The role of surgery in metastatic breast cancer

Current perspectives and trends in nanoparticle drug delivery systems in breast cancer: bibliometric analysis and review

The treatment of breast cancer (BC) is a serious challenge due to its heterogeneous nature, multidrug resistance (MDR), and limited therapeutic options. Nanoparticle-based drug delivery systems (NDDSs) represent a promising tool for overcoming toxicity and chemotherapy drug resistance in BC treatment. No bibliometric studies have yet been published on the research landscape of NDDS-based treatment of BC. In this review, we extracted data from 1,752 articles on NDDS-based treatment of BC published between 2012 and 2022 from the Web of Science Core Collection (WOSCC) database. VOSviewer, CiteSpace, and some online platforms were used for bibliometric analysis and visualization. Publication trends were initially observed: in terms of geographical distribution, China and the United States had the most papers on this subject. The highest contributing institution was Sichuan University. In terms of authorship and co-cited authorship, the most prolific author was Yu Zhang. Furthermore, Qiang Zhang and co-workers have made tremendous achievements in the field of NDDS-based BC treatment. The article titled "Nanomedicine in cancer therapy: challenges, opportunities, and clinical applications" had the most citations. The Journal of Controlled Release was one of the most active publishers in the field. "Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries" was the most cited reference. We also analysed "hot" and cutting-edge research for NDDSs in BC treatment. There were nine topic clusters: "tumour microenvironment," "nanoparticles (drug delivery)," "breast cancer/triple-negative breast cancer," "combination therapy," "drug release (pathway)," "multidrug resistance," "recent advance," "targeted drug delivery", and "cancer nanomedicine." We also reviewed the core themes of research. In summary, this article reviewed the application of NDDSs in the treatment of BC.

Boosting the Potential of Chemotherapy in Advanced Breast Cancer Lung Metastasis via Micro-Combinatorial Hydrogel Particles

Breast cancer cell colonization of the lungs is associated with a dismal prognosis as the distributed nature of the disease and poor permeability of the metastatic foci challenge the therapeutic efficacy of small molecules, antibodies, and nanomedicines. Taking advantage of the unique physiology of the pulmonary circulation, here, micro-combinatorial hydrogel particles (µCGP) are realized via soft lithographic techniques to enhance the specific delivery of a cocktail of cytotoxic nanoparticles to metastatic foci. By cross-linking short poly(ethylene glycol) (PEG) chains with erodible linkers within a shape-defining template, a deformable and biodegradable polymeric skeleton is realized and loaded with a variety of therapeutic and imaging agents, including docetaxel-nanoparticles. In a model of advanced breast cancer lung metastasis, µCGP amplified the colocalization of docetaxel-nanoparticles with pulmonary metastatic foci, prolonged the retention of chemotoxic molecules at the diseased site, suppressed lesion growth, and boosted survival beyond 20 weeks post nodule engraftment. The flexible design and modular architecture of µCGP would allow the efficient deployment of complex combination therapies in other vascular districts too, possibly addressing metastatic diseases of different origins.

Role of Surgery in Metastatic Breast Cancer: Insights from a Narrative Review

Metastatic breast cancer is difficult to cure and has a worse prognosis with higher rates of mortality. Recently, breast surgery is believed to improve the survival rates among these women, but due to limited evidence, definite conclusions cannot be made. Therefore, we undertook this narrative review to synthesize the evidence from existing studies to assess the effectiveness of locoregional surgery and surgery of metastatic sites in improving the outcomes among women diagnosed with metastatic cancer disease along with the summary of current treatment guidelines. We reviewed PubMed and Embase and included both observational studies and randomized controlled trials (RCTs) that were published in English between 2000 and 2021. Outcomes were either survival, quality of life, toxicity related to local treatment assessed by mortality at the end of one month, progression-free survival, and breast cancer-specific survival. The main effect size assessed was hazard ratio with their 95% CIs. After literature search, we found 8 observational studies and 3 RCTs. The findings of the observational studies revealed that breast cancer surgery improves survival from 30% to 50% among women. However, findings from RCTs were mixed for local and distant progression survival. Surgery improved the local progression-free survival but worsened the distant progression-free survival. Besides, there was no effect of breast surgery on quality of life. Regarding the surgery of metastatic site, studies are complex with mixed findings and variation in survival depending upon the type of metastatic site and response to initial systematic therapy and other factors. Based on the existing mixed evidence, it is not possible to make firm and definite conclusions about the effectiveness of breast surgery in improving the survival or quality of life among women with metastatic breast cancer. In future, more RCTs are required with a larger sample size to confirm the findings of observational studies.

