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

The impact of liver resection on survival for patients with metastatic breast cancer - A systematic review and meta-analysis

INTRODUCTION

There is uncertainty surrounding the role of resection as an option for curative treatment of breast cancer with liver metastases (BCLM).

AIM

To perform a systematic review and meta-analysis evaluating the role of liver resection for BCLM.

METHODS

A systematic review was performed as per PRISMA guidelines. Hazard ratio (HR) for overall survival (OS) and standard error was obtained from each study and expressed using the generic inverse variance method, with a corresponding 95% confidence interval (CI). OS outcomes at 1- 3- and 5-years were expressed as dichotomous variables and pooled as odds ratios (OR) using the Mantel-Haenszel method.

RESULTS

Nine studies with 1732 patients were included. Of these, 24.5% underwent surgical resection of BCLM (424/1732) and 75.5% did not (1308/1732). Overall, OS was significantly better among those who underwent surgery versus controls (HR: 0.69, 95% CI: 0.59-0.80, P < 0.00001). Mortality rates were significantly reduced at 1-year (7.5% (10/134) vs 20.3% (79/390), OR: 0.25, 95% CI: 0.08-0.74, P = 0.010) and 5-years (54.0% (190/352) vs 75.3% (940/1249), OR: 0.46, 95% CI: 0.25-0.87, P = 0.020) respectively for those undergoing surgery versus controls. Mortality rates at 3 years after surgery were lower than the control group (19.1% (29/152) vs 53.0% (222/419)), however this failed to achieve statistical significance at meta-analysis (OR: 0.32, 95% CI: 0.09-1.12, P = 0.070).

CONCLUSION

Liver resection may be considered at multidisciplinary meetings for those with BCLM and offers a potentially curative option. However, judicious patient selection is crucial prior to making decisions in relation to resection of BCLM.

Breast cancer liver metastases: systematic review and time to event meta-analysis with comparison between available treatments

INTRODUCTION

The current gold standard treatment for breast cancer liver metastases (BCLM) is systemic chemotherapy and/or hormonal therapy. Nonetheless, greater consideration has been given to local therapeutic strategies in recent years. We sought to compare survival outcomes for available systemic and local treatments for BCLM, specifically surgical resection and radiofrequency ablation.

METHODS

A review of the PubMed (MEDLINE), Embase and Cochrane Library databases was conducted. Data from included studies were extracted and subjected to time-to-event data synthesis, algorithmically reconstructing individual patient-level data from published Kaplan-Meier survival curves.

FINDINGS

A total of 54 studies were included, comprising data for 5,430 patients (surgery, n=2,063; ablation, n=305; chemotherapy, n=3,062). Analysis of the reconstructed data demonstrated survival rates at 1, 3 and 5 years of 90%, 65.9% and 53%, respectively, for the surgical group, 83%, 49% and 35% for the ablation group and 53%, 24% and 14% for the chemotherapy group (p<0.0001).

CONCLUSION

Local therapeutic interventions such as liver resection and radiofrequency ablation are effective treatments for BCLM, particularly in patients with metastatic disease localised to the liver. Although the data from this review support surgical resection for BCLM, further prospective studies for managing oligometastatic breast cancer disease are required.

Survival advantage of locoregional and systemic therapy in oligometastatic breast cancer: an international retrospective cohort study (OLIGO-BC1)

BACKGROUND

An international retrospective cohort study was conducted to clarify the survival advantage of combination therapy with locoregional and systemic therapy (ST) in oligometastatic breast cancer (BC).

METHODS

Patients with oligometastatic BC diagnosed from 2007 to 2012 were enrolled in center hospitals in China, Korea and Japan. It was defined as a low-volume metastatic disease at up to five sites and not necessarily in the same organ. Cases with brain, pleural, peritoneal and pericardial metastases were excluded. The primary endpoint was overall survival (OS) from the initial diagnosis of oligometastases. OS was summarized using the Kaplan-Meier method. A multivariable Cox regression model was used to estimate the hazard ratio (HR) for clinicopathological factors.

RESULTS

Among 1,295 cases registered from February 2018 to May 2019, 932 remained for analysis after the exclusion of unavailable cases and locoregional recurrence. One metastatic site was found in 400 cases, 2 in 243, 3 in 130, 4 in 86 and 5 in 73. At the median follow-up of 4.5 years, 5-year OS was 54.7% and 39.7% for 321 cases in the combination therapy group and 611 cases in the ST group, respectively. An adjusted HR was 0.66 (95% confidence interval: 0.55, 0.79). Some types of ST without chemotherapy alone, younger age, ECOG performance status 0, early-stage BC, non-triple negative subtype, fewer metastatic sites and longer duration of surgery to relapse were significantly favorable prognostic factors.

CONCLUSION

Combination therapy may be considered for longer survival under some conditions in oligometastatic BC.

Prognostic Factors in Patients with Breast Cancer Liver Metastases Undergoing Liver Resection: Systematic Review and Meta-Analysis

Simple Summary

Robust predictive and prognostic tools are needed in the management of breast cancer liver metastases (BCLMs). Until now, surgery has not been the gold standard of treatment of patients with BCLMs. The present manuscript highlights several predictive factors related to the primary tumor and the BCLM that may help to identify candidates for surgery with favorable outcomes in a large cohort of patients.

Abstract

Background: The role of surgical resection of liver metastases in patients with breast cancer liver metastasis (BCLM) remains controversial. A systematic review and meta-analysis of prognostic factors related to survival after BCLM resection was performed. Methods: An electronic search of relevant publications was performed. Pooled outcome measures were expressed as hazard ratios (HRs), including 95% confidence interval values (95% CIs), and calculated through a random-effects model. Heterogeneity was tested through the I² index. Results: Thirty-five publications reported analyses on prognostic factors and survival. A total of 2782 patients who underwent liver resection for BCLM were included. Positive axillary lymph nodes at breast cancer diagnosis were an unfavorable survival factor (HR 1.74, 95% CI 1.25 to 2.41, I² = 0%). Cumulative predictive factor HRs (multiple liver metastases, size of the metastases, short interval between primary tumor and onset of liver disease) related to the BCLM pattern were 1.32 (95% CI 1.17 to 1.48, I² = 71%) and 1.51 (95% CI 1.15 to 1.98, I² = 76%) for surgical and pathological features (resection margin and presence of extrahepatic disease), respectively. Conclusion: Resection of BCLM may provide a survival benefit for selected patients. For better long-term results, surgical selection should consider both primary tumor and BCLM features such as negative axillary lymph nodes at breast resection, a single hepatic lesion, a time longer than 24 months between breast and hepatic diagnosis, and a realizable R0 liver resection. However, the high heterogeneity among studies suggests the need for an RCT to validate the present findings.

