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

Comparative Analysis of Women's Breast Cancer Survival Time at Three Selected Government Referral Hospitals in Ethiopia's Amhara Region Using Parametric Shared Frailty Models

Background

One in five people will eventually develop cancer, and one in eleven women will lose their lives to the disease. The main aim of this study is to determinants of survival time of women with breast cancer using appropriate Frailty models.

Methods

A study involving 632 Ethiopian women with breast cancer was conducted between 2018 and 2020, utilizing medical records from Felege-Hiwot Referral Hospital, the University of Gondar, and Dessie Referral Hospital. To compare survival, the Kaplan-Meier plot (s) and Log rank test were employed; to assess mean survival, one-way analysis of variance and the t test were utilized. The factors influencing women's survival times from breast cancer were identified using the parametric shared frailty model and the accelerated failure time model.

Results

The median time to die for breast cancer patients treated at FHRH, UoGCSH, and DRH was 14.91 months, 11.14 months, and 12.32 months, respectively. The parametric model of shared frailty fit those who were statistically significant in univariate analysis. The results showed that survival of women with breast cancer was significantly influenced by age, tumor size, comorbidity, nodal status, stage, histologic grade, and type of primary treatment initiated. When comparing mean survival times between hospitals, the results showed a significant difference; patients who were treated in FHRH live significantly longer than patients treated in UoGCSH and DRH, whereas patients treated in UoGCSH have comparatively lower survival. Women with stage IV and comorbidities have 22.4% and 27.1% shorter expected survival, respectively.

Conclusion

This finding suggests that improving the availability and accessibility of radiation therapy and surgery, eliminating disparities between hospitals, raising awareness of early signs and symptoms of breast cancer and encouraging women to seek clinical help, and highlighting women with comorbidities at diagnosis are important ways to increase survival time.

Update Breast Cancer 2023 Part 3 - Expert Opinions of Early Stage Breast Cancer Therapies

The St. Gallen (SG) International Breast Cancer Conference is held every two years, previously in St. Gallen and now in Vienna. This year (2023) marks the eighteenth edition of this conference, which focuses on the treatment of patients with early-stage breast carcinoma. A panel discussion will be held at the end of this four-day event, during which a panel of experts will give their opinions on current controversial issues relating to the treatment of early-stage breast cancer patients. To this end, questions are generally formulated in such a way that clinically realistic cases are presented - often including poignant hypothetical modifications. This review reports on the outcome of these discussions and summarises the data associated with individual questions raised.

Development of a predictive model to identify patients most likely to benefit from surgery in metastatic breast cancer

Primary tumor resection for metastatic breast cancer (MBC) has demonstrated a survival advantage, however, not all patients with MBC benefit from surgery. The purpose of this study was to develop a predictive model to select patients with MBC who are most likely to benefit from surgery at the primary site. Data from patients with MBC were obtained from the Surveillance, Epidemiology and End Results (SEER) cohort and patients treated at the Yunnan Cancer Hospital. The patients from the SEER database were divided into surgery and non-surgery groups and a 1:1 propensity score matching (PSM) was used to balance baseline characteristics. We hypothesized that patients who underwent local resection of primary tumors had improved overall survival (OS) compared to those who did not undergo surgery. Based on the median OS time of the non-surgery group, patients from the surgery group were further categorized into beneficial and non-beneficial groups. Logistic regression analysis was performed to identify independent factors associated with improved survival in the surgery group and a nomogram was established using the most significant predictive factors. Finally, internal and external validation of the prognostic nomogram was also evaluated by concordance index (C-index) and using a calibration curve. A total of 7759 eligible patients with MBC were identified in the SEER cohort and 92 with MBC patients who underwent surgery at the Yunnan Cancer Hospital. Amongst the SEER cohort, 3199 (41.23%) patients received surgery of the primary tumor. After PSM, the OS between the surgery and non-surgery group was significantly different based on Kaplan-Meier survival analysis (46 vs. 31 months, P < 0.001), In the surgery group, 562 (55.20%) patients survived for longer than 31 months and were classified in the beneficial group. Significant differences were observed in patient characteristics between the beneficial and non-beneficial groups including age, grade, tumor size, liver metastasis, breast cancer subtype and marital status. These factors were used as independent predictors to create a nomogram. The internally and externally validated C-indices of the nomogram were 0.703 and 0.733, respectively, indicating strong consistency between the actual and predicted survival. A nomogram was developed and used to identify MBC patients who are most likely to benefit from primary tumor resection. This predictive model has the potential to improve clinical decision-making and should be considered routine clinical practice.

Targeted Inhibition of Tumor Inflammation and Tumor-Platelet Crosstalk by Nanoparticle-Mediated Drug Delivery Mitigates Cancer Metastasis

Sowing malignant cells (the "seeds" of metastasis) to engraft secondary sites requires a conducive premetastatic niche (PMN, the "soil" of metastasis). Inflammation and tumor associated platelet (TAP) has been hijacked by primary tumors to induce PMN "soil" in distant organs, as well as facilitate the dissemination of "seeds". This study reports a combinatory strategy with activated platelet-targeting nanoparticles to aim at the dynamic process of entire cancer metastasis, which exerts robust antimetastasis efficacy by simultaneously inhibiting tumor inflammation and tumor-platelet crosstalk. Our results reveals that the PSN peptide (a P-selectin-targeting peptide) modification enriched the accumulation of nanoparticles in primary tumor, pulmonary PMN, and metastases via capturing activated platelet. Such characteristics contribute to the efficient inhibition on almost every crucial and consecutive step of the metastasis cascade by retarding epithelial-mesenchymal transition (EMT) progression within tumors, specifically blocking the tumor-platelet crosstalk to remove the platelets "protective shield" around disseminated "seeds", and reversing the inflammatory microenvironment to interfere with the "soil" formation. Consisting of inflammation inhibiting and TAP impeding nanoparticles, this approach prominently reduces various metastasis in abscopal lung, including spontaneous metastasis, disseminated tumor cells metastasis, and post-operative metastasis. This work provides a generalizable nanoplatform of parallel inflammation disturbance and tumor-TAP crosstalk blockade to resist metastatic tumors.

Real-world evidence of the management and prognosis of young women (⩽40 years) with de novo metastatic breast cancer

Background:

Breast cancer (BC) in young women merits a specific approach given the associated fertility, genetic and psychosocial issues. De novo metastatic breast cancer (MBC) in young women is an even more serious condition, with limited data available.

Methods:

We evaluated management of women aged ⩽40 years with de novo MBC in a real-life national multicentre cohort of 22,463 patients treated between 2008 and 2016 (NCT0327531). Our primary objective was to compare overall survival (OS) in young women versus women aged 41–69 years. The secondary objectives were to compare first-line progression-free survival (PFS1) and to describe treatment patterns.