Biomarkers and Treatment Strategies for Breast Cancer Recurrence

Despite recent treatment advancements, breast cancer remains a life-threatening disease. Although treatment is successful in the early stages, a significant proportion of individuals with breast cancer eventually experience a recurrence of the disease. Breast tumour recurrence poses a significant medical issue. Despite tumours being a primary cause of mortality, there remains a limited understanding of the fundamental mechanisms underlying tumour recurrence. The majority of the time, after surgery or medical treatment, this metastatic disease manifests itself after the disease is undiagnosed for a considerable amount of time. This phenomenon is commonly referred to as a relapse or recurrence. Metastatic breast cancer has the potential to recur at varying intervals, ranging from a few months to several decades following the initial diagnosis and treatment. This article aimed to summarise the primary causes of breast cancer recurrence and highlight the key issues that need to be addressed in order to effectively decrease the mortality rate among breast cancer patients. This article discusses various therapeutic approaches currently employed and emerging treatment strategies that hold the potential for the complete cure of cancer.

Bibliometric analysis of worldwide research trends on breast cancer about inflammation

Background

The most prevalent cancer and the second-leading cause of cancer-related mortality in women is breast cancer. Growing interest has been shown in recent years in learning more about the processes behind the development of breast cancer. It has been shown that persistent inflammation may play a significant role in the advancement of breast cancer. However, a comprehensive and objective analysis on the state of inflammation in breast cancer research is still lacking. This study was aim to undertake a bibliometric analysis of breast cancer research associated with inflammation between 2013 and 2022 in order to identify the trends, dynamics, and scientific outputs in the field.

Methods

From 2013 to 2022, original and review publications on breast cancer and inflammation-associated research were retrieved from the Web of Science Core Collection (WOSCC) database. To examine the position of yearly publications, journals, nations, institutions, and authors, we employed two bibliometric tools (CiteSpace and VOSviewer). After that, by examining keyword visualization and keyword bursts, we determined the hot research fields related to inflammation in breast cancer.

Results

we discovered 6902 publications regarding inflammation in breast cancer by using our retrieval approach. In terms of the number of publications, The United States ranked first in the global study, followed by China and Italy. In terms of institutions, the University of Texas System, UT MD Anderson Cancer Center, and University of California System are in the top 3 for the quantity of publications published. The most popular journal for this field research is "CANCERS." Ueno NT, Woodward WA, Cristofanilli M, and others have made significant contributions to the understanding of inflammation in breast cancer. In the end, we conducted a biclustering analysis on keywords and discovered three clusters that represent research hotspots.

Conclusion

According to the global trend, the research output of inflammation in breast cancer is increasing. The information provided in this article, including the cooperation network information of authors, nations, journals, and institutions, may help researchers to better understand hotspots and developing patterns in this discipline. At present, the focus of study gradually shifts from "phenotype study" to "therapeutic research". It is recommended to pay attention to the latest hot spots, such as targeted therapy, antimicrobial activity and nanoparticle.

Nomogram Predicts the Role of Primary Tumor Surgery on De Novo Stage-IV Breast Cancer Patients: A SEER-Based Competing Risk Analysis Model

Objective

The efficacy of primary tumor surgery on survival in female patients with de novo stage IV breast cancer (BC) remains unclear. Our study endeavored to develop comprehensive competing risk nomograms to predict clinical outcomes and guide precision treatment in these patients.

Participants and Methods

A total of 12281 patients who had distant metastasis at initial BC diagnosis between 2010 and 2017 in the Surveillance Epidemiology and End Results (SEER) database, were enrolled in this study. First, we assessed the impacts of primary tumor surgery on overall survival (OS) and breast cancer-specific survival (BCSS) using the Kaplan-Meier curves. Then subgroup analyses stratified by different metastatic patterns were performed using Cox and competing risk models (CRM). Based on the filtered independent prognostic parameters by CRM, we established two nomograms to predict the probability of breast cancer-specific death (BCSD) at 1-,2- and 3-year intervals. Furthermore, calibration curves and area under the curves (AUC) were conducted for validation.