Oligometastatic Breast Cancer: How to Manage It?

Breast cancer (BC) is the most frequent cancer among women and represents the second leading cause of cancer-specific death. A subset of patients with metastatic breast cancer (MBC) presents limited disease, termed 'oligometastatic' breast cancer (OMBC). The oligometastatic disease can be managed with different treatment strategies to achieve long-term remission and eventually cure. Several approaches are possible to cure the oligometastatic disease: locoregional treatments of the primary tumor and of all the metastatic sites, such as surgery and radiotherapy; systemic treatment, including target-therapy or immunotherapy, according to the biological status of the primary tumor and/or of the metastases; or the combination of these approaches. Encouraging results involve local ablative options, but these trials are limited by being retrospective and affected by selection bias. Systemic therapy, e.g., the use of CDK4/6 inhibitors for hormone receptor-positive (HR+)/HER-2 negative BC, leads to an increase of progression-free survival (PFS) and overall survival (OS) in all the subgroups, with favorable toxicity. Regardless of the lack of substantial data, this subset of patients could be treated with curative intent; the appropriate candidates could be mostly young women, for whom a multidisciplinary aggressive approach appears suitable. We provide a global perspective on the current treatment paradigms of OMBC.

Hepatectomy, RFA, and Other Liver Directed Therapies for Treatment of Breast Cancer Liver Metastasis: A Systematic Review

Background

The liver is the second most common site of breast cancer metastasis. Liver directed therapies including hepatic resection, radiofrequency ablation (RFA), transarterial chemo- and radioembolization (TACE/TARE), and hepatic arterial infusion (HAI) have been scarcely researched for breast cancer liver metastasis (BCLM). The purpose of this review is to present the known body of literature on these therapies for BCLM.

Methods

A systematic review was performed with pre-specified search terms using PubMed, MEDLINE, EMBASE, and Cochrane Review resulting in 9,957 results. After review of abstracts and application of exclusion criteria, 51 studies were included in this review.

Results

Hepatic resection afforded the longest median overall survival (mOS) and 5-year survival (45 mo, 41%) across 23 studies. RFA was presented in six studies with pooled mOS and 5-year survival of 38 mo and 11–33%. Disease burden and tumor size was lower amongst hepatic resection and RFA patients. TACE was presented in eight studies with pooled mOS and 1-year survival of 19.6 mo and 32–88.8%. TARE was presented in 10 studies with pooled mOS and 1-year survival of 11.5 mo and 34.5–86%. TACE and TARE populations were selected for chemo-resistant, unresectable disease. Hepatic arterial infusion was presented in five studies with pooled mOS of 11.3 months.

Conclusion

Although further studies are necessary to delineate appropriate usage of liver directed therapies in BCLM, small studies suggest hepatic resection and RFA, in well selected patients, can result in prolonged survival. Longitudinal studies with larger cohorts are warranted to further investigate the effectiveness of each modality.

Liver Metastasectomy for Metastatic Breast Cancer Patients: A Single Institution Retrospective Analysis

The liver represents the first metastatic site in 5–12% of metastatic breast cancer (MBC) cases. In absence of reliable evidence, liver metastasectomy (LM) could represent a possible therapeutic option for selected MBC patients (patients) in clinical practice. A retrospective analysis including MBC patients who had undergone an LM after a multidisciplinary Tumor Board discussion at the Hepatobiliary Surgery Unit of Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS in Rome, between January 1994 and December 2019 was conducted. The primary endpoint was overall survival (OS) after a MBC-LM; the secondary endpoint was the disease-free interval (DFI) after surgery. Forty-nine MBC patients underwent LM, but clinical data were only available for 22 patients. After a median follow-up of 71 months, median OS and DFI were 67 months (95% CI 45–103) and 15 months (95% CI 11–46), respectively. At univariate analysis, the presence of a negative resection margin (R0) was the only factor that statistically significantly influenced OS (78 months versus 16 months; HR 0.083, p < 0.0001) and DFI (16 months versus 5 months; HR 0.17, p = 0.0058). A LM for MBC might represent a therapeutic option for selected patients. The radical nature of the surgical procedure performed in a high-flow center and after a multidisciplinary discussion appears essential for this therapeutic option.

Evolving Role of Liver Resection in Selected Patients With Metastatic Breast Cancer

BACKGROUND

More effective chemotherapy regimens combined with metastasectomy have improved overall survival (OS) in several cancer populations. The value of liver resection (LR) in breast cancer liver metastasis (BCLM) remains controversial. We sought to investigate the role of LR in BCLM as a therapeutic option in patients with isolated liver metastasis.

METHODS

The National Cancer Data Base (NCDB) was queried for patients with BCLM diagnosed from 2010 to 2014. The primary outcome was the OS. Kaplan-Meier and Cox proportional hazards regression were performed for intergroup comparison.

RESULTS

A total of 9244 patients with BCLM were included. The median age was 58 y (IQR 49-68 y). Of them, 2632 (28.5%) patients had isolated liver metastasis, 1957 (78.2%) received chemotherapy, 93 (3.6%) underwent LR, and only 83 (3.2%) received chemotherapy and LR. Median OS for the entire cohort and for patients with isolated BCLM was 18.3 mo and 29 mo, respectively. Chemotherapy with LR was associated with superior OS compared to chemotherapy alone (69.7 versus 49.2 mo, P < 0.001) in patients with BCLM: ER+ (69.6 versus 54.1 mo, P = 0.002) and triple-negative BC (49.2 versus 17.6 mo, P = 0.006). Cox regression showed that LR, chemotherapy, and positive hormone receptor status (ER+, PR+, and/or HER2+) were independent predictors of improved OS. Advanced age and comorbidity score negatively impacted OS.