Results:

Of the 4524 women included, 598 (13%) were ⩽40 years. Median age at MBC diagnosis was 36 years (range = 20–40). Compared with women aged 41–69 years, young women had more grade III tumours (49% versus 35.7%, p < 0.0001), human epidermal growth factor receptor 2 amplified (HER2+) disease (34.6% versus 26.4%, p < 0.0001) and HR–/HER2– disease known as “triple negative breast cancer” (TNBC) (17.1% versus 12.7%, p < 0.0001). BRCA testing was performed for 260 young women, with a BRCA1/2 mutation in 44 (17% of those tested) In young HR+/HER2– patients, chemotherapy (CT) was given as the frontline treatment more frequently compared with older ones (89.6% versus 68.8%, respectively, p < 0.0001). After median follow-up of 49.7 months (95% confidence interval, CI = 48.0–51.7), the median OS of young women was 58.5 months, 20.7 months and not attained in HR+/HER2–, TNBC and HER2+ subgroups, respectively. After adjustment for histological subtype, tumour grade, and number and type of metastasis, young women had significantly better OS compared with older ones, except for the TNBC subgroup, for which the outcome was similar. PFS1 was statistically different only in the TNBC subgroup, with 7.8 months for young women and 6.3 months for older women ( p = 0.0015).

Conclusion:

De novo MBC affects a significant proportion of young women. A subgroup of these patients achieves long OS and merits multidisciplinary care.

OUP accepted manuscript

Purpose

About 10% of breast cancer (BC) is diagnosed in stage IV. This study sought to identify factors associated with time to progression (TTP) and overall survival (OS) in a cohort of patients diagnosed with de novo metastatic breast cancer (MBC), from a single cancer center in Colombia, given that information on this aspect is limited.

Methodology

An observational, analytical, and retrospective cohort study was carried out. Time to progression and OS rates were estimated using the Kaplan–Meier survival functions. Cox models were developed to assess association between time to progression and time to death, using a group of fixed variables.

Results

Overall, 175 patients were included in the study; 33.7% of patients had luminal B HER2-negative tumors, 49.7% had bone involvement, and 83.4% had multiple metastatic sites. Tumor biology and primary tumor surgery were the variables associated with TTP and OS. Patients with luminal A tumors had the lowest progression and mortality rates (10 per 100 patients/year (95% CI: 5.0-20.0) and 12.6 per 100 patients/year (95% CI: 6.9-22.7), respectively), and patients with triple-negative tumors had the highest progression and mortality rates (40 per 100 patients/year (95% CI: 23.2-68.8) and 44.1 per 100 patients/year (95% CI: 28.1-69.1), respectively). Across the cohort, the median TTP was 2.1 years (95% CI: 1.6; the upper limit cannot be reached) and the median OS was 2.4 years (95% CI: 2-4.3).

Conclusions

In this cohort, patients with luminal A tumors and those who underwent tumor surgery given that they presented clinical benefit (CB) after initial systemic treatment, had the lowest progression and mortality rates. Overall, OS was inferior to other series due to high tumor burden and difficulties in accessing and continuing oncological treatments.

Breast cancer

Breast cancer is still the most common cancer worldwide. But the way breast cancer is viewed has changed drastically since its molecular hallmarks were extensively characterised, now including immunohistochemical markers (eg, ER, PR, HER2 [ERBB2], and proliferation marker protein Ki-67 [MKI67]), genomic markers (eg, BRCA1, BRCA2, and PIK3CA), and immunomarkers (eg, tumour-infiltrating lymphocytes and PD-L1). New biomarker combinations are the basis for increasingly complex diagnostic algorithms. Neoadjuvant combination therapy, often including targeted agents, is a standard of care (especially in HER2-positive and triple-negative breast cancer), and the basis for de-escalation of surgery in the breast and axilla and for risk-adapted post-neoadjuvant strategies. Radiotherapy remains an important cornerstone of breast cancer therapy, but de-escalation schemes have become the standard of care. ER-positive tumours are treated with 5-10 years of endocrine therapy and chemotherapy, based on an individual risk assessment. For metastatic breast cancer, standard therapy options include targeted approaches such as CDK4 and CDK6 inhibitors, PI3K inhibitors, PARP inhibitors, and anti-PD-L1 immunotherapy, depending on tumour type and molecular profile. This range of treatment options reflects the complexity of breast cancer therapy today.

Axillary surgical approach in metastatic breast cancer patients: a systematic review and meta-analysis

A systematic review and meta-analysis were conducted to evaluate the benefit of an axillary surgical approach on overall survival and secondarily of breast surgery amongst patients with metastatic breast cancer which is considered to be an incurable disease. However, an axillary surgical approach showed no association with overall survival in patients with metastatic breast cancer. The true impact of locoregional therapies on long-term outcomes remains unknown, and randomised clinical trials are needed.

Primary tumor removal improves the prognosis in patients with stage IV breast cancer: A population-based study (cohort study)

Adjuvant therapy including chemotherapy, hormonal therapy, and radiotherapy were often used as a common stereotypy for female stage IV breast cancer rather than surgery. This study aimed to define the role of local surgery in metastatic breast cancer. Female metastatic breast cancer patients were identified in the Surveillance, Epidemiology, and End Results (SEER) program data (2010-2013). We compared survival time between patients who received primary tumor removal (PTR) versus those who did not. Multivariate Cox regression models and competitive risk models were built to adjust potential confounders. Of 7669 female stage IV breast cancer patients, 2704 (35.3%) had surgery on their breast tumor and 4965 (64.7%) did not. In the entire cohort, women who underwent PTR had a 45% reduced risk of breast cancer-related death (multi-adjusted hazard ratio [HR], 0.55; 95% CI, 0.50 to 0.60) compared with women who did not undergo PTR (P < 0.001). In a cause-specific hazard model (CS model), the multivariable HRs (95% CI) for the association of PTR with breast cancer related-death were 0.54 (0.50-0.60) in the multivariate-adjusted analysis. Similar results were also observed in the sub-distribution hazard function model (SD model) with corresponding multivariate HRs (95%CI) of 0.57 (0.52-0.63). Our study suggested that PTR was associated with improved survival in female stage IV breast cancer patients. The role of PTR in these patients needs to be re-evaluated.

Effect of local surgery on outcomes of stage IV breast cancer

Metastatic breast cancer (MBC), including de novo stage IV, is regarded as being incurable and the mainstay of clinical management is systemic therapy. Traditionally, locoregional surgery is performed only for local control, such as to prevent ulceration and bleeding. In recent years, however, both retrospective and prospective studies have demonstrated the prognostic efficacy of primary surgery for de novo stage IV patients. Therefore, we conducted a meta-analysis to evaluate whether surgical therapy contributes to overall survival (OS) extension. We searched for clinical trials published in electronic databases (PubMed, Embase, and the Cochrane databases) and performed a meta-analysis of the data collected. There were five prospective randomized controlled phase III trials (RCTs). The results of three have been reported. According to our meta-analysis of these RCTs, primary surgery for de novo stage IV breast cancer patients significantly improves OS. However, the Tata trial showed that systemic therapy does not achieve a sufficient effect. Another trial, conducted in Turkey, had statistical shortcomings and patient randomization was not adequately performed The ABCSG (Austrian Breast and Colorectal Cancer Study Group) trial had too few subjects. Meta-analysis of 12 retrospective studies showed that patients with stage IV breast cancer receiving surgery as the initial treatment experienced longer OS (HR: 0.65, P<0.00001). Based on our meta-analysis of three reported RCTs, surgery as the primary treatment does not significantly impact the outcomes of de novo stage IV breast cancer patients. However, these trials had limitations. We await the results of the remaining two ongoing RCTs (ECOG 2108 and JCOG 1017). These trials are anticipated to resolve current controversies and provide many eagerly awaited answers.