Results

Kaplan-Meier analysis revealed that surgery was associated with better OS and BCSS (P<0.001). Subgroup analyses demonstrated that in bone-only metastases pattern, relative to breast-conserving surgery (BCS), patients receiving mastectomy had worse prognosis and the poorest survival belonged to non-surgery individuals (BCSS: mastectomy: HR=1.35; 95%CI=1.15-1.60; non-surgery: 2.42; 2.08-2.82; OS: mastectomy: 1.44; 1.23-1.68; non-surgery: 2.40; 2.08-2.78). Additionally, no survival difference was observed between BCS and reconstruction recipients (BCSS: HR=1.10; 95%CI=0.85-1.43; OS: 1.11; 0.86-1.44). Furthermore, patients undergoing BCS possessed similar BCSS with mastectomy recipients as well as reconstruction recipients in viscera metastases pattern, whereas non-surgery individuals had a worse survival (mastectomy: HR=1.04; 95%CI=0.92-1.18; reconstruction: 0.86; 0.69-1.06; non-surgery: 1.83; 1.63-2.05). Two competing risk nomograms of distinct metastatic patterns were established to comprehensively predict the survival of patients. Calibration curves indicated the terrific consistency of the models. Moreover, the AUC values in the training and validation sets were in the range of 0.70–0.80, exhibiting good specificity and sensitivity.

Conclusion

The surgery implementation was associated with a lower probability of BCSD in de novo stage-IV BC patients. Our nomograms could offer a relatively accurate and individualized prediction of the cumulative incidence rate of BCSD after primary tumor resection.

The global status of research in breast cancer liver metastasis: a bibliometric and visualized analysis

This study aimed to investigate the distribution laws and research frontiers of international literature, so as to present a holistic bibliometric evaluation of the studies on breast cancer liver metastasis(BCLM). Data were collected from the Web of Science Core Collection database, including publications, year, country, journal, author and keywords. The software VOSviewer and CiteSpace were used for bibliometric coupling, co-authorship, co-citation and co-occurrence analysis. In total, 1,031 publications were analyzed from 2004 to 2020 on BCLM. The year with the highest number of publications was 2006, with 103 papers. The United States, followed by China and Germany were the leading countries on BCLM, accounting for 59% of the whole. The journals that published about BCLM were mainly located in Q1/Q2. Keywords co-occurrence analysis divides BCLM into five clusters:"basic research", "auxiliary diagnosis and therapy", "liver resection", "clinical trial" and "prognosis". Main treatment therapies were the latest focus. Burst detection indicated that the trends in BCLM concentrated on subtype and SEER. There is apparently brighter perspective for BCLM research in the coming years, especially in liver resection, subtype and bioinformatics. The consequence of our study as the exclusive scientific evaluation offered an integral overview of BCLM, particularly for research focus and future directions, which can further accurately guide scholars on diagnosis, treatment, and personalized prevention.

CT-guided microwave ablation in patients with lung metastases from breast cancer

Background

Computed tomography (CT)‐guided percutaneous microwave ablation (MWA) is a very common ablation method that shows a good local tumor control rate in primary and secondary lung tumors. At present, few reports have explored the safety and efficacy of MWA for lung metastases from breast cancer.

Methods

From January 2012 to January 2018, 32 breast cancer patients with 46 pulmonary metastases received CT‐guided percutaneous MWA. The study was approved by the local institutional review board. The clinical efficacy and complications of MWA were investigated.

Results

The median follow‐up time was 32 months and the main effective rate was 97.8% (45/46). Five of 46 lesions had local progression (10.9%), with a median progression time of 10 months. The 1‐, 3‐, and 5‐year overall survival (OS) rates were 96.9%, 53.3%, and 17.8%, respectively. The median OS time was 36 months. Among 46 MWA treatments, 11 (23.9%) had massive pneumothorax, two (4.3%) had massive pleural effusion, and two (4.3%) had a pulmonary infection.

