Transarterial chemoembolisation (TACE) with gemcitabine: phase II study in patients with liver metastases of breast cancer

Role of Interventional Radiology in Managing Primary and Metastatic Breast Cancer

Percutaneous image-guided locoregional therapies are emerging in the treatment of primary and metastatic breast cancer. Cryoablation has emerged as the dominant ablative approach as an alternative to surgery for primary breast cancer in patients who do not wish to have surgery or are poor surgical candidates. Cryoablation is well tolerated and provides excellent local control and cosmesis. Thermal ablation may also be used in the treatment of oligometastatic breast cancer, allowing patients to achieve long disease-free intervals. Transarterial therapies have been studied in the treatment of oligoprogressive hepatic metastasis, though further supportive data would be helpful to demonstrate its efficacy.

Locoregional Therapies for Primary and Metastatic Breast Cancer: AJR Expert Panel Narrative Review

Minimally invasive locoregional therapies have a growing role in the multidisciplinary treatment of primary and metastatic breast cancer. Factors contributing to the expanding role of ablation for primary breast cancer include earlier diagnosis, when tumors are small, and increased longevity of patients whose condition precludes surgery. Cryoablation has emerged as the leading ablative modality for primary breast cancer owing to its wide availability, the lack of need for sedation, and the ability to monitor the ablation zone. Emerging evidence suggests that in patients with oligometastatic breast cancer, use of locoregional therapies to eradicate all disease sites may confer a survival advantage. Evidence also suggests that transarterial therapies-including chemoembolization, chemoperfusion, and radioembolization-may be helpful to some patients with advanced liver metastases from breast cancer, such as those with hepatic oligoprogression or those who cannot tolerate systemic therapy. However, the optimal modalities for treatment of oligometastatic and advanced metastatic disease remain unknown. Finally, locoregional therapies may produce tumor antigens that in combination with immunotherapy drive anti-tumor immunity. Although key trials are ongoing, additional prospective studies are needed to establish the inclusion of interventional oncology in societal breast cancer guidelines to support further clinical adoption and improved patient outcomes.

Interventional oncology in breast cancer

Breast cancer (BC) is the most common cancer and one of the most important causes of death in women. Surgery is the standard therapy for breast cancer and in the last decades evolved towards a more conservative approach, with lumpectomy, followed by radiation therapy, the most common option. Unfortunately, up to 40% of women affected by BC will develop metastases and will receive systemic therapy, which improves survival and quality of life. Interventional oncology (IO), thanks to the improvement in technology and clinical experience, is gaining an important role in the field of breast cancer, both in treating the primary tumour and also in metastasis in well-selected cases. Percutaneous thermal ablation and more recently cryoablation are reported to achieve promising results in the radical treatment of small breast cancer, with optimal cosmetic outcome and a very high safety profile. Percutaneous ablation as well as intra-arterial therapies, such as chemoembolization and radioembolization, might also be indicated in metastatic BC patients. In advanced stage disease, breast cancer liver metastases (BCLM) represent the main factor affecting the overall survival. Metastatic breast disease is a systemic disease, with tumour deposits potentially spread into different organs and tissues for which systemic therapy is the standard approach. Local therapies for liver metastases might have an important role in improving survival and quality of life in well-selected patients. Clinical and technical indications with their limitations, results and potential complications in local IO treatment for BCLM, will be also described.

New Frontiers in the Role of Locoregional Therapies in Breast Cancer: Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel

Emerging evidence regarding the effectiveness of locoregional therapies (LRTs) for breast cancer has prompted investigation of the potential role of interventional radiology (IR) in the care continuum of patients with breast cancer. The Society of Interventional Radiology Foundation invited 7 key opinion leaders to develop research priorities to delineate the role of LRTs in both primary and metastatic breast cancer. The objectives of the research consensus panel were to identify knowledge gaps and opportunities pertaining to the treatment of primary and metastatic breast cancer, establish priorities for future breast cancer LRT clinical trials, and highlight lead technologies that will improve breast cancer outcomes either alone or in combination with other therapies. Potential research focus areas were proposed by individual panel members and ranked by all participants according to each focus area's overall impact. The results of this research consensus panel present the current priorities for the IR research community related to the treatment of breast cancer to investigate the clinical impact of minimally invasive therapies in the current breast cancer treatment paradigm.