Ulcerated breast cancer with single brain metastasis: A combined surgical approach. Clinical presentation at one year follow up - A case report

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Solitary brain metastasis of breast cancer in a patient with neurological symptoms as first presentation is a rare complication.

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Simultaneously perform a metastasectomy surgery plus right mastectomy, right axillary dissection and immediate breast reconstruction is unusual event.

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Successful combined surgical approach in a stage IV de novo breast cancer patient with single site brain metastasis at one year follow-up.

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Combined surgical approach offers the opportunity to treat two different oncological urgencies, reducing the unnecessary repeated surgical and anesthesiologic trauma.

Introduction

Breast cancer is the most common malignancy in woman. Approximately 5–10% of breast cancer occurs as de novo stage IV and some studies have shown that from 10% to 30% of those patients presents Brain Metastasis.

Presentation of case

In this study, we report a case of solitary brain metastasis of breast cancer in a 63-year-old Italian Caucasian woman with neurological symptoms as first clinical presentation. After the correct diagnosis and multidisciplinary meeting it was decided to simultaneously perform a metastasectomy surgery plus right mastectomy, right axillary dissection and immediate breast reconstruction. In our clinical practice we report a successful combined surgical approach in a stage IV de novo breast cancer patient with single site brain metastasis at one year follow-up.

Discussion

Metastasectomy plus mastectomy provided neurological control of acute complication of metastatic disease and complete breast cancer local control. One-time operation could be the best option when diagnosis of breast cancer is made thanks to the onset of oncological emergency like intracranial hypertension due to single brain metastasis.

Conclusion

Combined surgical approach offers the opportunity to treat two different oncological urgencies, reducing the unnecessary repeated surgical and anesthesiologic trauma.

Role of surgery in patients with synchronous metastatic breast cancer: Is there a need for axillary lymph node removal?

INTRODUCTION

About 6% of women with breast cancer present with synchronous metastases. Treatment remains palliative in international recommendations but the impact of loco-regional surgery remains controversial.

OBJECTIVE

We conducted a multicentre, cohort study to evaluate the impact of axillary lymph node (ALN) surgery on overall survival in stage IV breast cancer at diagnosis.

METHODS

Patients presenting with breast cancer and synchronous metastases between 2005 and 2014 were included. Follow up was conducted up to 1st June 2018. The only exclusion criterion was a history of previous malignancies. Breast surgery was defined as lumpectomy or mastectomy. Axillary surgery included full ALN dissection, and sentinel lymph node biopsy (SLNB). If the SLN was invaded on the frozen section, full axillary dissection was performed.

RESULTS

152 patients were included. 71 women had no surgery, 81 had primary site surgery of which 64 (79%) had breast and axillary surgery and 17 (21%) breast surgery only. 5-year overall survival was 59.8% (95% CI=[49.5; 69.5]) for women with breast and axillary surgery, 23.5% (95% CI=[15.6; 33]) for women with breast surgery only and 9.8% (95% CI=[4.7; 17.5]) for women without any surgery, p < 0.001. Combined with breast surgery, axillary surgery significantly added a mean of 33 months to patient overall survival.

CONCLUSION

ALN surgery combined with breast surgery in metastatic breast cancer significantly increased overall survival. Thus surgical indications should not differ from those in women with breast cancer without metastases.

Primary Tumor Surgery for Patients with De Novo Stage IV Breast Cancer can Decrease Local Symptoms and Improve Quality of Life

BACKGROUND

It was unknown whether surgery for primary tumor would affect the occurrence of local symptoms caused by tumor progression in patients with de novo stage IV breast cancer (BC). Our work attempted to probe the effect of local resection on controlling local symptoms and improving the quality of life in de novo stage IV BC patients.

METHODS

Our study included patients presenting with de novo stage IV BC at the Cancer Hospital of the Chinese Academy of Medical Sciences from January 2008 to December 2014. In this study, we defined a new term called "local progress/recurrence of symptoms" (LPRS) to refer to the local problems caused by tumor progression/recurrence. All the patients were grouped into surgery and non-surgery groups. The characteristics of the two groups were analyzed by Chi square and Fisher's test. Univariate and multivariate Cox regression models were designed to evaluate independent prognostic factors.

RESULTS

This study contained 177 patients. The follow-up deadline was April 1, 2019. The median follow-up time was 33 months (range 1-135 months). In included patients, 77 (43.5%) underwent surgery for primary tumors. Primary tumor surgery could reduce the occurrence of LPRS (relative risk/risk ratio (RR = 0.440; 95% CI 0.227-0.852; p = 0.015)) and patients without LPRS had longer OS (45 months vs 29 months, p < 0.001). In addition, patients who had only one symptom had better OS than those who had two or three symptoms (p = 0.0175).

CONCLUSIONS

The quality of life in patients with de novo stage IV breast cancer can be improved by reducing the incidence of local symptoms through primary tumor surgery.

Better survival after surgery of the primary tumor in stage IV inflammatory breast cancer

INTRODUCTION

Information regarding the effects of resection of the primary tumor in stage IV inflammatory breast cancer (IBC) is scarce. We analyzed the impact of resection of the primary tumor on overall survival (OS) in a large stage IV IBC population.

MATERIALS AND METHODS

Patients diagnosed with stage IV IBC between 2005 and 2016 were selected from the Netherlands Cancer Registry, excluding patients without any treatment. To correct for immortal time bias, we performed a landmark analysis including patients alive at least six months after diagnosis. With propensity score matching, patients undergoing surgery of the primary tumor were matched to patients not receiving surgery. Multivariable Cox proportional hazard analyses were performed to determine the association between treatment strategy and OS in the non-matched and matched cohort.

RESULTS

Of the 580 included patients after landmark analysis, 441 patients (76%) received only non-surgical treatments and 139 (24%) underwent surgery (96% mastectomy). Median follow-up was 28.8 and 20.0 months in the surgery and no surgery group, respectively. Surgery in the non-matched cohort was independently associated with better survival (HR0.56[95%CI:0.42-0.75]). In the matched cohort (n = 202), surgically treated patients had improved survival over nonsurgically treated patients (p < 0.005). Multivariable analysis of the matched cohort revealed that surgery was still associated with better survival (HR0.62[95%CI:0.44-0.87]).

CONCLUSION

Although residual confounding and confounding by severity cannot be ruled out, this study suggests that surgery of the primary tumor is associated with improved OS and should be considered as part of the treatment strategy in stage IV IBC.

Surgical Resection of the Primary Tumor in Women With De Novo Stage IV Breast Cancer: Contemporary Practice Patterns and Survival Analysis

OBJECTIVE

We evaluated patterns of surgical care and their association with overall survival among a contemporary cohort of women with stage IV breast cancer.

BACKGROUND

Surgical resection of the primary tumor remains controversial among women with stage IV breast cancer.

METHODS

Women diagnosed with clinical stage IV breast cancer from 2003 to 2012 were identified from the American College of Surgeons National Cancer Database. Those with intact primary tumors who were alive 12 months after diagnosis were categorized by treatment sequence: (1) surgery before systemic therapy, (2) systemic therapy before surgery, and (3) systemic therapy alone. Multivariate logistic regression was used to estimate the association of treatment sequence with surgery type. Overall survival was estimated using multivariate Cox proportional hazards models.