CONCLUSIONS

This is the largest series thus far assessing the role of LR in patients with BCLM. LR plus chemotherapy may be associated with acceptable outcomes in selected patients with BCLM. LR should be considered in patients with isolated BCLM who had a good response to systemic therapy.

Surgical therapy for breast cancer liver metastases

Breast cancer is the most commonly diagnosed cancer in females worldwide. If diagnosed early, patients generally have good outcomes. However, approximately 20% to 30% of all women diagnosed with breast cancer develop metastatic disease. Metastatic breast cancer is incurable, but there is growing evidence that resection or other local therapy for breast cancer liver metastases (BCLM) may improve survival. We aimed to review indications for and outcomes of perioperative liver resection and other local therapies for BCLM. In this series, we reviewed 11 articles (605 patients) focusing on surgical resection and 7 articles (266 patients) describing radiofrequency ablation (RFA) for BCLM. Median disease-free survival (DFS) after surgical resection was 23 months (range, 14–29 months) and median overall survival (OS) was 39.5 months (range, 26–82 months). One, 3- and 5-year survivals were 89.5%, 70%, and 38%, respectively. The factors favoring better outcomes are hormone receptor positive primary breast cancer status, R0 resection, no extrahepatic metastases (EHM), small BCLM, and solitary liver metastases. On the other hand, the median DFS with RFA was 11 months, median OS was 32 months, and the 3- and 5-year OS were 43% and 27%, respectively. The clinical features that are indications for RFA are smaller tumor and higher EHM rate than those favoring surgical resection (2.4 vs. 4.0 cm and 46% vs. 27%). The merits of RFA are its high technical success rate, low morbidity, short hospital stay, and that it can be repeated. Although results are as yet limited, in carefully selected patients, resection or other local therapies such as RFA, render BCLM potentially provide prognostic improvement.

Comparison of hepatic resection and systemic treatment of breast cancer liver metastases: A propensity score matching study

BACKGROUND

The role of surgery in breast cancer liver metastases (BCLM) remains elusive, and current application is limited. Our aim is to investigate whether hepatic resection (HR) of BCLM improves survival compared with non-hepatic resection (NHR) treatment.

METHODS

Three hundred and eighty-four patients with BCLM from 2008 to 2018 were divided into two groups. Propensity score matching (PSM) analysis was used to compare the clinical outcomes.

RESULTS

After PSM the mean overall survival (OS) and the 1, 3, and 5-year OS rates in HR group were 61.8 months, 92.6%, 54.7% and 54.7%, respectively; while for NHR group these values were 38.6 months, 79.2%, 45.6% and 21.9%, respectively (p < 0.007). Multivariate analysis indicated hormonal receptor status (p = 0.039) and hepatic resection (p = 0.032) were independent prognostic factors.

CONCLUSION

Our study revealed that hepatectomy yields a survival benefit safely compared with medical treatments, especially for patients with positive hormonal receptors.

Survival analysis of breast cancer liver metastasis treated by hepatectomy: A propensity score analysis for Chinese women in Hong Kong

BACKGROUND

Survival of patients with breast cancer liver metastasis is very poor. This study aimed to analyze the survival outcome of hepatectomy for this patient population.

METHODS

From January 1995 to December 2014, 2522 patients with liver cancer received hepatectomy at our hospital. Twenty-one of them, all female, received the operation for breast cancer liver metastasis. Performance was compared with patients with colorectal liver metastasis treated with hepatectomy after propensity score analysis in a ratio of 1:3.

RESULTS

Twenty-one patients received hepatectomy for breast cancer. After propensity score matching, 63 patients who had hepatectomy for colorectal cancer were selected for comparison. There was no significant difference in immediate or short-term outcomes between the two groups of patients in terms of operative time, blood loss and surgical morbidities. All patients with breast cancer had R0 resection. No hospital death occurred. After hepatectomy, the 1-, 3- and 5-year overall survival rates were 100.0%, 58.9% and 58.9% respectively in patients with breast cancer. The 1-, 3- and 5-year overall survival rates were 95.0%, 57.2% and 39.7% respectively in patients with colorectal cancer (P = 0.572). On multivariate analysis, triple negative status was the only independent poor prognostic factor in breast cancer liver metastasis (OR = 6.411; 95% CI: 1.351-30.435; P = 0.019).

CONCLUSIONS

Hepatectomy is a safe and effective way of treating breast cancer liver metastasis at experienced centers where multidisciplinary adjuvant treatments are available. It can be considered more frequently as part of the multidisciplinary care for this patient population.

Local Treatment of Breast Cancer Liver Metastasis

Breast cancer represents a leading cause of death worldwide. Despite the advances in systemic therapies, the prognosis for patients with breast cancer liver metastasis (BCLM) remains poor. Especially in case of failure or cessation of systemic treatments, surgical resection for BCLMs has been considered as the treatment standard despite a lack of robust evidence of benefit. However, due to the extent and location of disease and physical condition, the number of patients with BCLM who are eligible for surgery is limited. Palliative locoregional treatments of liver metastases (LM) include transarterial embolization (TAE), transarterial chemoembolization (TACE), and selective internal radiotherapy (SIRT). Percutaneous thermal ablation methods, such as radiofrequency ablation (RFA) and microwave ablation (MWA), are considered potentially curative local treatment options. They are less invasive, less expensive and have fewer contraindications and complication rates than surgery. Because conventional ultrasound- and computed tomography-guided single-probe thermal ablation is limited by tumor size, multi-probe stereotactic radiofrequency ablation (SRFA) with intraoperative image fusion for immediate, reliable judgment has been developed in order to treat large and multiple tumors within one session. This review focuses on the different minimally invasive local and locoregional treatment options for BCLM and attempts to describe their current and future role in the multidisciplinary treatment setting.

A Population-Based Study on Liver Metastases in Women with Newly Diagnosed Breast Cancer

BACKGROUND

Population-based estimates for prognosis among patients with liver metastases in newly diagnosed breast cancer are not generally available.

METHODS

Within the Surveillance, Epidemiology and End Results (SEER) database, we identified 298,370 patients with breast cancer and 4,285 patients diagnosed with initial liver metastases between 2010 and 2014. Data were stratified according to subtype, age, and race. Multivariate logistic and Cox regression were used to identify predictors for the presence of initial liver metastases and prognostic factors, respectively. Kaplan-Meier procedure was used for survival analysis.