CalliSpheres drug-eluting beads transarterial-chemoembolization in the treatment of liver metastases from breast cancer: Initial experience in 14 patients

Breast cancer patients with liver metastases are associated with high mortality. However, no standardized treatment approach is available for these patients who have undergone chemotherapy and hormonal therapy. We aimed to assess the clinical outcomes of patients with breast cancer liver metastases (BCLM) who underwent drug-eluting beads used for transarterial-chemoembolization (DEB-TACE).We retrospectively enrolled 14 patients with 39 lesions who underwent DEB-TACE for liver metastases following mastectomy for primary breast cancer. The incidence of complications, overall survival (OS), and local tumor progression-free survival (PFS) were assessed.A total of 14 patients with 39 liver metastases were treated with DEB-TACE from July 2017 to July 2020. The objective response rates (ORR) and disease control rates (DCR) were 71.4% and 92.8% at the 3-month period and 50% and 71.4% at the 6-month period, respectively. During the follow-up period the local tumor PFS was 8.0 months. The median OS was 20.0 months (range, 8-40 months) and the 1-, 2-year OS rates were 84.4% and 47.4%, respectively. No severe complications caused by this technique were detected.DEB-TACE for BCLM was characterized as a low trauma technique, with a limited number of complications. The results indicated that this method was safe and effective for patients with BCLM and could be widely adopted as a palliative treatment in clinical practice.

Clinical Effectiveness of Hypofractionated Proton Beam Therapy for Liver Metastasis From Breast Cancer

Background

Few studies of proton beam therapy (PBT) for patients with liver metastasis from breast cancer (LMBC) are available to date. The aim of the present study was to evaluate the clinical effectiveness of PBT for patients with LMBC.

Material and Methods

Seventeen patients with LMBC treated with PBT were included in this study. The median prescribed dose of PBT was 66 GyE (range, 60-80) in 10 fractions, 5 times a week. In patients with LMBC receiving PBT, freedom from local progression (FFLP), progression-free survival (PFS), and overall survival (OS) rates were assessed.

Results

The median follow-up time was 34.2 months (range, 11.5-56.1). The median FFLP time was not yet reached, and the 3-year FFLP rates were 94.1% (95% confidence interval [CI], 82.9-105.3). The median times of PFS and OS were 7.9 months (95% CI, 5.3-10.5) and 39.3 months (95% CI, 33.2-51.9), respectively, and the 3-year PFS and OS rates were 19.6% (95% CI, -1.8-41.0) and 71.7% (95% CI, 46.8-96.6), respectively. Grade 3 or higher adverse events were not observed.

Conclusion

PBT for patients with LMBC showed promising FFLP and OS with safe toxicity profiles. These findings suggest that PBT can be considered a local treatment option in patients with LMBC.

Hepatic Artery Infusion Pump Combined With Systemic Chemotherapy for Patients With Liver Metastases From Breast Carcinoma

Background: When liver metastasis in patients with breast cancer is diagnosed, treatment is generally palliative and usually consists of systemic therapies only. This study aimed to evaluate the efficacy and safety of hepatic arterial infusion (HAI) combined with systemic chemotherapy in patients with breast carcinoma liver metastases (BCLM). Methods: From January 2012 to December 2019, HAI catheter systems were implanted under the guide of digital subtract angiography (DSA) in 19 patients with BCLM. All patients received systemic chemotherapy and HAI gemcitabine plus floxuridine (FUDR). Methods: The overall response rate (ORR) of intrahepatic lesions was 73.7%, including 2 patients (10.5%) with complete remission (CR) and 12 patients (63.2%) with partial remission (PR). Additionally, we found that young patients (age < 55 years) had a higher ORR than the older (100% vs 44.4%, P = .011). The median overall survival (mOS) was 13.1 months. Kaplan-Meier survival curves demonstrated that the mOS was not significantly different between patients with < 9 intrahepatic lesions and those with ≥ 9 lesions (13.7 months vs 10.9 months, P = .225). The mOS was 14.3 and 10.6 months for patients without extrahepatic metastases and with extrahepatic metastases, respectively (P = .016). None of the patients had grade 4 toxicity. The grade 3 toxicities included leucopenia, neutropenia and diarrhea. Conclusions: HAI gemcitabine plus FUDR combined with systemic chemotherapy is effective in achieving a high local response and prolonging mOS for patients with BCLM and is associated with a relatively low rate of toxicity.

