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

Long-term outcomes after breast cancer liver metastasis surgery: A European, retrospective, snapshot study (LIBREAST STUDY)

INTRODUCTION

Breast cancer (BC) is the most common malignant tumor in women. Between 20 % and 30 % of patients develop metastases from BC, 50 % of them in the liver. The mean survival rate reported in patients with liver metastases from BC (LMBC) ranges from 3 to 29 months. The role of surgery in LMBC is not clearly defined. The objective of the present study was to determine the long-term survival and disease-free survival of patients undergoing surgery for LMBC and to identify the patients who most likely benefit from surgery.

MATERIAL AND METHODS

This retrospective multicenter cohort study included all consecutive patients undergoing LMBC surgery at the participating European centers from January 1, 2010, to December 31, 2015. The ClinicalTrials.gov ID is NCT04817813.

RESULTS

A hundred women (mean age 52.6 years) undergoing LMBC surgery were included. Five-year disease-free survival was 29 %, and 5-year overall survival was 60 %. Median survival after BC surgery was 12.4 years, and after LMBC surgery, 7 years. Patients with ECOG 1, ASA score I-II, metachronous LMBC, positive hormone receptors, and who had received neoadjuvant and adjuvant hormone treatment obtained the best overall and disease-free survival results.

CONCLUSIONS

In cases of correct patient selection and as part of a comprehensive onco-surgical strategy, surgery for LMBC improves overall long-term survival. In our series, certain factors were linked to better disease-free and overall survival; consideration of these factors could improve the selection of the best candidates for LMBC surgery.

CLINICALTRIALS

GOV ID

NCT04817813.

Surgery for liver metastases from primary breast cancer: A reconstructed individual patient data meta-analysis

BACKGROUND

Currently, the outcomes of standard-of-care palliative treatment for BCLM remain poor. Recent literature has shown promising results of hepatic resection, however, not all studies concur. Given the lack of standardized international guidelines in this field, the aim of this study is to provide gold-standard evidence for breast cancer liver metastases (BCLM) through a reconstructed individual patient data meta-analysis approach.

METHODS

Four databases were searched for articles comparing surgical and non-surgical treatment for BCLM. One-stage meta-analysis was performed using patient-level survival data reconstructed from Kaplan-Meier curves with plot digitizer software. Shared-frailty and stratified Cox models were fitted to compare survival endpoints.

RESULTS

Four propensity-score matched (PSM) studies involving 205 surgical and 291 non-surgical patients for BCLM were included. There was a significant difference between both groups for overall survival (OS) (Hazard Ratio [HR] = 0.40, 95%CI 0.32-0.51). Sensitivity analyses for hormone receptor status of breast cancer (HR = 0.41, 95%CI 0.31-0.55) and type of resection performed (HR = 0.45, 95%CI 0.33-0.61) yielded HRs in favor of surgery.

CONCLUSIONS

This meta-analysis concludes that surgery offers superior OS outcomes, compared to non-surgery, in a select group of patients. Future randomized controlled trials and PSM studies are warranted, using this study as a point of reference for similar parameters.

Improved survival in patients with isolated liver metastasis at initial diagnosis with surgery at primary and metastatic sites: A population-based study in patients with breast cancer

BACKGROUND

The aim of this study was to investigate epidemiological characteristics, risk factors, optimal treatment options, and survival outcomes of breast cancer patients with isolated liver metastasis (BCILM).

METHODS

Patients with breast cancer (BC) were selected from Incidence-Surveillance, Epidemiology, and End Results (SEER) Research Plus Data, 17 registries between 2010 and 2019. The Kaplan-Meier method and log-rank test were used to compare survival rates between patients who received or did not receive surgery for the primary and liver metastatic sites. Univariate and multivariate analyses were conducted using Cox regression analysis.

RESULTS

This study included 17 743 stage IV BC patients, with 3604 (20.3%) patients experiencing liver metastasis at initial diagnosis. Of 3604 liver metastasis patients, 951 were diagnosed with BCILM. The median survival time of patients with BCILM who underwent surgery at the primary site (52.0 months) or distant sites (85.0 months) was significantly longer than that of patients who did not undergo surgery at the primary site (23.0 months) or distant sites (32.0 months). Univariate analysis indicated that age, race, histological grade, molecular subtype, T stage, N stage, surgery of the primary site, surgery to other regional/distant sites, radiotherapy, and chemotherapy were prognostic factors affecting the overall survival (OS) and cancer-specific survival (CSS) of patients with BCILM (p < 0.05). Multivariate analysis suggested that age, race, molecular subtype, T stage, surgery of the primary site, radiotherapy, and chemotherapy were independent prognostic factors. In the BCILM cohort, HR+ /HER2+ patients exhibited the best OS and CSS, followed by HR- /HER2+ , HR+ /HER2- , and HR- /HER2- patients (p < 0.0001; p < 0.0001).

CONCLUSION

Surgery at the primary and metastatic sites was associated with better survival in patients with BCILM. HER2+ patients with BCILM had a significantly better prognosis than HER2- 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.

Potential molecular mechanisms and clinical progress in liver metastasis of breast cancer

Breast cancer is the most common malignant tumor in women and the leading cause of cancer death in women. About 30% of breast cancer patients have metastasis every year, which greatly increases the mortality rate of breast cancer. The main target organs for metastasis are bone, brain, liver and lung. The breast cancer liver metastasis (BCLM) mechanism is not fully clarified. This is a complex process involving multiple factors, which is not only related to the microenvironment of the primary tumor and liver, but also regulated by a variety of signaling pathways. Clarifying these mechanisms is of great help to guide clinical treatment. With the in-depth study of BCLM, a variety of new treatment schemes such as targeted therapy and endocrine therapy provide new ideas for the cure of BCLM. In this review, we will summarize the molecular mechanism and treatment of BCLM.