RESULTS

A total of 4,285 patients with initial liver metastases (1.4% of the entire cohort, 29.6% of the subset with metastatic disease) were identified. Patients with hormone receptor (HR)-negative human epidermal growth factor receptor 2 (HER2)-positive (4.4% of entire cohort, 52.5% of patients with metastatic disease to any distant site) and HR-positive HER2-positive (2.8% of entire cohort, 40.4% of patients with metastatic disease to any distant site) subtypes had highest incidence proportions. The median survival of patients with liver metastases in the entire cohort was 15.0 months. Patients with HR-positive HER2-positive subtype showed the longest median survival (31.0 months); however, patients with triple-negative subtype showed the shortest median survival (8.0 months).

CONCLUSIONS

Our findings provide population-based estimates of epidemiologic characteristics and prognosis in breast cancer patients diagnosed with initial liver metastases.

IMPACT

This study lends support to the diagnosis of the liver among patients at high risk of liver metastases, including those with HER2-positive and other systemic metastases.

Outcomes of 1,639 hepatectomies for non-colorectal non-neuroendocrine liver metastases: a multicenter analysis

BACKGROUND

Whether non-colorectal non-neuroendocrine liver metastasis (NCNNLM) should be treated surgically remains unclear.

METHODS

Data regarding 1,639 hepatectomies performed between 2001 and 2010 for 1,539 patients with NCNNLM were collected from 124 institutions. Patient characteristics, types of primary tumor, characteristics of liver metastases, and post-hepatectomy outcomes were analyzed.

RESULTS

The five most frequent primary tumors were gastric carcinoma (540 patients [35%]), gastrointestinal stromal tumor (204 patients [13%]), biliary carcinoma (150 patients [10%]), ovarian cancer (107 patients [7%]), and pancreatic carcinoma (77 patients [5%]). R0/1 hepatectomy was achieved in 90% of patients, with 1.5% in-hospital mortality rate. Overall and disease-free survival rates of 1,465 patients included in survival analysis were 41% and 21%, respectively, at 5 years, and 28% and 15%, respectively, at 10 years. Five-year survival associated with the five frequent primary tumors were 32%, 72%, 17%, 52%, and 31%, respectively, and factors predictive of a poor outcome differed by the primary tumor type.

CONCLUSIONS

Our data indicated that hepatectomy is safe for NCNNLM and that patient prognoses vary depending on the type of primary tumors. Indications for hepatectomy should be determined with reference to survival rates and risk factors specific to each of the various types of primary tumor.

Cure in metastatic breast cancer

Oligometastatic disease characterizes a distinct subgroup of metastatic breast cancer patients that might benefit from different treatment strategies to achieve long-lasting remission and potentially cure. Those long-lasting remissions are reported after locoregional treatment of the primary tumor and all metastatic sites in several case series; however, unlike other tumor entities, prospective data are lacking. Furthermore, tumor eradication by excellent systemic anticancer therapy with novel chemotherapies and targeted agents can lead to long-term survival. In addition, reactivation of the host immune defense by immuno-oncologic drugs can achieve long-lasting tumor control. So far, unfortunately, checkpoint inhibitors as monotherapy have led to responses only in a small percentage of patients with metastatic breast cancer. This short review summarizes available data on long-lasting remissions and potential cure in metastatic breast cancers. It describes and discusses data on locoregional treatment, chemo-, antibody- and immunotherapy and tries to select individual patients for whom a multidisciplinary treatment approach with curative intention might be an option to achieve long-term survival.

Survival outcomes following aggressive treatment of oligometastatic breast cancer: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this systematic review is to assess the effectiveness of aggressive treatment of oligometastatic breast cancer (OMBC) on survival outcomes by conducting a meta-analysis of current available evidence.More specifically, the objectives are to identify the effectiveness of intensified multidisciplinary treatment with aggressive locoregional therapies on survival time, five-year survival rates and disease free survival. The population is adult women (18 years and over) with OMBC defined as single or few (five or less) metastases limited to a single organ and the comparative group is conventional palliative treatment aimed at disease control. Secondary objectives to be assessed will be adverse outcomes associated with intensified treatment regimes.

The role of liver resection in patients with metastatic breast cancer: a systematic review examining the survival impact

INTRODUCTION

Approximately 10% of breast cancer patients will present with solid organ metastases, while up to 30% will develop metastatic disease during their treatment course. Liver metastases are usually treated with systemic chemotherapy. Although colorectal liver metastases are routinely resected, this is not yet the standard of care for breast cancer-related liver metastases. This review examines the evidence for resection of breast cancer-related liver metastases.

METHODS

A systematic review identified 25 articles for inclusion, 12 papers concerning patients with isolated liver metastases, and 13 papers concerning patients with extrahepatic metastases. Data from 1080 patients were included.

RESULTS

Two hundred eighty patients underwent hepatic resections for breast cancer-associated metastases with no extrahepatic metastases. Reported 5-year survival ranged from 24.6 to 78%. Median overall survival ranged from 29.5 to 116 months. For patients with oligometastatic disease undergoing resection, 5-year survival ranged from 21 to 57%, with median overall survival ranging from 32 to 58 months. Reported 30-day morbidity ranged from 14 to 42% for isolated and multiple metastases.

CONCLUSION

Hepatic resection can be considered in the management of breast cancer patients with isolated liver metastases as well as those with oligometastatic disease.

Ten-Year Survival after Liver Resection for Breast Metastases: A Single-Center Experience

BACKGROUND

The role of liver resection for metastatic breast carcinoma is still debated.

METHODS

Fifty-one resected patients were reviewed. All patients received adjuvant chemotherapy after resection of the primary tumor. Clinicopathological characteristics and immunohistochemistry expression of estrogen (ER), progesterone (PR), human epidermal growth factor (HER2), or Ki67 were evaluated.