Conclusion

CT‐guided percutaneous MWA may be safe and effective for treating lung metastases from breast cancer.

Prognostic Score for De Novo Metastatic Breast Cancer With Liver Metastasis and Its Predictive Value of Locoregional Treatment Benefit

Background

There is a significant survival difference and lack of effective treatment among breast cancer patients with liver metastasis. This present study aimed to construct a novel prognostic score for predicting the prognosis and locoregional treatment benefit of de novo metastatic breast cancer with liver metastasis (BCLM).

Methods

In total, 2,398 eligible patients between 2010 and 2016 were selected from the Surveillance, Epidemiology, and End Results (SEER) database. They were assigned to the training set including 1,662 patients (2010–2014) and validation set comprising 736 patients (2015–2016) depending on the time of diagnosis. The prognostic score was based on regression coefficients in the multivariate Cox regression analysis. And then, patients were stratified into low-, intermediate-, and high-risk groups by the prognostic score. The discrimination and calibration of prognostic score were evaluated using time-dependent receiver operating characteristic (ROC) curves analysis and calibration curves, respectively. Subgroup analysis was performed to evaluate locoregional surgery and chemotherapy benefit in different risk groups.

Results

Age, race, insurance and marital status, T stage, pathological grade, molecular subtypes, and extrahepatic metastasis were identified as independent prognostic variables in the prognostic score. The prognostic score showed high discrimination power with an area under the curve (AUC) of 0.77 and 0.72 and excellent agreement suggested by calibration plots in the training and validation sets, respectively. Intermediate-risk [hazard ratio (HR) 2.39, 95% confidence interval (CI) 2.09–2.73, P<0.001] and high-risk groups (HR 4.88; 95% CI 4.13–5.76; P<0.001) had significantly worse prognosis in comparison with the low-risk group. The median overall survival (OS) in three prognostic groups were 44, 18, and 7 months, with a 3-year survival rate of 56, 23, and 7%, respectively. Apart from the high-risk group (HR 0.79; 95% CI 0.56–1.10; P=0.157), the low-risk (HR 0.64; 95% CI 0.49–0.84; P=0.001) and intermediate-risk groups (HR 0.68; 95% CI 0.55–0.85; P=0.001) could benefit from the surgery of primary site, while chemotherapy improved prognosis in all risk groups.

Conclusions

A prognostic score was developed to accurately predict the prognosis of de novo BCLM patients. Moreover, it may be useful for further subdividing them into different risk groups and helping guide clinicians in treatment decisions.

Gastrectomy for stage IV gastric cancer: a comparison of different treatment strategies from the SEER database

In the West, more than one third of newly diagnosed subjects show metastatic disease in gastric cancer (mGC) with few care options available. Gastrectomy has recently become a subject of debate, with some evidence showing advantages in survival beyond the sole purpose of treatment tumor-related complications. We investigated the survival benefit of different strategies in mGC patients, focusing on the role and timing of gastrectomy. Data were extracted from the SEER database. Groups were determined according to whether patients received gastrectomy, chemotherapy, supportive care. Patients receiving a multimodality treatment were further divided according to timing of surgery, whether performed before (primary gastrectomy, PG) or after chemotherapy (secondary gastrectomy, SG). 16,596 patients were included. Median OS was significantly higher (p < 0.001) in the SG (15 months) than in the PG (13 months), gastrectomy alone (6 months), and chemotherapy (7 months) groups. In the multivariate analysis, SG showed better OS (HR = 0.22, 95%CI = 0.18-0.26, p < 0.001) than PG (HR = 0.25, 95%CI = 0.23-0.28, p < 0.001), gastrectomy (HR = 0.40, 95%CI = 0.36-0.44, p < 0.001), and chemotherapy (HR = 0.42, 95%CI = 0.4-0.44, p < 0.001). The survival benefits persisted even after the PSM analysis. This study shows survival advantages of gastrectomy as multimodality strategy after chemotherapy. In selected patients, SG can be proposed to improve the management of stage IV disease.