Are spine metastasis survival scoring systems outdated and do they underestimate life expectancy? Caution in surgical recommendation guidance

OBJECTIVE

Survival scoring systems for spine metastasis (SPM) were designed to help surgical practice. The authors sought to validate the prognostic accuracy of the main preoperative scoring systems for SPM.

METHODS

It was hypothesized that true patient survival in SPM was better than that predicted using prognosis scores. To investigate this hypothesis, the authors designed a French national retrospective study of a prospectively collected multicenter database involving 739 patients treated for SPM between 2014 and 2017.

RESULTS

In this series, the median survival time for all patients from an SPM diagnosis was 17.03 ± 1.5 months. Sensitivity and specificity were estimated using the area under the curve (AUC). The AUC of Tomita's prognosis score was the lowest and poorest (0.4 ± 0.023, range 0.35-0.44), whereas the AUC of the Tokuhashi score was the highest (0.825). The Lei score presented an AUC of 0.686 ± 0.022 (range 0.64-0.7), and the Rades score showed a weaker AUC (0.583 ± 0.020, range 0.54-0.63). Differences among AUCs were all statistically significant (p < 0.001). The modified Bauer score and the Rades score had the highest rate of agreement in predicting survival, with a weighted Cohen's kappa of 0.54 and 0.41, respectively, indicating a moderate agreement. The revised Tokuhashi and Lei scores had a fair rate of agreement (weighted Cohen's kappa = 0.24 and 0.22, respectively). The van der Linden and Tomita scores demonstrated the worst performance, with only a "slight" rate of agreement (weighted Cohen's kappa = 0.19 and 0.16, respectively) between what was predicted and the actual survival.

CONCLUSIONS

The use of prognostic scoring systems in the estimation of survival in patients with SPM has become obsolete and therefore underestimates survival. Surgical treatment decisions should no longer be based on survival estimations alone but must also take into account patient symptoms, spinal instability, and quality of life.

Intra-Arterial Therapies for Liver Metastatic Breast Cancer: A Systematic Review and Meta-Analysis

PURPOSE

Performing a systematic review and meta-analysis to assess the evidence of intra-arterial therapies in liver metastatic breast cancer (LMBC) patients.

METHODS

A systemic literature search was performed in PubMed, EMBASE, SCOPUS for studies regarding intra-arterial therapies in LMBC patients. Full text studies of LMBC patients (n ≥ 10) published between January 2010 and December 2020 were included when at least one outcome among response rate, adverse events or survival was available. Response rates were pooled using generalized linear mixed models. A weighted estimate of the population median overall survival (OS) was obtained under the assumption of exponentially distributed survival times.

RESULTS

A total of 26 studies (1266 patients) were included. Eleven articles reported on transarterial radioembolization (TARE), ten on transarterial chemoembolization (TACE) and four on chemo-infusion. One retrospective study compared TARE and TACE. Pooled response rates were 49% for TARE (95%CI 32-67%), 34% for TACE (95%CI 22-50%) and 19% for chemo-infusion (95%CI 14-25%). Pooled median survival was 9.2 months (range 6.1-35.4 months) for TARE, 17.8 months (range 4.6-47.0) for TACE and 7.9 months (range 7.0-14.2) for chemo-infusion. No comparison for OS was possible due to missing survival rates at specific time points (1 and 2 year OS) and the large heterogeneity.

CONCLUSION

Although results have to be interpreted with caution due to the large heterogeneity, the superior response rate of TARE and TACE compared to chemo-infusion suggests first choice of TARE or TACE in chemorefractory LMBC patients. Chemo-infusion could be considered in LMBC patients not suitable for TARE or TACE.

LEVEL OF EVIDENCE

3a.

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

Background

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

Methods

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

Results

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

Conclusion

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

Hepatic Metastasis from Breast Cancer

Breast cancer is the most common cancer in women and breast cancer liver metastasis may be associated with poor outcomes. Emerging locoregional therapies can be given in outpatient settings or with short hospital stays, to provide local control, support quality of life, preserve liver function, and potentially prolong survival. This review discusses retrospective studies suggesting potential benefits of locoregional treatment of breast cancer liver metastasis. Future prospective studies are needed to demonstrate efficacy and optimize patient selection.

