < .0002).

CONCLUSIONS

These data support the notion that improved local control may play a role in improving outcomes in women with stage IV breast cancer, and resection of in-breast tumors can help to achieve this. A randomized trial is needed to rule out selection bias as an explanation for these findings.