Breast cancer liver metastases in a UK tertiary centre: Outcomes following referral to tumour board meeting

Radioembolisation of liver metastases

This review aims to present contemporary data for SIRT in the treatment of secondary hepatic malignancies including colorectal, neuroendocrine, breast and uveal melanoma.

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.

Clinical significance of the neutrophil-to-lymphocyte ratio in oligometastatic breast cancer

Purpose

This study investigated the clinical impact of pretreatment neutrophil-to-lymphocyte ratio (NLR) on survival in patients with oligometastatic breast cancer.

Patients and methods

We collected data from 397 patients who underwent primary breast surgery from 2004 to 2015 and developed recurrence during the follow-up. We reviewed the images and clinical information and defined OMD according to the European Society for Medical Oncology advanced breast cancer guidelines. The NLR was calculated using pretreatment data of primary breast cancer. The cutoff value of the NLR was determined by receiver operating characteristic curve with Youden Index.

Results

Among 397 patients, 131 had OMD at recurrence. The low-NLR group included patients of significantly older age at primary cancer than those in the high-NLR group. A low NLR indicated a better overall survival (p = 0.023) after adjusting for relevant factors, including estrogen receptor status, surgical resection of metastatic disease, metastatic organ number, disease-free interval, and liver metastasis than did the high-NLR group. We developed prognostic models for OMD using six independent prognostic factors, including the NLR. The number of factors was associated with overall survival; patients with all six favorable factors showed a good overall survival of 90.9% at 8 years and those with four or more factors showed 70.4%.

Conclusions

The NLR was an independent prognostic factor for overall survival in OMD. The number of favorable prognostic factors was associated with overall survival. A prognostic model, including the NLR, will help identify patients with a favorable prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06726-w.

Surgical Management of Metastatic Breast Cancer: A Mini Review

Breast cancer with distant metastases is a systemic disease. While systemic therapies are the main treatment strategy, locoregional therapy for metastatic breast cancer (MBC) is generally palliative only. However, recent progress in systemic and local therapies has improved the prognosis of patients with MBC and some may expect long-term survival. More vigorous local therapies for MBC may, therefore, be clinically justified in selected patients. A number of clinical trials and studies have investigated the clinical significance of surgical therapy for primary tumors and distant metastases in patients with MBC. Four prospective randomized trials and multiple retrospective studies have investigated the benefit of surgical resection of primary lesions in patients with MBC, with conflicting results. There have been a number of case-control studies examining the impact of surgical resection of distant metastases, but the benefit of this approach in terms of survival is controversial because selection bias is unavoidable in retrospective studies. The present review discusses the state of the literature relating to local management of the primary breast cancer through surgical resection and surgical management of distant metastatic lesions including pulmonary and liver metastases with future perspectives.

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.

Risk Factors and Survival of Patients With Liver Metastases at Initial Metastatic Breast Cancer Diagnosis in Han Population

The risk factors for morbidity and mortality in patients with breast cancer liver metastases (BCLM) upon initial metastatic breast cancer (MBC) diagnosis have not been adequately identified in Han population. Data of 3,161 female patients who were initially diagnosed with MBC from December 1991 to September 2019 and treated in the China National Cancer Center were extracted and a total of 2,263 MBC patients were included in our study, among which 550 patients had liver metastases. Multivariable logistic regression was performed to identify risk factors for the presence of liver metastases at initial MBC diagnosis. Univariable and multivariable Cox proportional hazards regression analyses were conducted to determine prognostic factors for the survival of BCLM patients. Patients with hormone receptor (HR)-negative, human epidermal growth factor receptor 2 (HER2)-positive (35.0% of the entire population) subtype had the highest incidence of liver metastases. De novo stage IV breast cancer, HR−/HER2+ and HR+/HER2+ subtypes were associated with higher odds of liver metastases and patients with lung metastases had lower risk of liver metastases at initial MBC diagnosis. The median overall survival of BCLM patients was 31.4 months and BCLM patients with HR+/HER2− subtype had the longest survival of 38.2 months. Older age, worse performance status, later stage of initial breast cancer, triple-negative subtype and lung metastases were significantly associated with a poorer prognosis in BCLM patients. Our study offers insights into the incidence and prognosis of BCLM patients at initial MBC diagnosis in Han population.

Risk and prognostic factors of breast cancer with liver metastases

Background

Liver metastasis is a significant adverse predictor of overall survival (OS) among breast cancer patients. The purpose of this study was to determine the risk and prognostic factors of breast cancer with liver metastases (BCLM).

Methods

Data on 311,573 breast cancer patients from the Surveillance, Epidemiology, and End Results (SEER) database and 1728 BCLM patients from Fudan University Shanghai Cancer Center (FUSCC) were included. Logistic regression was used to identify risk factors for liver metastasis. Cox proportional hazards regression model was adopted to determine independent prognostic factors in BCLM patients.