Surgical therapy for breast cancer liver metastases

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

Role of Diffusional Kurtosis Imaging in Evaluating the Efficacy of Transcatheter Arterial Chemoembolization in Patients with Liver Cancer

Objective: To explore the role of diffusional kurtosis imaging (DKI) in evaluating the efficacy of transcatheter arterial chemoembolization (TACE) in patients with liver cancer. Materials and Methods: A total of 54 patients with primary liver cancer underwent TACE were selected as the study subjects. Magnetic resonance imaging and DKI scans were carried out before and after TACE, and the relevant parameters were analyzed. Results: Compared with those before TACE, the values of radial diffusivity (Dr), axial diffusivity (Da), and mean diffusivity (MD) of tumor tissues in the patients after TACE were significantly increased, whereas the values of axial kurtosis (Ka), fractional anisotropy of kurtosis (FA_k), hepatic blood volume (HBV), hepatic blood flow (HBF), and hepatic artery perfusion (HAP) were notably decreased (p < 0.05). There were no significant changes regarding FA, radial kurtosis (Kr), mean kurtosis (MK), hepatic arterial fracture (HAF), permeability-surface area product (PS), mean transit time (MTT), and portal vein perfusion (PVP) (p > 0.05). The differences in apparent diffusion coefficients (ADCs) of different liver cancer tissues in patients under different b values after operation were statistically significant, and the ADC values of liver cancer tissues were evidently higher than those of other tumor tissues (p < 0.05). Conclusion: DKI is characterized with advantages such as fastness, simpleness, high resolution, and impregnability of the density of lipiodol. It can not only directly reflect the changes in blood perfusion at the lesion but also accurately and efficiently evaluate the remnants, necrosis, and recurrence of tumor tissues based on changes in ADC under different b values. It provides certain clinical assistance for the evaluation of the efficacy before and after TACE.

Local Treatment of Breast Cancer Liver Metastasis

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

Multimodality palliative treatment with transarterial chemoembolization and high-intensity focused ultrasound for gastric leiomyosarcoma multiple liver metastasis pain: A case report

INTRODUCTION

Gastric leiomyosarcoma (LMS) is a rare malignancy with minimal therapeutic options and has poor prognosis once metastasis develops.

PATIENT CONCERNS

A case of gastric LMS with multiple metastases, pain, and progressive anemia 13 months after the initial diagnosis in a 43-year-old woman.

DIAGNOSIS

Gastric LMS with liver metastases and multiple retroperitoneal lymphatic metastases.

INTERVENTIONS

Minimally invasive therapies of repeated tetrahydropalmatine and oxaliplatin-based transarterial chemoembolization and high-intensity focused ultrasound treatment were performed.

OUTCOMES

The treatments resulted in significant pain relief (numerical rating scale from 8-2 points) after the initial treatment, improvement in performance status and quality of life, and a progression-free survival of 4 months after treatment.

CONCLUSION

This combined modality palliative treatment approach was well tolerated with noticeable pain relief.

Palliative TACE for hepatic metastases of chromophobe renal cell carcinoma

We describe the case of a man with chromophobe renal cell carcinoma (chRCC) and numerous metastatic lesions restricted to the liver. Despite extensive courses of various systemic targeted chemotherapies, progressive disease was noted on CT and MRI and the patient suffered from persistent abdominal pain associated with his metastatic lesions. The liver lesions and associated symptoms were effectively palliated with serial transarterial chemoembolisation (TACE). While it is unclear if TACE has impacted his overall survival, this case encourages the use of TACE for palliative intent for patients with metastatic chRCC.

Retracted Article: Gemcitabine aggravates miR-199a-5p-mediated breast cancer cell apoptosis by promoting VEGFA downregulation via inactivating the AKT signaling pathway