RESULTS

Among 24,015 women, 56.2% (13,505) underwent systemic therapy alone and 43.8% (10,510) underwent surgical resection. Rates of surgery decreased slightly over time (43.1% in 2003 to 41.9% in 2011). Treatment with systemic therapy before surgery was associated with larger tumor size (median 4.5 vs 3.1 cm, P < 0.001) and receipt of mastectomy (81.4% vs 52.2%, P < 0.001) when compared to those who underwent surgery first. Receipt of surgery, whether before or after systemic therapy (Hazard Ratio, 0.68; 95% confidence interval, 0.62-0.73; Hazard Ratio, 0.56; 95% confidence interval, 0.52-0.61; P < 0.001), was independently associated with improved adjusted overall survival when compared to systemic therapy alone.

CONCLUSIONS

Surgical resection of the primary tumor occurs in almost half of women with stage IV breast cancer alive 1 year after diagnosis, and is increasingly occurring after systemic therapy. Coordinated multidisciplinary care remains highly relevant in the setting of metastatic breast cancer, where surgical decisions should be made on an individual basis and may affect survival in select women.

Surgery and survival in patients with stage IV breast cancer

BACKGROUND

Retrospective studies have shown some improvement in survival for patients receiving surgical management of the intact primary tumor in patients with presenting with Stage IV disease, while prospective studies have revealed mixed results.

METHODS

An examination of the NCDB from 2004-2013 was undertaken to examine factors related to the utilization of surgery and overall survival in patients with de novo Stage IV disease. Univariate and multivariable analyses were conducted to determine factors related to survival. Propensity score matching method was implemented to balance patients' baseline characteristics.

RESULTS

A total of 11 694 patients with Stage IV breast cancer at diagnosis met inclusion criteria. Surgical intervention occurred in 5202 patients (44.5%), with the use of surgery decreasing throughout the study period (53.6% surgery 2004-2006; 31.8% surgery 2011-2013). Selection for surgical intervention was associated with small tumors (T1) and a higher nodal burden (N2/3). Uninsured patients, those treated at academic centers, those treated in the Northeast, and those with hormone receptor positive tumors were less likely to undergo surgery. Surgery was independently associated with a better overall survival. Propensity score matching revealed a persistent survival advantage for surgical patients receiving surgery, regardless of the receipt of systemic therapy.

CONCLUSIONS

Surgery on the intact primary tumor for patients presenting with de novo Stage IV breast cancer is associated with improved overall survival. Surgical resection in patients with Stage IV breast cancer should be considered for well-selected patients as a part of multimodality therapy.

Site-specific metastases of intrahepatic cholangiocarcinoma and its impact on survival: a population-based study

Aim: Limited data exist on impact of the metastatic sites on survival in patients with metastatic intrahepatic cholangiocarcinoma (ICC). Methods: Patients with metastatic ICC were identified in the SEER from 2010 to 2015. Results: A total of 981 patients were identified, of this population, liver (57.9%) is the most common site of ICC metastases, followed by lung, bone and brain. Respective median overall survival and cancer-specific survival were 6 and 9 months in entire population. Further analysis suggested that patients treated by surgery to primary and/or metastatic lesions had a better survival outcome than patients had no surgery (p ≤ 0.001). Conclusion: Liver is the most common site for ICC metastases, local treatment such as surgery to primary or metastatic lesions obviously benefit patients.

Locoregional surgical treatment improves the prognosis in primary metastatic breast cancer patients with a single distant metastasis except for brain metastasis

BACKGROUND

We aimed to validate the clinical significance of locoregional surgery in improving the prognosis of primary metastatic breast cancer (pMBC).

METHODS

We conducted a population-based retrospective study by analyzing clinical data obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database. Stratification analysis was employed to assess the effect of breast surgery on breast cancer-specific survival and overall survival. Then propensity score matching and COX regression models were employed to evaluate the survival advantages of breast surgery, if any in patients with pMBC.

RESULTS

The median BCSS and OS in the surgery group were almost twice of that in the group without surgery. Breast surgery provided a survival advantage for patients with a single metastasis in the bone, liver or lung, but not in the brain. We found that axillary lymph node dissection performed in combination with specific breast surgical procedures did not result in a significant improvement in survival. Additionally, when combined with radiotherapy and/or chemotherapy, surgery significantly improved the survival and was not influenced by the molecular subtype and tumor size. Finally, using COX regression models before and after propensity score matching, breast surgery was found to reduce the risk of mortality in patients with MBC by more than 40%.

CONCLUSIONS

The effect of locoregional surgery has been underestimated in pMBC patients. Surgical procedures should be seriously considered when planning combination treatments for pMBC patients with a single metastasis except for brain metastasis.

SEOM clinical guidelines in advanced and recurrent breast cancer (2018)

Although the metastasic breast cancer is still an incurable disease, recent advances have increased significantly the time to progression and the overall survival. However, too much information has been produced in the last 2 years, so a well-based guideline is a valuable document in treatment decision making. The SEOM guidelines are intended to make evidence-based recommendations on how to manage patients with advanced and recurrent breast cancer to achieve the best patient outcomes based on a rational use of the currently available therapies. To assign a level of certainty and a grade of recommendation the United States Preventive Services Task Force guidelines methodology was selected as reference.

Therapeutic Options for Metastatic Breast Cancer

Metastatic breast cancer is the most common cancer in women after skin cancer, with a 5-year survival rate of 26%. Due to its high prevalence, it is important to develop therapies that go beyond those that just provide palliation of symptoms. Currently, there are several types of therapies available to help treat breast cancer including: hormone therapy, immunotherapy, and chemotherapy, with each one depending on both the location of metastases and morphological characteristics. Although technological and scientific advancements continue to pave the way for improved therapies that adopt a targeted and personalized approach, the fact remains that the outcomes of current first-line therapies have not significantly improved over the last decade. In this chapter, we review the current understanding of the pathology of metastatic breast cancer before thoroughly discussing local and systemic therapies that are administered to patients diagnosed with metastatic breast cancer. In addition, our review will also elaborate on the genetic profile that is characteristic of breast cancer as well as the local tumor microenvironment that shapes and promotes tumor growth and cancer progression. Lastly, we will present promising novel therapies being developed for the treatment of this disease.

Breast surgery for metastatic breast cancer

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Survival Time and Prognostic Factors for Breast Cancer among Women in North-East Peninsular Malaysia

Background:

Breast cancer is the most common malignant disease and the leading cause of cancer death among women globally. This study aimed to determine the median survival time and prognostic factors for breast cancer patients in a North-East State of Malaysia.

Methods:

This retrospective cohort study was conducted from January till April 2017 using secondary data obtained from the state’s cancer registry. All 549 cases of breast cancer diagnosed from 1st January 2007 until 31st December 2011 were selected and retrospectively followed-up until 31st December 2016. Sociodemographic and clinical information was collected to determine prognostic factors.

