Sternal/para-sternal resection for parasternal local recurrence in breast cancer

Metastasectomy versus radiation of secondary sites in stage IV breast cancer: Analysis from a national cancer registry

PURPOSE

Locoregional therapy at primary or secondary sites in breast cancer may be associated with improved survival as compared to systemic therapy alone. We explored the sociodemographic and clinicopathologic factors associated with the use of radiation versus surgical resection of metastatic sites (metastasectomy) in patients with de novo stage IV breast cancer, followed by the associated overall survival.

METHODS

We sampled the National Cancer Database for patients with de novo stage IV breast cancer, (2010-2017) and described cohort's characteristics using univariate analyses. We identified 5 subgroups based on malignant site involvement: 1. Bone only, 2. Brain only, 3. Liver only, 4. Lung only, and 5. Metastasis involving >1 site. Kaplan-Meier modeling with log-rank testing and multivariate Cox Regression analysis were used to explore differences in overall survival between those that received radiation at secondary sites and those that underwent metastasectomy.

RESULTS

N = 22,749patients were included in this analysis. Radiation (81.2%) was used more commonly than metastasectomy (28.8%). Metastasectomy was associated with better median overall survival across all 5 cohorts (p < .001), with the survival benefit being the most pronounced with lung only (OS: 56.9 months; HR 0.8, 95% CI 0.7-0.9, p = .032), or liver only (OS: 41.6 months; HR: 0.9; 95% CI: 0.7-1.1, p < .001) metastasis.

CONCLUSION

Metastasectomy in patients with de novo stage IV breast cancer may be associated with improved overall survival as compared to radiation of secondary lesions, particularly in those with only liver or lung involvement. Prospective randomized controlled trials investigating surgical resection of metastatic sites in patients with breast cancer are warranted.

Treatment Strategies for Oligometastatic Breast Cancer

OPINION STATEMENT

Oligometastatic breast cancer, typically defined as the presence of 1-5 metastases, represents an intermediate state between locally advanced and widely metastatic disease. Emerging research suggests that oligometastatic cancer has a unique molecular signature distinct from widely metastatic disease, and that it carries a superior prognosis. Owing to its more limited capacity for widespread progression, oligometastatic disease may benefit from aggressive ablative therapy to known metastases. Options for ablation include surgical excision, radiofrequency ablation, and hypofractionated image-guided radiotherapy (HIGRT). The phase II SABR-COMET trial, which enrolled patients with oligometastatic disease of multiple histologies and randomized them to HIGRT vs. standard of care, found a notable survival advantage in favor of HIGRT. Other data suggest that HIGRT may synergize with immunotherapy by releasing powerful cytokines that increase anti-tumor immune surveillance and by recruiting tumor infiltrating lymphocytes, helping to overcome resistance to therapy. There are many ongoing trials exploring the role of ablative therapy, most notably HIGRT, with or without immunotherapy, for the treatment of oligometastatic breast cancer.We believe that patients with oligometastatic breast cancer should be offered enrollment on prospective clinical trials when possible. Outside the context of a clinical trial, we recommend that select patients with oligometastatic breast cancer be offered treatment with a curative approach, including ablative therapy to all sites of disease if it can be safely accomplished. Currently, selection criteria to consider for ablative therapy include longer disease-free interval from diagnosis to metastasis (>2 years), fewer metastases, and fewer involved organs. Undoubtedly, new data will refine or even upend our understanding of the definition and optimal management of oligometastatic disease.

Single-fraction stereotactic ablative body radiotherapy for sternal metastases in oligometastatic breast cancer: Technique and single institution experience

INTRODUCTION

Due to size and close proximity to skin, the sternum is a complicated target for stereotactic ablative body radiotherapy (SABR). This is a retrospective case series of single-fraction SABR to sternal metastasis in patients with oligometastatic breast cancer.

METHODS

Between June 2014 and June 2018, ten breast cancer patients received 20 Gy in 1 fraction to a solitary sternal metastasis. Eligible patients had Eastern Cooperative Oncology Group performance status of 0-2, oligometastatic disease (defined as 1-5 metastases) and a controlled primary site. Patients were treated with 3-dimensional conformal radiotherapy, each patient case comprising of> 6 coplanar beams and 2-6 non-coplanar beams. Local control, pain response and adverse events were retrospectively reviewed.