RESULTS

The median number of metastases was 2; single metastases were present in 24 (47%) patients. The median tumor diameter was 4 cm. Major hepatectomies were performed in 31 (61%) patients. Postoperative mortality was null. Postoperative morbidity was 13.7%. The 1-, 5-, and 10-year survival rates were 92, 36, and 16% respectively. Eleven (21.6%) patients survived longer than 5 years and 8.9% are alive without recurrence 10 years after surgery. At the univariate analysis, tumor diameter, lymph node status, PR receptor status, and triple positive receptors (ER+/PR+/Her2+) were significantly related to survival. At the multivariate analysis, tumor diameter, PR receptor, and triple negative status were significantly related to the long-term outcome.

CONCLUSION

Liver resection seems to be a safe and effective treatment for metastases from breast cancer, and encouraging long-term survival can be obtained with acceptable risk in selected patients. Tumors less than 5 cm and positive hormone receptor status are the best prognostic factors.

The safety and effectiveness of liver resection for breast cancer liver metastases: A systematic review

Breast cancer liver metastases have traditionally been considered incurable and any treatment given therefore palliative. Liver resections for breast cancer metastases are being performed, despite there being no robust evidence for which patients benefit. This review aims to determine the safety and effectiveness of liver resection for breast cancer metastases. A systematic literature review was performed and resulted in 33 papers being assembled for analysis. All papers were case series and data extracted was heterogeneous so a meta-analysis was not possible. Safety outcomes were mortality and morbidity (in hospital and 30-day). Effectiveness outcomes were local recurrence, re-hepatectomy, survival (months), 1-, 2-, 3-, 5- year overall survival rate (%), disease free survival (months) and 1-, 2-, 3-, 5- year disease free survival rate (%). Overall median figures were calculated using unweighted median data given in each paper. Results demonstrated that mortality was low across all studies with a median of 0% and a maximum of 5.9%. The median morbidity rate was 15%. Overall survival was a median of 35.1 months and a median 1-, 2-, 3- and 5-year survival of 84.55%, 71.4%, 52.85% and 33% respectively. Median disease free survival was 21.5 months with a 3- and 5-year median disease free survival of 36% and 18%. Whilst the results demonstrate seemingly satisfactory levels of overall survival and disease free survival, the data are of poor quality with multiple confounding variables and small study populations. Recommendations are for extensive pilot and feasibility work with the ultimate aim of conducting a large pragmatic randomised control trial to accurately determine which patients benefit from liver resection for breast cancer liver metastases.

Liver Resection for Non-Colorectal Liver Metastases - Standards and Extended Indications

Background

Due to the uncertain benefit of liver resection for non-colorectal liver metastases (NCLM), patient selection for surgery is generally difficult. Therefore, the aim of this article was to propose standard and extended indications for liver resection in this heterogeneous disease collective.

Methods

Review of the literature.

Results

The myriad of biologically different primary tumor entities as well as the mostly small and retrospective studies investigating the benefit of surgery for NCLM limits the proposal of general recommendations. Only resection of neuroendocrine liver metastases (NELM) appears to offer a clear benefit with a 5- and 10-year overall survival (OS) of 74 and 51%, respectively, in the largest series. Resection of liver metastases from genitourinary primaries might offer reasonable benefit in selected cases – with a 5-year OS of up to 61% for breast cancer and of 38% for renal cell cancer. The long-term outcome following surgery for other entities was remarkably poorer, e.g., gastric cancer, pancreatic cancer, and melanoma reached a 5-year OS of 20-42, 17-25, and about 20%, respectively.

Conclusion

Liver resection for NELM can be defined as a standard indication for the resection of NCLM while lesions of genitourinary origin might be defined as an extended indication.

Surgery for liver metastases from breast cancer

INTRODUCTION

Liver metastases from breast cancer (BCLM) confer poor survival. Liver resection in BCLM patients has been increasingly employed.

AIM

We undertook a systematic review to evaluate the role of hepatic resection in patients with breast cancer metastatic to the liver.

MATERIALS & METHODS

In total, 36 studies were overviewed. Patient populations, characteristics, morbidity, mortality and survival were documented.

RESULTS

Median overall survival was 41 months. Major morbidity was rare while 30-day postoperative mortality was near nil.

CONCLUSION

Liver surgery for BCLM can be performed with low mortality, acceptable morbidity and promising survival benefit in carefully selected patients.

Pathologic Features of Primary and Metastatic Hepatic Malignancies

In the mammalian liver, 60 % of the cellular components are hepatocytes while the remainder (35 %) includes biliary epithelium, Kupffer cells, endothelial cells, fat storing cells and connective tissue cells. Although neoplasms of hepatocytes are the most common, a significant number of both benign and malignant primary liver neoplasms arising from other cell types can develop, such as tumors of bile duct epithelium (Table 1). In addition, the liver is one of the most susceptible sites for metastatic tumors arising from other organs of the body. Not too long ago, liver tumors were left untreated because the liver was considered a complex and mysterious organ inaccessible to surgery. Advances in imaging procedures and surgical techniques over the past 40 years have revolutionized the approaches to the treatment of benign and malignant liver tumors. Subsegmentectomy, segmentectomy, lobectomy, and transplantation are routinely performed for the treatment of primary and metastatic liver tumors with minimal morbidity and mortality. Since accurate diagnosis remains the key to clinical and surgical management, the emphasis of this chapter is on classification, morphological features and differential diagnosis of malignant neoplasms of the liver.

Prognostic factors in breast cancer with extracranial oligometastases and the appropriate role of radiation therapy

Purpose

To identify prognostic factors for disease progression and survival of patients with extracranial oligometastatic breast cancer (EOMBC), and to investigate the role of radiation therapy (RT) for metastatic lesions.

Materials and Methods

We retrospectively reviewed the medical records of 50 patients who had been diagnosed with EOMBC following standard treatment for primary breast cancer initially, and received RT for metastatic lesions, with or without other systemic therapy between January 2004 and December 2008. EOMBC was defined as breast cancer with five or less metastases involving any organs except the brain. All patients had bone metastasis (BM) and seven patients had pulmonary, hepatic, or lymph node metastasis. Median RT dose applied to metastatic lesions was 30 Gy (range, 20 to 60 Gy).