Results:

The average (SD) age at diagnosis was 50.4 (11.2) years, the majority of patients having Malay ethnicity (85.8%) and a histology of ductal carcinoma (81.5%). Median survival times for those presenting at stages III and IV were 50.8 (95% CI:25.34, 76.19) and 6.9 (95% CI:3.21, 10.61) months, respectively. Ethnicity (Adj. HR for Malay vs non-Malay ethnicity=2.52; 95% CI: 1.54, 4.13; p<0.001), stage at presentation (Adj. HR for Stage III vs Stage I=2.31; 95% CI: 1.57, 3.39; p<0.001 and Adj. HR for Stage IV vs Stage I=6.20; 95%CI: 4.45, 8.65; p<0.001), and history of surgical treatment (Adj. HR for patients with no surgical intervention=1.95; 95%CI: 1.52, 2.52; p<0.001) were observed to be the statistically significant prognostic factors associated with death caused by breast cancer.

Conclusion:

The median survival time among breast cancer patients in North-East State of Malaysia was short as compared to other studies. Primary and secondary prevention aimed at early diagnosis and surgical management of breast cancer, particularly among the Malay ethnic group, could improve treatment outcome.

Hormone receptor status may impact the survival benefit of surgery in stage iv breast cancer: a population-based study

Introduction

The role of surgery in stage IV breast cancer is controversial. We used the Surveillance, Epidemiology, and End Results database to explore the impact of surgery on the survival of patients with stage IV breast cancer.

Methods

In total, 10,441 eligible stage IV breast cancer patients from 2004 to 2008 were included. They were divided into four groups as follows: R0 group (patients who underwent primary site and distant metastatic site resection), primary site resection group, metastases resection group, and no resection group.

Results

The four groups achieved a median survival time (MST) of 51, 43, 31 and 21 months, respectively, P < 0.001. The Cox proportional hazards model showed that the R0 group, primary resection group and metastases resection group had a good survival benefit, with hazard ratios of 0.558 (95% CI, 0.471-0.661), 0.566 (95% CI, 0.557-0.625) and 0.782 (95% CI, 0.693-0.883), respectively. In the hormone receptor (HR)-positive population, the R0 group (MST = 66 m, 5-year OS = 54.1%) gained an additional survival benefit compared with the primary resection group (MST = 52 m; 5-year OS = 44.9%; P < 0.001). The metastases resection group (MST = 38 m; 5-year OS = 31.7%) survived longer than the no resection group (MST = 28 m; 5-year OS = 22.0%; P < 0.001). In the HR-negative population, the R0 group and primary resection group had a similar survival (P = 0.691), and the metastases resection group had a similar outcome to that of the no resection group (P = 0.526).

Conclusion

Patients who underwent surgery for stage IV breast cancer showed better overall survival than the no resection group. Cytoreductive surgery could provide a survival benefit in HR+ stage IV breast cancer; however, in the HR- population, extreme caution should be exercised when considering surgery.

Significance of primary lesion resection in Stage IV breast cancer

Systemic treatment with drugs is administered to prolong survival and palliate symptoms in Stage IV breast cancer patients who have distant metastases at diagnosis. Surgical procedures for the primary tumor are not actively recommended in guidelines due to lack of evidence indicating prognostic benefit. Recently, several retrospective studies have shown primary tumor resection to prolong overall survival in patients with Stage IV breast cancer. Prospective randomized trials began enrolling patients to examine this possibility and two have already reported results. However, the results of these two trials were discordant. The first trial, conducted in India, reported negative effects of primary tumor resection after primary systemic therapy. A Turkish trial then obtained a positive effect of surgery as primary treatment. Several questions regarding the effects, timing, methods and eligibility for primary surgery have yet to be answered. Robust evidence, which is anticipated from other ongoing trials examining surgery for metastatic breast cancer, is eagerly awaited.

Surgical resection of a primary tumor improves survival of metastatic pancreatic cancer: a population-based study

INTRODUCTION

Pancreatic cancer is a lethal disease with a very poor prognosis. This study investigates survival of patients diagnosed with metastatic pancreatic cancer (mPC) based on local treatment of the primary tumor.

METHODS

Patients diagnosed with stage IV mPC between 2004 and 2013 were identified from the Surveillance, Epidemiology and End Results (SEER) database. Cancer-specific survival (CSS) and overall survival (OS) were examined. CSS and OS were examined by using the Kaplan-Meier method with the log-rank test. Multivariable survival analyses of CSS and OS were conducted using the Cox proportional hazard model.

RESULTS

A total of 28918 patients with mPC were included in this analysis. There were 467 patients who received surgical resection (1.6%) and 28451 patients who did not (98.4%). Patients who were younger than 70 years (odds ratio [OR]=1.45, 95% CI=1.04-2.03, p=0.03), diagnosed from 2004 to 2008 (OR=1.49, 95% CI=1.25-1.80, p<0.001), female (OR=1.31, 95% CI=1.08-1.58, p<0.001), married (OR=1.56, 95% CI=1.27-1.90, p<0.001), at T3 stage (OR=3.53, 95% CI=1.10-11.37, p=0.035), at N1 stage (OR=2.05, 95% CI=1.68-2.50, p<0.001), presenting histological types other than adenocarcinoma (OR=2.04, 95% CI=1.43-2.94, p<0.001), and with tumor of the pancreatic head (OR=1.90, 95% CI=1.27-2.82, p=0.002) were more likely to be treated with surgical resection. The results of multivariate analysis showed that surgical resection of the primary tumor was associated with CSS (hazard ratio [HR]=0.58, 95% CI=0.52-0.64, p<0.001) and OS (HR=0.59, 95% CI=0.53-0.65, p<0.001) benefits. In addition, not receiving chemotherapy (HR=2.33, 95% CI=2.27-2.39, p<0.001), age >50 years (HR=1.25, 95% CI=1.09-1.42, p=0.001), male (HR=1.121, 95% CI=1.09-1.15, p<0.001), black ethnicity (HR=1.11, 95% CI=1.1-1.15, p<0.001), unmarried (HR=1.20, 95% CI=1.17-1.23, p<0.001), histological type of adenocarcinoma (HR=1.18, 95% CI=1.14-1.22, p<0.001), and primary site other than the pancreatic head (HR=1.08, 95% CI=1.05-1.11, p<0.001) are factors associated with poor survival.

CONCLUSION

This study reveals that local treatment has the primary benefit of both CSS and OS in patients with mPC. These results may guide the management of this patient population.

Effect of age on rates of palliative surgery and chemotherapy use in patients with locally advanced or metastatic gastric cancer

BACKGROUND

This study assessed trends in the treatment and survival of palliatively treated patients with gastric cancer, with a focus on age-related differences.

METHODS

For this retrospective, population-based, nationwide cohort study, all patients diagnosed between 1989 and 2013 with non-cardia gastric cancer with metastasized disease or invasion into adjacent structures were selected from the Netherlands Cancer Registry. Trends in treatment and 2-year overall survival were analysed and compared between younger (age less than 70 years) and older (aged 70 years or more) patients. Analyses were done for five consecutive periods of 5 years, from 1989-1993 to 2009-2013. Multivariable logistic regression analysis was used to examine the probability of undergoing surgery. Multivariable Cox regression analysis was used to identify independent risk factors for death.