Phase II trial of high dose stereotactic body radiation therapy for lymph node oligometastases

Lymph nodes are common sites of oligometastases for several primaries. Stereotactic body radiation therapy (SBRT) represents an effective treatment but no consensus exists regarding dose and fractionation. Aim of this trial was to evaluate safety and efficacy of high-dose SBRT. We included patients with 1 to 3 lymph node metastases. Primary end-point was safety, while secondary end-points were in-field local control (LC), out-field lymph nodal progression free survival (LPFS), distant metastasis free survival (DMFS), progression free survival (PFS) and overall survival (OS). 64 lesions in 52 patients were treated from 2015 to 2019. Most common primary tumor was genitourinary cancer (75%), in particular prostate cancer (65.4%). With a median follow-up of 24.4 months (range 3-49), treatment was very well tolerated, with only 4 (7.7%) patients reporting acute side effects, all classified as grade 1, in the form of pain, fatigue, nocturia and dysuria. No toxicity ≥ grade 2 were reported. Rates of LC at 1, 2 and 3 years were 97.9%, 82.1% and 82.1%. Male sex (HR 0.12, p value 0.014) was associated with improved LC. LPFS at 1, 2 and 3 years were 69.6%, 49.6% and 46.1%, respectively, and DMFS was 81.74%, 67.5% and 58.5%, respectively. Presence of lesions in other organs was correlated with inferior DMFS (HR 3.82, p = 0.042). PFS at 1, 2 and 3 years were 67.4%, 42.4% and 31.86%, respectively. OS at 1, 2 and 3 years were 97.3%, 94.2%, 84%, respectively and significantly correlated with in-field recurrence (HR 8.72, p = 0.000). Our prospective trial confirms safety and efficacy of SBRT in the management of lymph node metastases. Registered Clinical trial NCT02570399.

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

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

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Survival benefit of radiotherapy after surgery in de novo stage IV breast cancer: a population-based propensity-score matched analysis

The survival benefit from radiotherapy in stage IV breast cancer has not been fully evaluated. We investigated the survival benefit of radiotherapy after surgery in de novo stage IV breast cancer. Using a population-based database (the Surveillance, Epidemiology, and End Results database 18, 2010-2013), patients diagnosed with de novo stage IV breast cancer were divided into those undergoing surgery alone (no-radiotherapy group) and those undergoing surgery followed by radiotherapy (radiotherapy group). After propensity-score matching (PSM), the cancer-specific survival (CSS) rates were estimated. Multivariate analysis was performed to evaluate the prognostic value of radiotherapy on survival. After PSM, the 3-year CSS rates in the no-radiotherapy (n = 882) and radiotherapy (n = 882) groups were 57.1% and 70.9% (P < 0.001), respectively. On multivariate analysis, radiotherapy after surgery was a significant prognosticator (hazard ratio [HR] 0.572; 95% confidence interval [CI] 0.472-0.693, P < 0.001). Regardless of surgery type and lymph node involvement, the radiotherapy group showed significantly higher CSS rates. For patients who survived six months or more, radiotherapy after surgery demonstrated favorable prognosis compared to surgery alone (HR 0.593; 95% CI 0.479-0.733, P < 0.001). In conclusion, radiotherapy after surgery increased CSS rates in de novo stage IV breast cancer compared to surgery alone.

Effect of primary tumor resection on overall survival in patients with stage IV breast cancer

We aimed to evaluate the effect of primary tumor resection on overall survival in stage IV breast cancer patients. In total, 284 breast cancer patients presenting with breast cancer at stage IV at initial diagnosis, between 2001 and 2014, were enrolled in the study. Patients were divided into two groups based on surgical resection of the primary tumor. Overall survival (OS) between the two groups was analyzed. Patients in the surgery group (n = 92) had smaller tumors than those in the no-surgery group (n = 192, T0-1:17.7% vs 34.8%, P < 0.001). The surgery group more often had negative nodal status (5.7% vs 33.7%, P < 0.001). Multiple metastatic organ sites were more common in the no-surgery group than in the surgery group (55.7% vs 15.2%, P < 0.001). The surgery group showed a better OS than the no-surgery group (P = 0.01). Multivariate analysis showed that surgical resection of primary tumors tended to be associated with improved OS (HR = 0.67, P = 0.055). T stage, ER, HER2 and metastatic organ sites were independent prognostic factors for OS in multivariate analysis. Surgical resection of the primary tumor may be a treatment option for patients with stage IV disease and may not have a negative effect on overall survival.