Results

The 5-year tumor local control (LC) and 3-year distant progression-free survival (DPFS) rate were 66.1% and 36.8%, respectively. High RT dose (≥50 Gy₁₀) was significantly associated with improved LC. The 5-year overall survival (OS) rate was 49%. Positive hormone receptor status, pathologic nodal stage of primary cancer, solitary BM, and whole-lesion RT (WLRT), defined as RT whose field encompassed entire extent of disease, were associated with better survival. On analysis for subgroup of solitary BM, high RT dose was significantly associated with improved LC and DPFS, shorter metastasis-to-RT interval (≤1 month) with improved DPFS, and WLRT with improved DPFS and OS, respectively.

Conclusion

High-dose RT in solitary BM status and WLRT have the potential to improve the progression-free survival and OS of patients with EOMBC.

Liver metastases from non-gastrointestinal non-neuroendocrine tumours: review of the literature

Liver resection is integrated in the oncological surgical management of metastatic gastrointestinal and neuroendocrine tumours. However, the good prognosis reached in these cases has not been obtained for metastatic tumours of other histological types. In this review, we analysed the published case reports and series of hepatectomies in patients with metastatic breast cancer, melanoma, sarcoma, genitourinary tumours, pulmonary and adrenocortical tumours. From the reported data the surgical resection of oligometastases yields good results in terms of improved survival, in particular when the disease-free time period is longer than 1 year. Hepatic resection can be a valid surgical strategy to obtain a survival benefit in patients with liver metastases from non-gastrointestinal, non-neuroendocrine tumours. However, a careful patient selection is needed in order to obtain a real survival benefit; patients with a good performance status, with a disease-free period longer than 1 year and with oligometastases may obtain the best advantage from this approach.

Locally ablative treatment of breast cancer liver metastases: identification of factors influencing survival (the Mammary Cancer Microtherapy and Interventional Approaches (MAMMA MIA) study)

BACKGROUND

Liver metastases from breast cancer (LMBC) are typically considered to indicate systemic disease spread and patients are most often offered systemic palliative treatment only. However, retrospective studies suggest that some patients may have improved survival with local treatment of their liver metastases compared to systemic therapy alone. In the absence of randomized trials, it is important to identify patient characteristics indicating that benefit from local treatment can be expected.

METHODS

59 patients undergoing radiofrequency ablation (RFA), interstitial brachytherapy (BT), or radioembolization (RE) of LMBC as a salvage treatment were studied. Potential factors influencing survival were analyzed in a multivariate Cox model. For factors identified to have an independent survival impact, Kaplan-Meier analysis and comparison of overall survival (OS) using the log-rank test was performed.

RESULTS

Median OS following local interventional treatment was 21.9 months. Considering only factors evaluable at treatment initiation, maximum diameter of liver metastases (≥3.9 cm; HR: 3.1), liver volume (≥ 1376 mL; HR: 2.3), and history of prior chemotherapy (≥ 3 lines of treatment; HR: 2.5-2.6) showed an independent survival impact. When follow-up data were included in the analysis, significant factors were maximum diameter of liver metastases (≥ 3.9 cm; HR: 3.1), control of LMBC during follow-up (HR: 0.29), and objective response as best overall response (HR: 0.21). Neither the presence of any extrahepatic metastases nor presence of bone metastases only had a significant survival impact. Median OS was 38.7 vs. 16.1 months in patients with metastases < vs. ≥ 3.9 cm, 36.6 vs. 10.2 months for patients having objective response vs. stable/progressive disease, and 38.5 vs. 14.2 months for patients having controlled vs. non-controlled disease at follow-up.

CONCLUSION

Local control of LMBC confers a survival benefit and local interventional treatment for LMBC should be studied in a randomized trial. Patients with small metastases and limited history of systemic LMBC treatment are most likely to benefit from local approaches. Limited extrahepatic disease should not lead to exclusion from a randomized study and should not be a contraindication for local LMBC treatment as long as no randomized data are available.

A role for hepatic surgery in patients with liver metastatic breast cancer: review of literature

Traditionally, patients with metastatic breast cancer were seen as carrying a grim prognosis and therapy was based mainly on palliative chemotherapy and hormonal therapy, with surgery being considered as ineffective. However, in the last 20 years different centers worldwide published series of metastatic breast cancer patients who underwent resection for different metastatic sites (liver, brain, lung), reporting favorable results. Most of these papers addressed to the role of liver surgery in patients with breast cancer liver metastases, mainly due to the favorable results achieved by liver resection in patients with metastatic colorectal cancer. In this review are presented the results achieved by liver surgery in patients with breast cancer liver metastases.

Resection of single metachronous liver metastases from breast cancer stage I-II yield excellent overall and disease-free survival. Single center experience and review of the literature

PURPOSE

Improved survival after liver resection for breast cancer liver metastases (BCLM) has been proven; however, there is still controversy on predictive factors influencing outcomes. The analysis of factors related to primary and metastatic cancer eventually influencing long-term outcomes and a review of the literature are presented in this report.

METHODS

Twenty-seven patients diagnosed with metachronous BCLM between 1996 and 2013 were retrospectively reviewed. Patients who had a minimum disease-free interval between primary tumor and liver metastasis of 12 months, no more than 3 liver lesions, no macroscopic extra-hepatic disease and in which systemic therapy showed a good response were included.

RESULTS

Twenty-two patients (82%) were initially diagnosed with a stage I-II disease. Twelve patients presented with multiple liver metastases. The 5 years overall survival (OS) rate was 78%, while the 5 years disease-free survival (DFS) rate was 36%. Initial tumor stage III-IV at first diagnosis and number of metastases >1 was significantly associated with a shorter DFS at multivariate analysis (p = 0.03 and p = 0.04 respectively). Patients with multiple lesions had a median DFS of 15 months compared to 47 months in patients with a single lesion (p = 0.03).

CONCLUSIONS

Resection of single BCLM from primary stage I-II cancer offers very good long-term survival rates and a low morbidity.

The benefits of liver resection for non-colorectal, non-neuroendocrine liver metastases: a systematic review

PURPOSE

Defining the benefits of resection of isolated non-colorectal, non-neuroendocrine (NCRNNE) liver metastases is difficult. To better understand the survival benefit in this group of patients, we conducted a systematic review of the previous literature.

METHODS

Medline, Web of Knowledge, and manual searches were performed using search terms, such as "liver resection" and "primary tumor." Inclusion criteria were year>1990, >five patients, and median survival reported or derived. An expected median survival was calculated from weighted averages of median survivals, and differences were assessed using a permutation test.