RESULTS

Palliative resection rates decreased significantly in both younger and older patients, from 24·5 and 26·2 per cent to 3·0 and 5·0 per cent respectively. Compared with patients who received chemotherapy alone, both younger (21·6 versus 6·3 per cent respectively; P < 0·001) and older (14·7 versus 4·6 per cent; P < 0·001) patients who underwent surgery had better 2-year overall survival rates. Multivariable analysis demonstrated that younger and older patients who received chemotherapy alone had worse overall survival than patients who had surgery only (younger: hazard ratio (HR) 1·22, 95 per cent c.i. 1·12 to 1·33; older: HR 1·12, 1·01 to 1·24). After 2003 there was no association between period of diagnosis and overall survival in younger or older patients.

CONCLUSION

Despite changes in the use of resection and chemotherapy as palliative treatment, overall survival rates of patients with advanced and metastatic gastric cancer did not improve.

Hepatic Resection or Ablation for Isolated Breast Cancer Liver Metastasis: A Case-control Study With Comparison to Medically Treated Patients

OBJECTIVE

To evaluate the efficacy of surgical treatment for patients with isolated breast cancer liver metastases (BCLM).

BACKGROUND

Single-arm retrospective studies have shown promising results associated with surgery for isolated BCLM; however, this treatment remains controversial and its role is not well-defined.

METHODS

A review of 2150 patients with BCLM who underwent treatment in a single institution was conducted, and 167 (8%) patients with isolated BCLM were identified. A case-control study was conducted to compare outcomes in patients with isolated BCLM who underwent surgery and/or ablation to patients who underwent conventional medical therapy.

RESULTS

A total of 167 patients were included (surgery/ablation: 69; medical: 98), with a median follow-up for survivors of 73 months. Patients in the surgical cohort more frequently had estrogen receptor-positive tumors and received adjuvant chemotherapy and radiotherapy for their primary breast tumor. The hepatic tumor burden was less and the interval from breast cancer diagnosis to BCLM was significantly longer (53 vs 30 months) in the surgical cohort. Patients undergoing surgical treatment had a median recurrence-free interval of 28.5 months (95% confidence interval (CI): 19-38) with 10 patients (15%) recurrence free after 5 years. There was no significant difference in overall survival (OS) between the surgical and medical cohorts (median OS: 50 vs 45 months; 5-year OS: 38% vs 39%).

CONCLUSIONS

Hepatic resection and/or ablation was not associated with a survival advantage. However, significant recurrence-free intervals can be accomplished with surgical treatment. Surgical intervention might be considered in highly selected patients with the goal of providing time off of systemic chemotherapy.

Surgery of the primary tumor improves survival in women with stage IV breast cancer in Southwest China: A retrospective analysis

The International Consensus Guidelines for advanced breast cancer (ABC) considers that the surgery of the primary tumor for stage IV breast cancer patients does not usually improve the survival. However, studies have showed that resection of the primary tumor may benefit these patients. The correlation between surgery and survival remains unclear.The impact of surgery and other clinical factors on overall survival (OS) of stage IV patients is investigated in West China Hospital. Female patients diagnosed with stage IV breast cancer between 1999 and 2014 were included (N = 223). Univariate and multivariate analysis assessed the association between surgery and OS.One hundred seventy-seven (79.4%) underwent surgery for the primary tumor, and 46 (20.6%) had no surgery. No significant differences were observed in age at diagnosis, T-stage, N-stage, histological grade, molecular subtype, hormone receptor (HR), and number of metastatic sites between 2 groups. Patients in the surgery group had dramatically longer OS (45.6 vs 21.3 months, log-rank P < .001). In univariate analysis, survival was associated with surgical treatment, residence, tumor size, lymph node, HR status, hormonal therapy, and radiotherapy. In multivariate analysis, surgery was an independent prognostic factor for OS [hazard ratio (HR), 0.569; 95% confidence interval (CI) 0.329-0.984, P = .044]. Additional independent prognostic factors were hormonal therapy (HR, 0.490; 95% CI 0.300-0.800) and radiotherapy (HR, 0.490; 95% CI 0.293-0.819). In addition, a favorable impact of surgery was observed by subgroup analysis.Our study showed that surgery of the primary breast tumor has a positive impact on OS in with stage IV breast cancer patients.

Local Resection of Primary Tumor in Upfront Stage IV Breast Cancer

BACKGROUND

This study aimed to identify the association of local surgery of the primary tumor in metastatic breast cancer (MBC) patients with overall survival (OS) and prognostic factors.

PATIENTS AND METHODS

Patients with primary MBC (1990-2006) were included in our retrospective analysis (n = 236). 83.1% had surgery for the primary tumor. OS was evaluated using Kaplan-Meier estimates. Predictive factors for OS were determined.

RESULTS

Median follow-up was 123 months for all patients still alive at the time of analysis. In univariate analysis, patients with surgery of the primary tumor had significantly prolonged OS (28.9 vs. 23.9 months). Within the surgery group, patients with MBC limited to 1 organ system had a better outcome (39.3 vs. 24.9 months), as did asymptomatic patients. Independent risk factors for shorter OS were hormone receptor negativity, symptoms, and involvement of ≥ 1 organ system.

CONCLUSION

Patient selection for local therapy was confounded by a more favorable profile and a lesser tumor burden before surgery, which might implicate a bias. Nevertheless, our univariate results indicate that local surgery of the primary tumor in MBC patients could be considered as part of the therapeutic regimen in selected patients. However, larger patient numbers are needed to prove these findings in the multivariate model.

Survival of de novo stage IV breast cancer patients over three decades

BACKGROUND

De novo stage IV breast cancer patients (BC_IV) depict a clinical picture not influenced by adjuvant therapy. Therefore, the time-dependent impact of changes in diagnostics and treatments on progression and survival can best be evaluated in this subgroup.

METHODS

BC_IV patients from 1978 to 2013 registered in the Munich Cancer Registry were divided into four periods, and the trends were analysed. Survival was estimated by Kaplan-Meier methods, and prognostic factors were fitted with Cox proportional hazard models.

RESULTS

Between 1978 and 2013, 88,759 patients were diagnosed with 92,807 cases of invasive and non-invasive BC. Of these patients, 4756 patients had distant metastases (MET) at diagnosis. The 5-year survival rate improved from 17.4 to 24.7%, while the pattern of metastases did not change. Improved staging diagnostics, a screening programme and primary systemic therapy changed the composition of prognostic strata. Patients with a similar composition as the 1978-1987 cohort exhibited a median survival difference of 13 months; however, neither univariate nor multivariate analysis showed a survival effect for the four periods as a surrogate indicator for changing treatments. HER2+ patients have with 27.6 months a slightly longer survival than all other BC_IV patients.

CONCLUSIONS

Survival of de novo BC_IV has only modestly improved since the late 1970s, partially masked by changing distributions of prognostic factors due to changes in diagnostics.

Improved Survival With Prostate Radiation in Addition to Androgen Deprivation Therapy for Men With Newly Diagnosed Metastatic Prostate Cancer

Purpose

There is growing interest in the role of local therapies, including external beam radiotherapy (RT), for men with metastatic prostate cancer (mPCa). We used the National Cancer Database (NCDB) to evaluate the overall survival (OS) of men with mPCa treated with androgen deprivation (ADT) with and without prostate RT.