Carbon-ion radiotherapy for lymph node oligo-recurrence: a multi-institutional study by the Japan Carbon-Ion Radiation Oncology Study Group (J-CROS)

Background

The efficacy of carbon-ion radiotherapy (C-ion RT) for lymph node (LN) oligo-recurrence has only been evaluated in limited single-center studies. We aimed to investigate the benefit of C-ion RT for LN oligo-recurrence in a large multi-center study.

Methods

Patients who received C-ion RT between December 1996 and December 2015 at 4 participating facilities and who met the following eligibility criteria were included: (i) histological or clinical diagnosis of LN recurrence; (ii) controlled primary lesion; (iii) no recurrence other than LN; (iv) LN recurrence involved in a single lymphatic site; and (v) age ≥ 20 years.

Results

A total of 323 patients were enrolled. Median follow-up period was 34 months for surviving patients. The most common dose fractionation of C-ion RT was 48.0 Gy (relative biological effectiveness) in 12 fractions. Forty-seven patients had a history of RT at the recurrent site. The 2-year local control (LC) and overall survival (OS) rates after C-ion RT were 85% and 63%, respectively. Only 1 patient developed grade-3 toxicity. Factors such as LN diameter, histology, and history of previous RT did not correlate with LC. Smaller diameters (< 30 mm) and numbers (≤ 3) of LN metastases as well as longer disease-free intervals post-primary therapy (≥ 16 months) were associated with significantly better OS.

Conclusions

C-ion RT for LN oligo-recurrence appeared to be effective and safe. C-ion RT may provide a survival benefit to patients with LN oligo-recurrence, particularly to those with few LN metastases, smaller LN diameters, and longer disease-free intervals.

Electronic supplementary material

The online version of this article (10.1007/s10147-019-01440-y) contains supplementary material, which is available to authorized users.

Radiofrequency ablation versus hepatic resection for breast cancer liver metastasis: a systematic review and meta-analysis

OBJECTIVE

To evaluate the comparative therapeutic efficacy of radiofrequency ablation (RFA) and hepatic resection (HR) for breast cancer liver metastases (BCLMs).

METHODS

Studies that had examined the outcomes for both RFA and HR for BCLM were identified by searching the electronic databases PubMed, EMBASE, and the Cochrane Library. Pooled analyzes of the overall survival (OS), disease-free survival (DFS), and short-term outcomes of BCLM were performed.

RESULTS

Patients with BCLM gained many more survival benefits from HR than from RFA with regard to the 3-year OS rate (combined odds ratio (OR) 0.41, 95% confidence interval (CI) 0.29-0.59, P<0.001), 5-year OS rate (combined OR 0.38, 95% CI 0.32-0.46, P<0.001), 3-year DFS (combined OR 0.36, 95% CI 0.27-0.49, P<0.001), and 5-year DFS (combined OR 0.51, 95% CI 0.40-0.66, P<0.001). RFA had fewer postoperative complications (combined OR 0.30, 95% CI 0.20-0.44, P<0.001) and shorter hospital stays (combined OR -9.01, 95% CI -13.49-4.54, P<0.001) than HR.

CONCLUSIONS

HR takes precedence over RFA in the treatment of patients with BCLM, considering the better survival rate. RFA gives rise to fewer complications and can be carried out with a shorter hospital stay, compared to HR. RFA should be reserved for patients who are not optimum candidates for resection.

Could local surgery improve survival in de novo stage IV breast cancer?

Background

Resection of the primary tumor is recommended for symptom relief in de novo stage IV breast cancer. We explored whether local surgery could provide a survival benefit in these patients and attempted to characterize the population that could benefit from surgery.

Methods

Metastatic Breast cancer patients (N = 313) with intact primary tumor between January 2006 and April 2013 were separated into two groups according to whether or not they had undergone surgery. The difference in characteristics between the two groups was analyzed using chi-square test, Fisher’s exact test and Mann-Whitney test. Univariable and multivariable Cox regression and stratified survival analysis were used to assess the effect of surgery on survival.