Results

Young age, invasive ductal carcinoma, higher pathological grade, and subtype of triple-negative and human epidermal growth factor receptor 2 positive (HER2+) were risk factors for developing liver metastasis. The median OS after liver metastasis was 20.0 months in the SEER database and 27.3 months in the FUSCC dataset. Molecular subtypes also played a critical role in the survival of BCLM patients. We observed that hormone receptor-positive (HR+)/HER2+ patients had the longest median OS (38.0 for SEER vs. 34.0 months for FUSCC), whereas triple-negative breast cancer had the shortest OS (9.0 vs. 15.6 months) in both SEER and FUSCC. According to the results from the FUSCC, the subtype of HR+/HER2+ (hazard ratio (HR) = 2.62; 95% confidence interval (CI) = 1.88–3.66; P < 0.001) and HR−/HER2+ (HR = 3.43; 95% CI = 2.28–5.15; P < 0.001) were associated with a significantly increased death risk in comparison with HR+/HER2- patients if these patients did not receive HER2-targeted therapy. For those who underwent HER2-targeted therapy, however, HR+/HER2+ subtype reduced death risk compared with HR+/HER2- subtype (HR = 0.74; 95% CI = 0.58–0.95; P < 0.001).

Conclusions

Breast cancer patients at a high risk for developing liver metastasis deserve more attention during the follow-up. BCLM patients with HR+/HER2+ subtype displayed the longest median survival than HR+/HER2- and triple-negative patients due to the introduction of HER2-targeted therapy and therefore it should be recommended for HER2+ BCLM patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07968-5.

Renewed considerations on the utility (or the futility) of hepatic resections for breast cancer liver metastases

Importance

Indication for liver resection (LR) for localized hepatic metastases from breast cancer (BC) is still a matter of debate.

Objective

A literature review of recent scientific papers pertaining to hepatectomies for BC liver metastases (LM).

Evidence Review

We based our systematic review on case series on literature reviews, comparative studies and cost-utility analysis which have been selected based on criteria regarding surgery, possible prognostic factors and evaluation of long-term survival.

Findings

There is a strong inhomogeneity in the reported data, with 5-year survivals ranging from 21% to 58%. There is no agreement in the evaluation of prognostic variables predicting good survival, with the only exception of the time of treatment of the primary BC until the diagnosis of metastases. Three out of the four comparative studies report better survivals for patients who underwent a hepatectomy in comparison to those treated with chemotherapy alone, but their strength in terms of scientific evidence is weak. The only cost-utility analysis revealed that 2 out of the 3 scenarios considered were in favor of the treatment with surgery followed by conventional chemotherapy.

Conclusions

There is no definitive proof on the effectiveness of LRs for BC LM. Surgery can be proposed when it is possible to perform radical surgery, with R0 margins and saving at least 30% of the liver with its vascular and biliary connections. Stable skeletal metastases are not a contraindication. The interval between treatment of the primary location and diagnosis of hepatic metastases is the only prognosis criteria available.

Clinical practice guidelines for the management of liver metastases from extrahepatic primary cancers 2021

BACKGROUND

Hepatectomy is standard treatment for colorectal liver metastases; however, it is unclear whether liver metastases from other primary cancers should be resected or not. The Japanese Society of Hepato-Biliary-Pancreatic Surgery therefore created clinical practice guidelines for the management of metastatic liver tumors.

METHODS

Eight primary diseases were selected based on the number of hepatectomies performed for each malignancy per year. Clinical questions were structured in the population, intervention, comparison, and outcomes (PICO) format. Systematic reviews were performed, and the strength of recommendations and the level of quality of evidence for each clinical question were discussed and determined. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

RESULTS

The eight primary sites were grouped into five categories based on suggested indications for hepatectomy and consensus of the guidelines committee. Fourteen clinical questions were devised, covering five topics: (1) diagnosis, (2) operative treatment, (3) ablation therapy, (4) the eight primary diseases, and (5) systemic therapies. The grade of recommendation was strong for one clinical question and weak for the other 13 clinical questions. The quality of the evidence was moderate for two questions, low for 10, and very low for two. A flowchart was made to summarize the outcomes of the guidelines for the indications of hepatectomy and systemic therapy.

CONCLUSIONS

These guidelines were developed to provide useful information based on evidence in the published literature for the clinical management of liver metastases, and they could be helpful for conducting future clinical trials to provide higher-quality evidence.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPACT

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

Incidence and prognostic factors of patients with synchronous liver metastases upon initial diagnosis of breast cancer: a population-based study

Background

The purpose of this study was to analyze the incidence and prognostic factors of patients with breast cancer liver metastases (BCLM) at initial diagnosis.

Methods

We utilized the Surveillance, Epidemiology, and End Results database to extract data on patients with primary invasive breast cancer from 2010 to 2014. Multivariate logistic regression was conducted to determine factors associated with the presence of liver metastases upon initial diagnosis of breast cancer. Univariate and multivariate Cox regression analyses were performed to identify the prognostic factors in these patients.

Results

In total, 3,276 patients with liver metastases were identified upon initial diagnosis of breast cancer. Patients with hormone receptor-negative (HR−), human epidermal growth factor receptor 2-positive (HER2+) breast cancer had the highest incidence (4.6% among the entire population, 46.5% among the metastatic subgroup). Age, gender, race, pathological grade, extrahepatic metastases, tumor subtype, and marital status were identified as factors associated with the presence of liver metastases upon initial diagnosis of breast cancer. The median overall survival among the entire population with BCLM was 20.0 months. Patients with HR+/HER2+ breast cancer had the longest median survival of 36.0 months. The survival analyses indicated that older age, higher pathological grade, extrahepatic metastases, triple-negative subtype, unmarried status, and uninsured status were independent prognostic factors for a poorer prognosis.

Conclusion

The study provides insight into the incidence and prognostic factors for patients with BCLM at initial diagnosis, which is important clinical information for risk evaluation and prognostic assessment.