RESULTS

The median planned target volumes were 84.75cc (range, 14.4-197.8cc). The median conformity index was 1.29 (range, 1.2-1.49). At a median follow-up of 32 months, nine patients achieved in-field control. Two patients had triple negative disease, one of them developed marginal recurrence, and the other had in-field recurrence. Seven patients had sternal pain prior to SABR, and within 3 months after SABR treatment, the pain improved (n = 3) or resolved (n = 2). Four patients developed acute grade 1 and 2 skin reactions, and two patients had late grade 1 skin reactions. There were no grade 3 or 4 toxicities.

CONCLUSION

Our case series demonstrates safety of SABR with associated disease control and analgesic benefit in selected patients with oligometastatic breast cancer. The marginal recurrence observed in this cohort suggests wider margins could be beneficial to account for microscopic disease.

Sternal resection and reconstruction for metastasis due to breast cancer: the Marlex sandwich technique and implantation of a pedicled latissimus dorsi musculocutaneous flap

Background

The treatment of hemotogenous solitary sternal metastases by breast cancer remains a controversial issue. Sternal resection for select patients might provide good long-term local control.

Case presentation

A 63-year-old woman was admitted to our hospital with a mass at the sternum and right second to third costochondral cartilage. She had undergone bilateral mastectomy for breast cancer 13 years earlier. A percutaneous biopsy was performed, and the mass was diagnosed as solitary metastasis due to breast cancer. She received two courses of weekly paclitaxel and bevacizumab, and computed tomography (CT) revealed shrinking of the mass in the sternum. We performed surgical resection with curative intent for a multimodality approach. Parasternectomy and removal of the right second and third costochondral cartilage was performed. A prosthesis was created to fill the defect by sandwiching molded methylmethacrylate between polypropylene mesh. The prosthesis was fixed to the cut ends of the costochondral cartilage and the residual sternum. Finally, a harvested latissimus dorsi myoctaneous flap was transpositioned to cover the chest midline wound. Negative surgical margins at the stump of the sternum and costochondral cartilage were revealed.

Conclusion

Parasternal resection and reconstruction by the Marlex sandwich technique and implantation of a pedicled latissimus dorsi myocutaneous flap for metastasis due to breast cancer was safely performed.

Chest Wall Resection for Recurrent Breast Cancer in the Modern Era: A Systematic Review and Meta-analysis

OBJECTIVE

To review the literature on chest wall resection for recurrent breast cancer and evaluate overall survival (OS) and quality-of-life (QOL) outcomes.

BACKGROUND

Full-thickness chest wall resection for recurrent breast cancer is controversial, as historically these recurrences have been thought of as a harbinger of systemic disease.

METHODS

A systematic search in MEDLINE, EMBASE, and Cochrane CENTRAL identified 48 eligible studies, all retrospective, accounting for 1305 patients. The review is reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary end points were patient-centered QOL outcomes and OS; secondary outcomes included disease-free survival (DFS) and 30-day morbidity. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies instrument and the Oxford Centre for Evidence-Based Medicine's levels of evidence tool. Random-effects meta-analysis was used to create pooled estimates. Meta-regressions and sensitivity analyses were used to explore study heterogeneity by age, year of publication, risk of bias, and surgical intent (curative vs palliative).

RESULTS

Studies consistently reported excellent OS and DFS in properly selected patients. Pooled estimates for 5-year OS in all studies and those from the past 15 years were 40.8% [95% confidence interval (CI) 35.2-46.7) and 43.1% (95% CI 35.8-50.7), whereas pooled 5-year DFS was 27.1% (95% CI 16.6-41.0). Eight studies reported excellent outcomes related to QOL. Mortality was consistently low (<1%) and 30-day pooled morbidity was 20.2% (95% CI 15.3%-26.3%). Study quality varied, and risk of selection bias in included studies was high.

CONCLUSIONS

Full-thickness chest wall resection can be performed with excellent survival and low morbidity. Few studies report on QOL; prospective studies should focus on patient-centered outcomes in this population.

Resection of Primary and Secondary Tumors of the Sternum: An Analysis of Prognostic Variables

BACKGROUND

We sought to determine the prognostic variables associated with overall survival (OS) and recurrence-free probability (RFP) in patients with primary and secondary sternal tumors treated with surgical resection.