Results

Of the 313 patients, 188 (60.1%) underwent local surgery. Patients with local surgery had a 47% reduction in mortality risk vs. those with no surgery (median survival 78 months vs. 37 months; HR = 0.53; 95% CI, 0.36–0.78) after adjustment for clinical and tumor characteristics. Stratified survival analysis showed that patients with bone metastasis alone (and primary tumor ≤5 cm), soft tissue metastasis, or ≤ 3 metastasis sites benefit from surgery.

Conclusion

Surgical resection of the primary tumor can improve survival in selected de novo stage IV breast cancer patients.

Costs and effects of intra-operative fluorescence molecular imaging - A model-based, early assessment

Introduction

Successful breast conserving cancer surgeries come along with tumor free resection margins and account for cosmetic outcome. Positive margins increase the likelihood of tumor recurrence. Intra-operative fluorescence molecular imaging (IFMI) aims to focus surgery on malignant tissue thus substantially lowering the presence of positive margins as compared with standard techniques of breast conservation (ST). A goal of this paper is to assess the incremental number of surgeries and costs of IFMI vs. ST.

Methods

We developed a decision analytical model and applied it for an early evaluation approach. Given uncertainty we considered that IFMI might reduce the proportion of positive margins found by ST from all to none and this proportion is assumed to be reduced to 10% for the base case. Inputs included data from the literature and a range of effect estimates. For the costs of IFMI, respective cost components were added to those of ST.

Results

The base case reduction lowered number of surgeries (mean [95% confidence interval]) by 0.22 [0.15; 0.30] and changed costs (mean [95% confidence interval]) by €-663 [€-1,584; €50]. A tornado diagram identified the Diagnosis Related Group (DRG) costs, the proportion of positive margins of ST, the staff time saving factor and the duration of frozen section analysis (FSA) as important determinants of this cost.

Conclusions

These early results indicate that IFMI may be more effective than ST and through the reduction of positive margins it is possible to save follow-up surgeries–indicating further health risk–and to save costs through this margin reduction and the avoidance of FSA.

Survival Benefit of Surgical Removal of Primary Tumor in Patients With Stage IV Breast Cancer

BACKGROUND

Several studies have suggested that primary tumor removal improved overall survival for patients with stage IV breast cancer. However, the survival benefit of local treatment remains controversial. The purpose of the present study was to determine whether surgical removal of the primary tumor provides survival benefits to patients with stage IV breast cancer.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 155 patients with an initial diagnosis of stage IV breast cancer at Seoul National University Bundang Hospital from 2003 to 2014. Kaplan-Meier analysis was used to estimate the median survival. The log-rank test was used to compare differences in patient and tumor characteristics. Multivariate Cox regression analysis for survival was used, controlling for potential confounding variables.

RESULTS

Of 155 patients with stage IV breast cancer, 95 (61%) underwent surgical removal of the primary tumor. The median follow-up period was 59 months (95% confidence interval [CI], 45-73 months). The median survival was longer for the patients with a better response to chemotherapy (70 vs. 47 months; P = .010) and for those who had undergone surgery (118 vs. 28 months; P < .001) than for those who without a better chemotherapy response or surgery. The median survival of the patients who received radiotherapy was better than that of the patients who did not (65 vs. 39 months; P = .004). Patients with luminal A cancer had a median survival of 118 months, the longest compared with those with other subtypes (P = .001). In addition, patients with distant metastasis at a single site had a longer median survival than did those with multiple metastatic sites. The multivariate Cox regression analysis revealed that fewer distant metastases, surgery of the primary tumor, a better response to chemotherapy, and luminal A subtype were significant independent predictors of survival.

CONCLUSION

Our results showed that primary tumor removal was independently associated with improvement in survival. Therefore, surgical management for the primary tumor could be considered more actively in patients with stage IV breast cancer.

First site of recurrence after breast cancer adjuvant treatment in the era of multimodality therapy: which imaging for which patient during follow-up?

PURPOSE

We evaluated the relation between first site of recurrence of early breast cancer and disease profile at presentation and reported survival results, suggesting a personalized diagnostic imaging guidance during follow up.