Methods

The NCDB was queried for men with newly diagnosed mPCa, all treated with ADT, with complete datasets for RT, surgery, prostate-specific antigen (PSA) level, Gleason score, and Charlson-Deyo comorbidity score. OS was analyzed using the Kaplan-Meier method, log-rank test, Cox proportional hazards models, and propensity score-matched analyses.

Results

From 2004 to 2012, 6,382 men with mPCa were identified, including 538 (8.4%) receiving prostate RT. At a median follow-up of 5.1 years, the addition of prostate RT to ADT was associated with improved OS on univariate (P < .001) and multivariate analysis (hazard ratio, 0.624; 95% CI, 0.551 to 0.706; P < .001) adjusted for age, year, race, comorbidity score, PSA level, Gleason score, T stage, N stage, chemotherapy administration, treating facility, and insurance status. Propensity score analysis with matched baseline characteristics demonstrated superior median (55 v 37 months) and 5-year OS (49% v 33%) with prostate RT plus ADT compared with ADT alone (P < .001). Landmark analyses limited to long-term survivors of ≥1, ≥3, and ≥5 years demonstrated improved OS with prostate RT in all subsets (all P < .05). Secondary analyses comparing the survival outcomes for patients treated with therapeutic dose RT plus ADT versus prostatectomy plus ADT during the same time interval demonstrated no significant differences in OS, whereas both therapies were superior to ADT alone.

Conclusion

In this large contemporary analysis, men with mPCa receiving prostate RT and ADT lived substantially longer than men treated with ADT alone. Prospective trials evaluating local therapies for mPCa are warranted.

Occurrence and outcome of de novo metastatic breast cancer by subtype in a large, diverse population

PURPOSE

To examine the occurrence and outcomes of de novo metastatic (Stage IV) breast cancer, particularly with respect to tumor HER2 expression.

METHODS

We studied all 6,268 de novo metastatic breast cancer cases diagnosed from 1 January 2005 to 31 December 2011 and reported to the California Cancer Registry. Molecular subtypes were classified according to HER2 and hormone receptor (HR, including estrogen and/or progesterone receptor) expression. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95 % confidence intervals (CIs) of Stage IV versus Stage I-III breast cancer; Cox proportional hazards regression was used to assess relative hazard (RH) of mortality.

RESULTS

Five percent of invasive breast cancer was metastatic at diagnosis. Compared to patients with earlier stage disease, patients with de novo metastatic disease were significantly more likely to have HER2+ tumors (HR+/HER2+: OR 1.29, 95 % CI 1.17-1.42; HR-/HER2+: OR 1.40, 95 %CI 1.25-1.57, vs. HR+/HER2-). Median survival improved over time, but varied substantially across race/ethnicity (Asians: 34 months; African Americans: 6 months), neighborhood socioeconomic status (SES) (highest: 34 months, lowest: 20 months), and molecular subtype (HR+/HER2+: 45 months; triple negative: 12 months). In a multivariable model, triple negative (RH 2.85, 95 % CI 2.50-3.24) and HR-/HER2+ (RH 1.60, 95 % CI 1.37-1.87) had worse, while HR+/HER2+ had similar, risk of all-cause death compared to HR+/HER2- breast cancer.

CONCLUSIONS

De novo metastatic breast cancer was more likely to be HER2+. Among metastatic tumors, those that were HER2+ had better survival than other subtypes.

The role of liver-directed surgery in patients with hepatic metastasis from primary breast cancer: a multi-institutional analysis

BACKGROUND

Data on surgical management of breast liver metastasis are limited. We sought to determine the safety and long-term outcome of patients undergoing hepatic resection of breast cancer liver metastases (BCLM).

METHODS

Using a multi-institutional, international database, 131 patients who underwent surgery for BCLM between 1980 and 2014 were identified. Clinicopathologic and outcome data were collected and analyzed.

RESULTS

Median tumor size of the primary breast cancer was 2.5 cm (IQR: 2.0-3.2); 58 (59.8%) patients had primary tumor nodal metastasis. The median time from diagnosis of breast cancer to metastasectomy was 34 months (IQR: 16.8-61.3). The mean size of the largest liver lesion was 3.0 cm (2.0-5.0); half of patients (52.0%) had a solitary metastasis. An R0 resection was achieved in most cases (90.8%). Postoperative morbidity and mortality were 22.8% and 0%, respectively. Median and 3-year overall-survival was 53.4 months and 75.2%, respectively. On multivariable analysis, positive surgical margin (HR 3.57, 95% CI 1.40-9.16; p = 0.008) and diameter of the BCLM (HR 1.03, 95% CI 1.01-1.06; p = 0.002) remained associated with worse OS.

DISCUSSION

In selected patients, resection of breast cancer liver metastases can be done safely and a subset of patients may derive a relatively long survival, especially from a margin negative resection.

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

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

Prognostic factors for patients with skeletal metastases from carcinoma of the breast

Aims

Surgical intervention in patients with bone metastases from breast cancer is dependent on the estimated survival of the patient. The purpose of this paper was to identify factors that would predict survival so that specific decisions could be made in terms of surgical (or non-surgical) management.

Methods

The records of 113 consecutive patients (112 women) with metastatic breast cancer were analysed for clinical, radiological, serological and surgical outcomes. Their median age was 61 years (interquartile range 29 to 90) and the median duration of follow-up was 1.6 years (standard deviation (sd) 1.9, 95% confidence interval (CI) 0 to 5.9). The cumulative one- and five-year rates of survival were 68% and 16% (95% Cl 60 to 77 and 95% CI 10 to 26, respectively).

Results

Linear discriminant analysis identified a ‘quadruple A’ predictor of survival by reclassifying the sum of the albumin, adjusted calcium, alkaline phosphatase and age covariates each multiplied by a determined factor. The accuracy of this ‘quadruple A’ predictor was 90% with a sensitivity of 100% and a specificity of 88%. A receiver operating characteristic (ROC) curve revealed an area under the curve of 79%. Survival analysis for this ‘quadruple A’ predictor (<  = one or > one year survival) was statistically significant using the log rank test (p = 0.0004) and Cox proportional hazard (p = 0.001). Multivariate analysis showed the 'quadruple A' predictor to be the only independent predictor of survival (p = 0.01).

Discussion

The 'quadruple A' predictor, together with other positive predictors of survival, can be used by oncologists, orthopaedic and breast surgeons to estimate survival and therefore guide management. Cite this article: Bone Joint J 2016;98-B:266–70.

SEOM clinical guidelines in metastatic breast cancer 2015

Metastatic breast cancer is essentially an incurable disease. However, recent advances have resulted in a significant improvement of overall survival. The SEOM guidelines are intended to make evidence-based recommendations on how to manage patients with metastatic breast cancer to achieve the best patient outcomes based on a rational use of the currently available therapies. To assign a level of certainty and a grade of recommendation the United States Preventive Services Task Force guidelines methodology was selected as reference.

Surgical Management of de novo Stage IV Breast Cancer

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

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

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

Prognostic relevance of pretherapeutic gamma-glutamyltransferase in patients with primary metastatic breast cancer

Background

Gamma-glutamyltransferase (GGT) is a known marker for apoptotic balance and cell detoxification. Recently, an association of baseline GGT levels and breast cancer incidence, tumor progression and chemotherapy resistance was shown. The purpose of this study was to evaluate the association of pre-therapeutic GGT levels, clinical-pathological parameters and survival in patients with primary metastatic breast cancer (PMBC).