METHODS

A retrospective analysis of patients who underwent resection of primary or secondary sternal tumors at 2 cancer institutes between 1995 and 2013 was performed. OS and RFP were estimated using the Kaplan-Meier method, and predictors of OS and RFP were analyzed using the Cox proportional hazards model.

RESULTS

Sternal resection was performed in 78 patients with curative (67 [86%]) or palliative (6 [8%]) intent. Seventy-three patients (94%) had malignant tumors, of which 28 (36%) were primary and 45 (57%) were secondary malignancies. Sternal resections were complete in 13 patients (17%) and partial in 65 (83%). There were no perioperative deaths, and grade III/IV complications were noted in 17 patients (22%). The 5-year OS was 80% for patients with primary malignant tumors, 73% for patients with nonbreast secondary malignant tumors, and 58% for patients with breast tumors (p = 0.85). In the overall cohort, R0 resection was associated with prolonged 5-year OS (84% vs 20%) on univariate (p = 0.004) and multivariate (adjusted hazard ratio, 3.37; p = 0.029) analysis. On subgroup analysis, R0 resection was associated with improved OS and RFP only for patients with primary malignant tumors.

CONCLUSIONS

Sternal resection can achieve favorable OS for patients with primary and secondary sternal tumors. R0 resection is associated with improved 5-year OS and RFP in patients with primary malignant tumors. We did not detect a similar effect in patients with breast or nonbreast secondary tumors.

Adenovirally delivered enzyme prodrug therapy with herpes simplex virus-thymidine kinase in composite tissue free flaps shows therapeutic efficacy in rat models of glioma

INTRODUCTION

Free flap gene therapy exploits a novel therapeutic window when viral vectors can be delivered into a flap ex vivo. The authors investigated the therapeutic potential of an adenovirally-delivered thymidine kinase/ganciclovir prodrug system expressed following vector delivery into a free flap.

METHODS

The authors demonstrated direct in vitro cytotoxicity by treating a panel of malignant cell lines with the thymidine kinase/ganciclovir system and demonstrated significant cell kill proportional to the multiplicity of infection of adenoviral vector expressing thymidine kinase. Bystander cytotoxicity was demonstrated using conditioned media from producer cells (expressing adenovirally-delivered thymidine kinase and treated with ganciclovir) to demonstrate cytotoxicity in naive tumor cells. The authors investigated the effect of adenoviral vector expressing thymidine kinase/ganciclovir therapy in vivo, using models of microscopic and macroscopic residual disease in a rodent superficial inferior epigastric artery flap model.

RESULTS

The authors observed retardation of tumor volume growth in both microscopic (p = 0.0004) and macroscopic (p = 0.0005) residual disease models and prolongation of animal survival. Gene expression studies demonstrated that viral genomic material was found predominantly in flap tissues but declined over time.

CONCLUSIONS

The authors describe the utility of virally delivered enzyme/prodrug therapy, using a free flap as a vehicle for delivery. They discuss the merits and limitations of this approach and the unique role of therapeutic free flaps among reconstructive techniques available to the plastic surgeon.

Local recurrence involving the sternum and ribs following mastectomy and titanium mesh implants for chest wall reconstruction: A case report

Approximately 30% of breast carcinoma patients experience local recurrence, which is commonly considered the first sign of treatment failure. Local recurrence involving the deep chest wall may result in thoracic defects and influence normal cardiopulmonary function. Many studies have reported various techniques using different materials for chest wall reconstruction, and titanium mesh has recently received attention as a novel bone substitute. In the present case report, a 46-year-old female who had not yet entered menopause presented for routine follow-up. Her past history was significant for having had a left modified radical mastectomy followed by chemotherapy and tamoxifen treatment for an invasive ductal breast carcinoma. Examination results revealed an invasive ductal carcinoma invading the chest wall. The patient underwent surgical excision and received a titanium mesh implant for chest wall reconstruction. The patient chose to undergo local radiation therapy and endocrine treatment following surgery. Local recurrence of breast cancer involving the deep chest wall is relatively rare. According to the guidelines, surgical excision followed by radiotherapy is the standard treatment and chemotherapy is not recommended. In our case, a titanium mesh was successfully applied for chest wall reconstruction.