Breast cancer is the most frequent malignancy diagnosed in women, and Gemcitabine-based therapy is frequently used to treat late-stage breast cancer. miR-199a-5p plays a tumor-suppressive role in breast cancer. This work aimed to explore the mechanism of miR-199a-5p plus Gemcitabine in breast cancer cells. Expression of miR-199a-5p was measured by RT-qPCR, while expression of vascular endothelial growth factor A (VEGFA) was measured by Western blot and RT-qPCR. Overexpression of miR-199a-5p and/or silencing of VEGFA was obtained using transfection in breast cancer cells (MCF-7 and MDA-MB-231). Functional experiments were performed to explore cell viability, apoptosis rate, and expressions of apoptosis-related genes: cell viability was assessed by MTT staining, apoptosis rate was recorded by flow cytometry, and Western blot was used to evaluate the expressions of Bcl-2, Bax and cleaved caspase 3. The signaling pathway was studied with respect to AKT activity via determination of p-AKT expression levels. Our study found that miR-199a-5p was downregulated and VEGFA was upregulated in breast cancer tissues and cells. Overexpression of miR-199a-5p and/or silencing of VEGFA contributed to cell apoptosis and inhibited cell viability, which was promoted by Gemcitabine. VEGFA was a downstream target of miR-199a-5p, and was negatively regulated by Gemcitabine. Moreover, Gemcitabine aggravated the miR-199a-5p-induced suppression of the VEGFA level and AKT activity in breast cancer cells. Our data show that Gemcitabine aggravates miR-199a-5p-mediated VEGFA downregulation and apoptosis via inactivating the AKT signaling pathway in breast cancer cells, indicating a novel promising combined therapy of miR-199a-5p overexpression and Gemcitabine.

Hepatic Arterial Infusion Chemotherapy Is a Feasible Treatment Option for Breast Cancer with Liver-predominant Metastatic Disease

BACKGROUND

Patients with liver metastasis from breast cancer (LMBC) are usually offered systemic therapy. However, for those with progressive liver disease and limited extra-hepatic conditions, local liver management becomes an option. Herein we present our experience with hepatic arterial infusion chemotherapy (HAIC).

PATIENTS AND METHODS

From 1999 to 2018, 42 patients with LMBC, who had progressive liver metastasis after systemic therapy, were treated with HAIC. A catheter was placed angiographically into the hepatic artery and remained there for 5 consecutive days. One cycle of chemotherapy consisted of mitoxantrone, 5-fluorouracil, folinic acid, and cisplatin. This treatment was repeated at monthly intervals. The medical records were reviewed and analyzed for hepatic tumor response, progression-free survival, overall survival and adverse effects.

RESULTS

Complete response was observed in two patients (5%), partial response in 18 patients (43%) and stable disease in eight patients (19%). Fourteen patients (33%) had progressive disease after HAIC. The median progression-free survival and overall survival were 8.4 and 19.3 months, respectively. There was no death related to HAIC. The patients with response to the treatment had a significant survival benefit (p<0.005).

CONCLUSION

HAIC can be an option for those with progressive liver disease who are heavily pretreated while their extra-hepatic conditions are minimal or stable.

Metastatic and triple-negative breast cancer: challenges and treatment options

The major current conventional types of metastatic breast cancer (MBC) treatments include surgery, radiation, hormonal therapy, chemotherapy, or immunotherapy. Introducing biological drugs, targeted treatment and gene therapy can potentially reduce the mortality and improve the quality of life in patients with MBC. However, combination of several types of treatment is usually recommended. Triple negative breast cancer (TNBC) accounts for 10-20% of all cases of breast carcinoma and is characterized by the low expression of progesterone receptor (PR), estrogen receptor (ER), and human epidermal growth factor receptor 2 (HER2). Consequently, convenient treatments used for MBC that target these receptors are not effective for TNBC which therefore requires special treatment approaches. This review discusses the occurrence of MBC, the prognosis and predictive biomarkers of MBC, and focuses on the novel advanced tactics for treatment of MBC and TNBC. Nanotechnology-based combinatorial approach for the suppression of EGFR by siRNA and gifitinib is described.

Locoregional Therapies for the Treatment of Hepatic Metastases from Breast and Gynecologic Cancers

Breast cancer is the most common women's malignancy in the United States and is the second leading cause of cancer death. More than half of patients with breast cancer will develop hepatic metastases; this portends a poorer prognosis. In the appropriately selected patient, there does appear to be a role for curative (surgery, ablation) or palliative (intra-arterial treatments) locoregional therapy. Gynecologic malignancies are less common and metastases to the liver are most often seen in the setting of disseminated disease. The role of locoregional therapies in these patients is not well reported. The purpose of this article is to review the outcomes data of locoregional therapies in the treatment of hepatic metastases from breast and gynecologic malignancies.

Transarterial chemoembolisation for breast cancer with liver metastasis: A systematic review

BACKGROUND

There is limited data on the impact of transarterial chemoembolisation (TACE) on survival in patients of breast cancer with liver metastasis (BCLM).