Does hepatectomy improve outcomes of breast cancer with liver metastasis? A nationwide analysis of real-world data in Taiwan

Background

Liver metastases from breast cancer are associated with poor prognosis, and treatment options are usually restricted to palliative systemic therapy. The impact of liver resection on metastasis remains controversial. The aim of this study is to investigate whether liver resection can offer better survival outcomes in cases of isolated liver metastases from breast cancer.

Methods

We conducted a nationwide cohort study using a claims dataset from Taiwan’s National Health Insurance Research Database (NHIRD). We identified all patients with breast cancer (diagnostic code ICD-9: 174.x) from the Registry for Catastrophic Illness Patient Database (RCIPD) of the NHIRD who underwent mastectomy between January 1, 2000, and December 31, 2008. Patients with other malignancies (history, initially, or during follow-up), those with a history of metastasis prior to or at initial admission for mastectomy, and those without liver metastases were excluded. Patients with other metastases between mastectomy and liver metastasis and those who died at first admission for liver resection were also excluded. All patients were followed up until December 31, 2013, or withdraw from the database because of death.

Results

Data were analyzed for 1,116 patients who fulfilled the inclusion criteria (resection group: 89; non-resection group: 1,027). There were no differences in age, Charlson Comorbidity Index, or major coexisting diseases except renal disease between two groups. Kaplan–Meier analysis demonstrated that the liver resection group had significantly better overall survival (OS) than the non-resection group. (1-year: 96.6% vs. 52.3%, 2-year: 86.8% vs. 35.4%, 3-year: 72.3% vs. 25.2%, 5-year: 51.6% vs. 16.9%, respectively, p<0.001). Cox analysis revealed that the liver resection group exhibited a significant improvement in patient survival (hazard ratio [HR] = 0.321, 95% confidence interval [CI]: 0.234–0.440, p<0.001).

Conclusion

These findings indicate that liver resection may offer better survival benefit in patients with breast cancer who develop new liver metastases post mastectomy.

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.

Hepatic resection for breast cancer related liver metastases: A single institution experience

BACKGROUND & OBJECTIVE

Liver resection for breast cancer liver metastases is becoming a more widely accepted therapeutic option for selected groups of patients. The aim of this study was to describe the outcomes of patients undergoing liver resection for breast cancer-related liver metastases and identify any variables associated with recurrence or survival.

METHODS

A retrospective review of a prospectively maintained database was undertaken for the 12 year period between 2009 and 2021. Clinicopathological, treatment, intraoperative, recurrence, survival and follow-up data were collected on all patients. Kaplan-Meier methods, the log-rank test and Cox proportional hazards regression analysis were used to identify variables that were associated with recurrence and survival.

RESULTS

A total of 20 patients underwent 21 liver resections over the 12-year period. There were no deaths within 30 days of surgery and an operative morbidity occurred in 23.8% of cases. The median local recurrence free survival and disease free survival times were both 50 months, while the 5 year overall survival rate was 65%. The presence of extrahepatic metastases were associated with a decreased time to local recurrence (p < 0.01) and worse overall survival (p = 0.02).

CONCLUSIONS

This study has demonstrated that liver resection for breast cancer-related liver metastases is feasible, safe and associated with prolonged disease free and overall survival in selected patients. It is likely that this option will be offered to more patients going forward, however, the difficulty lies in selecting out those who will benefit from liver resection particularly given the increasing number of systemic treatments and local ablative methods available that offer good long-term results.

Survival Benefit of Surgical Treatment Added Into Systemic Treatment for Isolated Breast Cancer Liver Metastases: A Systematic Review and Meta-Analysis

Background: Compared with systemic treatment alone, whether surgical treatment combined with systemic treatment can improve survival outcomes of patients with isolated breast cancer liver metastases (BCLM) is still controversial. This meta-analysis was designed to evaluate the efficacy of surgical treatment for patients with isolated BCLM.

Methods: A systematic search of PubMed, Embase, and Cochrane Library up to May 13, 2021 was conducted for relevant studies. The primary outcome was overall survival. The meta-analysis was performed using R software. The quality of the pooled study was assessed using the Newcastle-Ottawa scale. The publication bias was evaluated by funnel plots and Begg's and Egger's tests. Fixed- and random-effects models were applied according to heterogeneity.

Results: 9 retrospective studies involving 13 cohorts (7 unmatched cohorts and 6 matched cohorts) were included in this study. The surgical cohorts had better overall survival than the systemic cohorts in the pooled analysis of all the included studies, in the subgroup analysis of liver resection, and in the subset of the matched cohorts.

Conclusions: Compared with systemic treatment alone, surgical treatment combined with systemic treatment was proven to be associated with superior survival outcomes, which should be considered in selected patients with isolated BCLM.

Surgical Management of Breast Cancer Liver Metastasis

Hepatic resection for patients with isolated breast cancer liver metastases (BCLM) is associated with prolonged disease-free interval and better overall survival in highly selected patients. Patients with limited disease who are not candidates for surgery benefit from ablative therapies for isolated breast cancer metastasis in addition to systemic chemotherapy. In the era of modern effective systemic chemotherapy for BCLM, local regional therapies are warranted, yet only in well-selected patients following discussion in a multidisciplinary setting. This article reviews data related to hepatic resection and ablative therapies of BCLM, as well as long-term outcomes of women treated with these approaches.