RESULTS

A total of 7,857 references were identified. Overall 4,735 abstracts were reviewed; 120 manuscripts evaluated and of these, 73 met the study inclusion criteria. The final population consisted of 3,596 patients with renal (n=234), ovarian (n=119), testicular (n=153), adrenal (n=90), small bowel (n=28), gallbladder (n=21), duodenum (n=38), gastric (n=481), pancreatic (n=55), esophageal (n=23), head and neck (n=15), and lung (n=36) cancers, gastrointestinal stromal tumors (GISTs) (n=106), cholangiocarcinoma (n=13), sarcoma (n=189), and melanoma (n=643). The greatest expected median was 63 months for genitourinary (GU) primaries (n=549; range 5.4-142 months) followed by 44.4 months for breast cancer (n=1,013; range 8-74 months), 22.3 months for gastrointestinal cancer (n=549; range 5-58 months), and 23.7 months for other tumor types (n=1,082; range 10-72 months). Using a permutation test, we observed that survival was best for patients with GU primaries followed by that for breast cancer patients. Additionally, we also observed that survival was similar for those with cancer of the GI tract and other primary sites.

CONCLUSIONS

There appears to be a benefit to resection for patients with NCRNNE liver metastases. The degree of survival advantage is predicated by primary site.

Intraoperative detection of liver tumors aided by a fluorescence goggle system and multimodal imaging

Real-time image guidance in the operating room is needed to improve instantaneous surgical decisions. Toward this goal, we utilized a new fluorescence goggle system and a near-infrared fluorescent dye approved for human use, indocyanine green, to demonstrate the feasibility of detecting liver tumors intraoperatively. The fluorescence goggle provided successful imaging of multifocal breast cancer metastases in mouse liver. Diffused tumor deposits as small as 0.8 mm in diameter were detected, which were not obvious without the fluorescence goggle. A combination of surface-weighted fluorescence imaging and deep tissue-sensitive ultrasound imaging allowed comprehensive image guidance with the fluorescence goggle system for tumor resection in a rabbit VX2 liver metastasis model. This multimodal detection and guided surgical intervention strategy using ultrasonic imaging and real-time intraoperative fluorescence guidance is a promising and innovative technology platform for improving surgical outcome of human patients with primary or metastatic liver cancer.

Liver resections of isolated liver metastasis in breast cancer: results and possible prognostic factors

Background. Breast cancer liver metastasis is a hematogenous spread of the primary tumour. It can, however, be the expression of an isolated recurrence. Surgical resection is often possible but controversial. Methods. We report on 29 female patients treated operatively due to isolated breast cancer liver metastasis over a period of six years. Prior to surgery all metastases appeared resectable. Liver metastasis had been diagnosed 55 (median, range 1–177) months after primary surgery. Results. Complete resection of the metastases was performed in 21 cases. The intraoperative staging did not confirm the preoperative radiological findings in 14 cases, which did not generally lead to inoperability. One-year survival rate was 86% in resected patients and 37.5% in nonresected patients. Significant prognostic factors were R0 resection, low T- and N-stages as well as a low-grade histopathology of the primary tumour, lower number of liver metastases, and a longer time interval between primary surgery and the occurrence of liver metastasis. Conclusions. Complete resection of metastases was possible in three-quarters of the patients. Some of the studied factors showed a prognostic value and therefore might influence indication for resection in the future.

A comparison of laparoscopic radiofrequency ablation versus systemic therapy alone in the treatment of breast cancer metastasis to the liver

OBJECTIVES

There is controversy about the roles of locoregional therapies in patients with liver metastases from breast cancer (LMBC). The aim of this study was to analyse survival after laparoscopic radiofrequency ablation (RFA) of LMBC and to compare this with survival in patients receiving systemic therapy (ST) alone.

METHODS

During 1996-2011, 24 patients who had failed to respond or had shown an incomplete response to ST underwent laparoscopic RFA for LMBC. Outcomes in these patients were compared with those in 32 patients with LMBC matched by tumour size and number, but treated with ST alone. Clinical parameters and overall survival were compared using t-tests, chi-squared tests and Kaplan-Meier analysis.

RESULTS

The groups were similar in hormone receptor status and chemotherapy exposure. In the laparoscopic RFA and ST groups, respectively, the mean ± standard deviation size of the dominant liver tumour and the number of tumours per patient were 3.7 ± 0.4 cm and 2.4 ± 0.4 cm, and 2.6 ± 0.4 tumours and 3.3 ± 0.4 tumours, respectively. These differences were not significant. At a median follow-up of 20 months in the laparoscopic RFA group, 42% of patients were found to have developed local liver recurrence, 63% had developed new liver disease and 38% had developed extrahepatic disease. Overall survival after the diagnosis of liver metastasis was 47 months in the laparoscopic RFA group and 9 months in the ST-only group (P = 0.0001). Five-year survival after the diagnosis of liver metastasis was 29% in the RFA group and 0% in the ST-only group.

CONCLUSIONS

This is the first study to compare outcomes in RFA and ST, respectively, in LMBC. The results show that survival after laparoscopic RFA plus ST is better than that after ST alone.

Prognostic factors related to surgical outcome of liver metastases of breast cancer

PURPOSE

The role of hepatectomy for patients with liver metastases of breast cancer (LMBC) remains controversial. The purpose of this study is to share our experience with hepatic resection in a relatively unselected group of patients with LMBC and analyse the prognostic factors and indications for surgery.

METHODS

In 2000 to 2006, 42 female patients with a mean age of 58.2 years (range, 39 to 69 years) with LMBC diagnosed by means of abdominal ultrasound, computed tomography and/or magnetic resonance imaging in the hospital. They were considered for surgery because of limited comorbidities, presence of seven or fewer liver tumors and absence of (or limited and stable) extrahepatic disease on preoperative imaging. Patients' demographics, metastatic characteristics as well as clinical and operative parameters were being studied. Overall actuarial 1-, 3-, and 5-year survival rates were calculated since the hepatic resection onwards using the Kaplan-Meier method.