METHODS

A systematic review was conducted to assess TACE effect on BCLM patients. A search for clinical studies published since 1/1/2000 to 1/1/2017 was performed. Survival data from all studies were extracted to evaluate the efficacy of TACE, including overall survival, disease free survival and response rate. Toxic side effects data were also extracted to assess the safety of TACE.

RESULTS

A total of 10 studies with 519 BCLM patients were identified. 78.0% patients were treated with TACE, 9.9% were treated with TACE plus systematic chemotherapy and 12.1% were treated with systematic chemotherapy alone. Pooled median overall survival of patients who received TACE ranged from 7.3 to 47.0 months, median disease free survival ranged from 2.9 to 17.0 months and response rates ranged from 7.0 to 73.5%. Pooled Grade 3 and 4 side effects (blood toxicities, liver toxicity and post-embolization syndrome) ranged from 0.0 to 17.4%.

CONCLUSIONS

TACE is one of an effective treatment for BCLM and whether a specific patient is appropriate to receive TACE depends on a multiple disciplinary team discussion.

Metastatic Liver Disease: Indications for Locoregional Therapy and Supporting Data

Metastatic liver disease is a major cause of cancer-related morbidity and mortality. Surgical resection is considered the only curative treatment, yet only a minority is eligible. Patients who present with unresectable disease are treated with systemic agents and/or locoregional therapies. The latter include thermal ablation and catheter-based transarterial interventions. Thermal ablation is reserved for those with limited tumor burden. It is used to downstage the disease to enable curative surgical resection, as an adjunct to surgery, or in select patients it is potentially curative. Transarterial therapies are indicated in those with more diffuse disease. The goals of care are to palliate symptoms and prolong survival. The indications and supporting data for thermal ablation and transarterial interventions are reviewed, technical and tumor factors that need to be considered prior to intervention are outlined, and finally several cases are presented.

Making the Case: Intra-arterial Therapy for Less Common Metastases

Intra-arterial therapies have high antitumor activity for both primary and secondary hepatic malignancies. Selective infusions allow increased delivery of cytoreductive therapy to the tumor bed while sparing the normal hepatic parenchyma. These therapies are now often applied in the outpatient setting or with short overnight hospital stays and have a growing role in the treatment of liver-dominant disease from metastatic colorectal cancer and from neuroendocrine tumors. Less commonly, intra-arterial therapies are applied to treat secondary hepatic malignancies from breast cancer, melanoma, pancreatic adenocarcinoma, and soft-tissue sarcomas. The available data are limited and generally retrospective observational cohort series of single institutions. The purpose of this article is to summarize the recent literature on outcomes for intra-arterial therapy in nonsurgical patients. Multi-institutional registries and prospective data are greatly needed, as intra-arterial therapies are increasingly applied in these patients to stop progression of chemorefractory tumors.

Intraarterial Liver-Directed Therapies: The Role of Interventional Oncology

BACKGROUND

Since the early 1990s, the minimally invasive image-guided therapies used in interventional oncology to treat hepatocellular carcinoma have continued to evolve. Additionally, the range of applications has been expanded to the treatment of hepatic metastases from colorectal cancer, neuroendocrine tumors, cholangiocarcinoma, breast cancer, melanoma, and sarcoma.

METHODS

We searched the literature to identify publications from 1990 to the present on various image-guided intraarterial therapies and their efficacy, as well as their role in the management of primary and secondary liver malignancies.

RESULTS

Chemoembolization and radioembolization are considered a standard of care in treating, delaying progression of disease, and downstaging to bridge to liver transplantation. Progression-free survival and overall survival outcomes are promising in patients with colorectal cancer and neuroendocrine tumors with liver metastases. Applications in the treatment of hepatic metastases from cholangiocarcinoma, breast cancer, melanoma, and sarcoma also show potential.

CONCLUSION

Interventional oncology and its image-guided intraarterial therapies continue to gain recognition as treatment options for primary and secondary liver cancers. Growing evidence supports their role as a standard of care alongside medical oncology, surgery, and radiation oncology.

Surgery for liver metastases from breast cancer

INTRODUCTION

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

AIM

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

MATERIALS & METHODS

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

RESULTS

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

CONCLUSION

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

Arterial Therapies of Non-Colorectal Liver Metastases

BACKGROUND

The unique situation of the liver with arterial and venous blood supply and the dependency of the tumor on the arterial blood flow make this organ an ideal target for intrahepatic catheter-based therapies. Main forms of treatment are classical bland embolization (TAE) cutting the blood flow to the tumors, chemoembolization (TACE) inducing high chemotherapy concentration in tumors, and radioembolization (TARE) without embolizing effect but very high local radiation. These different forms of therapies are used in different centers with different protocols. This overview summarizes the different forms of treatment, their indications and protocols, possible side effects, and available data in patients with non-colorectal liver tumors.