Methods

In this multicenter analysis, pre-therapeutic GGT levels and clinical-pathological parameters of 114 patients diagnosed with PMBC between 1996 and 2012 were evaluated. The association between GGT levels and clinical-pathological parameters were analysed. Patients were stratified into four GGT risk-groups (GGT < 18.00 U/L: normal low, 18.00 to 35.99 U/L: normal high, 36.00 to 71.99 U/L: elevated and ≥ 72.00 U/L: highly elevated) and survival analyses were performed.

Findings

Patients in the high risk GGT group had a poorer overall survival, when compared to the low risk group with five-year overall survival rates of 39.5% and 53.7% (p = 0.04), respectively. Patients with larger breast tumors had a trend towards higher GGT levels (p = 0.053). Pre-therapeutic GGT levels were not associated with indicators of aggressive tumor biology such as HER2-status, triple negative histology, or poorly differentiated cancers.

Conclusion

Pre-therapeutic GGT serum level might serve as a novel prognostic factor for overall-survival in patients with PMBC.

Prognosis of metastatic breast cancer: are there differences between patients with de novo and recurrent metastatic breast cancer?

Background:

We aimed to determine the prognostic impact of time between primary breast cancer and diagnosis of distant metastasis (metastatic-free interval, MFI) on the survival of metastatic breast cancer patients.

Methods:

Consecutive patients diagnosed with metastatic breast cancer in 2007–2009 in eight hospitals in the Southeast of the Netherlands were included and categorised based on MFI. Survival curves were estimated using the Kaplan–Meier method. Cox proportional hazards model was used to determine the prognostic impact of de novo metastatic breast cancer vs recurrent metastatic breast cancer (MFI ⩽24 months and >24 months), adjusted for age, hormone receptor and HER2 status, initial site of metastasis and use of prior (neo)adjuvant systemic therapy.

Results:

Eight hundred and fifteen patients were included and divided in three subgroups based on MFI; 154 patients with de novo metastatic breast cancer, 176 patients with MFI <24 months and 485 patients with MFI >24 months. Patients with de novo metastatic breast cancer had a prolonged survival compared with patients with recurrent metastatic breast cancer with MFI <24 months (median 29.4 vs 9.1 months, P<0.0001), but no difference in survival compared with patients with recurrent metastatic breast cancer with MFI >24 months (median, 29.4 vs 27.9 months, P=0.73). Adjusting for other prognostic factors, patients with MFI <24 months had increased mortality risk (hazard ratio 1.97, 95% CI 1.49–2.60, P<0.0001) compared with patients with de novo metastatic breast cancer. When comparing recurrent metastatic breast cancer with MFI >24 months with de novo metastatic breast cancer no significant difference in mortality risk was found. The association between MFI and survival was seen irrespective of use of (neo)adjuvant systemic therapy.

Conclusion:

Patients with de novo metastatic breast cancer had a significantly better outcome when compared with patients with MFI <24 months, irrespective of the use of prior adjuvant systemic therapy in the latter group. However, compared with patients with MFI >24 months, patients with de novo metastatic breast cancer had similar outcome.

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.

Current challenges and future perspectives of radiotherapy for locally advanced breast cancer

PURPOSE OF REVIEW

To discuss current issues in the field of radiation oncology for locally advanced breast cancer (LABC).

RECENT FINDINGS

Large randomized studies involving nodal irradiation have recently been completed. The incremental benefit of treating the internal mammary nodes (IMNs) remains controversial. A randomized study specifically evaluating internal mammary node radiation (IMNR) failed to demonstrate significant benefit. A high impact, population-based study detected a proportional increase in major coronary events with increasing radiation dose. Advanced treatment techniques should be employed to reduce cardiac exposure. In patients with stage IV breast cancer (BCa), there is increasing evidence to suggest that locoregional treatments may improve overall survival (OS). Radiotherapy alone, without surgery, may provide equivalent local control and OS in patients with distant metastasis. High-dose stereotactic radiation regimens can be used to treat breast tumors with good local control rates in as few as three visits.BCa biomarkers are predictive of locoregional recurrence risk and should be used to guide radiotherapy in conjunction with standard staging. Clinically validated genetic profiling can measure tumor radiosensitivity and also help to predict normal tissue toxicity.

SUMMARY

We are entering an era of personalized radiotherapy for LABC. Radiation treatments must be tailored to each individual patient's risk and intrinsic tumor biology.

Prolonged complete response after treatment withdrawal in HER2-overexpressed, hormone receptor-negative breast cancer with liver metastases: the prospect of disappearance of an incurable disease

BACKGROUND

Metastatic breast cancer has consistently been viewed as a non-curable disease. Specific palliative treatments such as chemotherapy and hormone therapy have resulted in a mean overall survival of approximately 30 months. While cases of prolonged complete response have been reported with hormone or trastuzumab monotherapy, rendering metastatic breast cancer a chronic disease, any treatment withdrawal has ineluctably led to relapse. Prolonged remission without any anti-cancer treatment has never been reported to our knowledge.

CASE PRESENTATION

We report here the unique observation of the spontaneous evolution of two breast cancer patients with synchronous liver metastases who decided to stop trastuzumab after achieving complete response. They were Caucasian women with synchronous liver metastatic breast carcinoma. Both breast cancers reached skin and regional lymph nodes. There were several liver metastases in both patients. They received surgery, radiotherapy and chemotherapy combined with trastuzumab. They decided to stop their treatment, despite guidelines. After a follow-up longer than 20 months, they did not relapse clinically, radiologically, and biologically.

CONCLUSION

This findings question the belief of the unavoidability of recurrence of metastatic breast cancer, specifically in the liver. It opens up the unprecedented possibility of a cure-like state in exceptional and probably special cases.

[Surgical possibilities in the treatment of advanced and locally recurrent breast cancers]

Stage IV breast cancer is an incurable but treatable condition. Therapy of distant metastatic disease consists primarily of systemic and symptomatic treatments, while the role of surgery is subordinate. Conventional medical treatments result in 18-24 months average overall survival, and about 5-20% 5-year overall survival. However, it seems that in selected cases with solitary or oligometastases, mainly in those which respond well to drug therapy, the aggressive surgical removal of both the primary tumour and visceral metastases results in a survival advantage. After accurate evaluation of the patients, the indication for surgical treatment should be established through a biological and multidisciplinary approach. Other possible indications for surgical treatment are ulceration, bleeding, hygienic conditions undignified of human life, central nervous system metastases, acute neurological disorders, hydro- and pneumothorax greatly reducing respiratory surface and impending fractures. Surgical procedures include simple pleural drainage, minimal invasive techniques, large body cavity surgeries, extensive resection of soft tissue and chest wall due to the primary tumor, and plastic surgical reconstruction as well. Scientific assessment of the oncological value of surgical oncological interventions in stage IV. breast cancer require further multicentric prospective comparative studies. The present paper provides a broad review of the literature on surgical interventions and results in patients with breast cancer and remote metastases, and the surgical options of locally recurrent tumours.