RESULTS

Metastatic tumor size of ≤4 cm (p=0.03), R0 resection (p=0.02), negative portal lymph nodes (p=0.01), response to chemotherapy (p=0.02), and positive hormone receptor status (p=0.03) were associated with better survival outcomes on univariate analysis. However, it did not show survival benefits on multivariate analysis. The disease-free survival and overall survival are 29.40 and 43 months, respectively. The 1-, 3- and 5-year survival rates were 84.61%, 64.11%, and 38.45%, respectively.

CONCLUSION

Selected patients with isolated LMBC may benefit from surgical management; although, indications remain unclear and the risks may outweigh the benefits in patients with a generally poor prognosis. Improvements in preoperative staging and progressive application of new multimodality treatments will be the key to improved survival rates in this severe disease. The careful selection of patients is associated with a satisfactory long-term survival rate.

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.

Optimal outcomes for liver-dominant metastatic breast cancer with transarterial chemoembolization with drug-eluting beads loaded with doxorubicin

The purpose of this study was to evaluate the efficacy of image-guided delivery of locoregional chemotherapy to breast cancer hepatic metastases using doxorubicin-loaded drug-eluting beads (DEBDOX). An IRB-approved multi-center, prospective, open, non-controlled repeat treatment registry to investigate the safety and efficacy of doxorubicin microspheres in the treatment of patients with unresectable liver metastasis from breast cancer was reviewed. Statistical analysis was performed with differences of P < 0.05 considered significant. About 40 patients with metastatic breast cancer (MBC) to the liver underwent a total of 75 image-guided procedures with hepatic arterial drug-eluting beads loaded with doxorubicin (DEBDOX). Treatment was well tolerated with a total of eight patients sustaining 13 adverse events within the 30 days of each treatment session. All adverse events were either a grade I or grade II in toxicity. After a median follow-up of 12 months in all patients, the hepatic progression-free survival was a median of 26 months and overall survival was a median of 47 months. The treatment of hepatic metastasis from MBC using DEBDOX is an effective local therapy with very high response rates and a very safe toxicity profile. In comparison to chemotherapy alone, consideration of hepatic-directed therapy is warranted in patients with liver-dominant metastatic disease.

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.

Hepatic resection for metastatic breast cancer: a systematic review

BACKGROUND

Systemic chemotherapy is the mainstay of treatment for metastatic breast cancer with the role of surgery being strictly limited for palliation of metastatic complications or locoregional relapse. An increasing number of studies examining the role of therapeutic hepatic metastasectomy show encouraging survival results. A systematic review was undertaken to define its safety, efficacy and to identify prognostic factors associated with survival.

METHODS

Electronic search of the MEDLINE and PubMed databases (January 2000-January 2011) to identify studies reporting outcomes of hepatectomy for breast cancer liver metastases (BCLM) with hepatectomy was undertaken. Two reviewers independently appraised each study using a predetermined protocol. Safety and clinical efficacy was synthesised through a narrative review with full tabulation of results of all included studies.

RESULTS

Nineteen studies were examined. This comprised of 553 patients. Hepatectomy for BCLM was performed at a rate of 1.8 (range, 0.7-7.7) cases per year in reported series. The median time to liver metastases occurred at a median of 40 (range, 23-77) months. The median mortality and complication rate were 0% (range, 0-6%) and 21% (range, 0-44%), respectively. The median overall survival was 40 (range, 15-74) months and median 5-year survival rate was 40% (range, 21-80%). Potential prognostic factors associated with a poorer overall survival include a positive liver surgical margin and hormone refractory disease.

CONCLUSION

Hepatectomy is rarely performed for BCLM but the studies described in this review indicate consistent results with superior 5-year survival for selected patients with isolated liver metastases and in those with well controlled minimal extrahepatic disease. To evaluate its efficacy and control for selection bias, a randomised trial of standard chemotherapy with or without hepatectomy for BCLM is warranted.

Liver resection and local ablation of breast cancer liver metastases--a systematic review

AIM

To analyze surgical treatment of breast cancer liver metastases (BCLM) regarding selection criteria, outcome and prognostic parameters.

METHODS

We searched Embase and Medline for all studies published 1999-2010.

RESULTS

Resection was associated with a median survival (MOS) of 20-67 months and 5-year survival of 21-61%. Local ablation also had a favorable outcome; MOS was 30-60 months and 5-year survival 27-41%. Regarding selection, no specific limits regarding the number and size of BCLM can be given. Features of the primary breast cancer (BC) were not significant for the prognosis. Microscopically radical (R0) resection is a positive prognostic factor, while the effects of disease interval, hormone receptor status and response to preoperative chemotherapy were divergent. The presence of EHD had a negative effect on survival in some studies, but failed to have so in other studies.

CONCLUSIONS

Surgical therapy may benefit a subset of patients with BCLM. Resection may be indicated, if an RO-resection can be done with a low risk of mortality. Liver resection in the presence of extrahepatic disease remains controversial, while patients with BCLM and bone metastases could possibly be managed differently than other EHD.

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.

Surgical management of breast cancer liver metastases

INTRODUCTION

Selected patients with isolated breast cancer liver metastases (BCLM) may benefit from surgical management; however, indications remain unclear and the risks may outweigh the benefits in patients with a generally poor prognosis.

METHODS

Between 1998 and 2006, 17 patients diagnosed with BCLM were considered for surgical management (<4 tumours, tumour <4 cm in diameter and no/stable extrahepatic metastases). Peri-operative and outcomes data were analysed and compared.

RESULTS

Eight patients were found to have extensive or untreatable disease on staging laparoscopy and intra-operative ultrasound (SL/IOUS). The remaining nine patients underwent surgical management [seven laparoscopic radiofrequency ablations (RFA) and two hepatic resections]. Median length of follow-up for patients treated surgically was 40.0 months, median disease-free survival (DFS) was 32.2 months and median time to disease progression was 17.7 months. Of the eight patients not amenable to surgery, median length of follow-up was 21.8 months.

CONCLUSION

SL/IOUS prevented unnecessary laparotomy in half of the patients taken to the operating room for surgical treatment of BCLM. In patients with BCLM, SL/IOUS should be considered standard of care before surgical intervention. The small number of patients and short follow-up may be inadequate to determine the true value of surgical management in this group of patients with BCLM.