METHODS

A research in PubMed was performed. Mainly clinical controlled trials were reviewed. The search terms were 'embolization liver', 'TAE', 'chemoembolization liver', 'TACE', 'radioembolization liver', and 'TARE' as well as 'chemosaturation' and 'TACP' in the indications 'breast cancer', 'neuroendocrine', and 'melanoma'. All reported studies were analyzed for impact and reported according to their clinical relevance.

RESULTS

The main search criteria revealed the following results: 'embolization liver + breast cancer', 122 results, subgroup clinical trials 16; 'chemoembolization liver + breast cancer', 62 results, subgroup clinical trials 11; 'radioembolization liver + breast cancer', 37 results, subgroup clinical trials 3; 'embolization liver + neuroendocrine', 283 results, subgroup clinical trials 20; 'chemoembolization liver + neuroendocrine', 202 results, subgroup clinical trials 9; 'radioembolization liver + neuroendocrine', 64 results, subgroup clinical trials 9; 'embolization liver + melanoma', 79 results, subgroup clinical trials 15; 'chemoembolization liver + melanoma', 60 results, subgroup clinical trials 14; 'radioembolization liver + melanoma', 18 results, subgroup clinical trials 3. The term 'chemosaturation liver' was tested without indication since only few publications exist and provided us with five results and only one clinical trial.

CONCLUSION

Despite many years of clinical use and documented efficacy on intra-arterial treatments of the liver, there are still only a few prospective multicenter trials with many different protocols. To guarantee the future use of these efficacious therapies, especially in the light of many systemic or surgical therapies in the treatment of non-colorectal liver metastases, further large randomized trials and transparent guidelines need to be established.

Rationale of transcatheter intra-arterial therapies of hepatic cancers

Transcatheter, intra-arterial therapies for primary and metastatic hepatic malignancies comprise angiographically guided procedures that provide for the administration of tumoricidal agents directly to liver tumors. These locoregional therapies have demonstrated encouraging clinical outcomes for liver tumors that are otherwise not amenable or not responsive to standard surgical or systemic treatments. This article provides a review of transcatheter therapies for hepatic cancers and reported clinical outcomes.

Yttrium-90 radioembolization stops progression of targeted breast cancer liver metastases after failed chemotherapy

PURPOSE

To determine, in an open-label, retrospective report, the safety and effectiveness of locoregional therapy with yttrium-90 ((90)Y) radioembolization for patients with progressing breast cancer liver metastases (BCLMs) despite multi-agent chemotherapy.

MATERIALS AND METHODS

Seventy-five patients with progressing BCLMs and stable extrahepatic disease were treated with radioembolization at a single institution. Retrospective review of a prospectively collected database was performed to evaluate clinical and biochemical toxicities, tumor response, overall survival (OS), and time to progression. Radiologic response assessments included Response Evaluation Criteria In Solid Tumors in primary index lesions and metabolic activity on positron emission tomography (PET). Univariate and multivariate analyses were performed.

RESULTS

The mortality rate at 30 days was 4% (n = 3). Clinical toxicity and hyperbilirubinemia of grade 3 or worse occurred in 7.6% (n = 5) and 5.9% of patients (n = 4), respectively. Partial response (PR) was seen in 35.3% of patients (n = 24), stable disease (SD) in 63.2% (n = 43), and progressive disease in 1.5% (n = 1). PET imaging was available in 25 patients, and 21 (84%) had a complete response, PR, or SD. The median OS was 6.6 months (95% confidence interval [CI], 5.0-9.2 mo). The hazard ratio (HR) for OS on multivariate analysis was 0.39 (95% CI, 0.23-0.66) for tumor burden less than 25% compared with greater burden. Elevated bilirubin levels were shown to reduce OS. The HR for hepatic progression was 0.22 (95% CI, 0.05-0.98) for solitary versus multifocal disease.

CONCLUSIONS

Locoregional therapy with (90)Y radioembolization is safe and stops or delays the progression of targeted chemorefractory BCLMs. Adverse prognosticators were identified.