METHODS

Among 1400 early breast cancer treated from 2000 to 2010, 324 relapses were divided into 4 groups according to first site: A-locoregional, B-bone, C-Brain and D-visceral. We analyzed redictive factors of each group compared to a control group of 100 non relapsing patients and the remaining groups matched.

RESULTS

In group A, patients were more likely to have histological tumor size above >2 cm, grade 1-2, HR positive and 0-3 involved lymph nodes. In group B, patients had more commonly grade 2-3, 1-3 positive lymph nodes and HR positive tumors. In group C, patients were more frequently young, with large tumor size, grade3, positive lymph nodes and HER2 positive tumors. In group D, patients were more likely to have tumors>2 cm in size, with nodal involvement, grade 3, HR negative and HER2 positive tumors. Annual recurrence rate in group A, was stable ranging between 15%-18%, within the first 3 years and peaked at 19.4% in the interval [1-2]year in group B. Median survival was 46 months in group A, 43 months in group B, with no significant difference.

CONCLUSION

Outcome of loco-regional and bone relapses was good, suggesting that both systematic mammography and bone-scan/CT scan for high risk patients (N+, gradeIII) during the first 2-3 years may represent a tailored relevant follow-up protocol for breast cancer patients.

Selecting patients for gastrectomy in metastatic esophago-gastric cancer: clinics and pathology are not enough

AIM

To evaluate the impact on overall survival (OS) of gastrectomy in asymptomatic metastatic esophago-gastric cancer.

PATIENTS & METHODS

Five hundred and thirteen patients were included. The role of surgery and other clinico-pathological factors was evaluated by univariate and Cox regression analyses. OS was the primary end point.

RESULTS

Multivariate analysis confirmed that gastrectomy was a predictor of longer OS (p < 0.001), as well as preserved performance status and benefit from first-line chemotherapy. None of the investigated clinico-pathological variables identified preferable candidates for surgery (all p > 0.05).

CONCLUSION

Palliative gastrectomy might play a role in asymptomatic metastatic esophago-gastric cancer patients with good performance status who received benefit from first-line chemotherapy. Future prospective trials integrating tumor biology among inclusion criteria may help defining the optimal candidates.

Critical risk-benefit assessment of the novel anti-cancer aurora a kinase inhibitor alisertib (MLN8237): A comprehensive review of the clinical data

BACKGROUND

Many current anticancer chemotherapeutics suffer from significant side effects, which have led to the exploration of more targeted therapies. This resulted in the exploration of inhibitors of Aurora A kinase as a potential anti-cancer treatment. Alisertib (MLN8237) has proven to be a potent Aurora A kinase inhibitor that had the highest safety profile among its therapeutic family. Phase I/II/III clinical trials with Alisertib have been carried out and reported promising efficacy, yet serious side effects. This article attempts to assess the clinical effect of Alisertib administration in various cancer phenotypes while describing the reported side effects.

METHODS

Alisertib clinical data were systematically retrieved from Medline, CINAHL, PubMed, and Cochrane Central Register of Controlled Trials and analyzed for quality, relevance, and originality in three stages prior to inclusion.

RESULTS

Overall, seven studies met inclusion criteria and enrolled a total of 630 patients. The reported "potential" clinical effect of Alisertib in various tumours is promising as it improved time to disease progression, progression-free survival, and the duration of disease stability. The achieved improvement therefore rationalizes its further investigation as a novel anticancer therapy. However, the administration of the drug was associated with serious haematological disturbances in a relatively high percentage of patients.

CONCLUSION

The evidence of the anti-tumour effect of Alisertib administration is compelling in various types of malignancies. The reported side effects were serious but manageable in many cases. Topical or more targeted routes of administration are suggested when possible to overcome off-target events with systematic administration of the drug.

Institutional analysis of stereotactic body radiotherapy (SBRT) for oligometastatic lymph node metastases

BACKGROUND

In limited metastatic burden of disease, stereotactic body radiotherapy (SBRT) has been shown to achieve high local control rates. It has been hypothesized that SBRT may translate to a better quality of life by delaying the need for systemic chemotherapy and possibly increasing survival. There is limited published literature on the efficacy of SBRT in limited nodal metastases. The primary aim is to review institutional outcomes of patients with solitary or oligometastatic lymph nodes treated with SBRT.

METHODS

A retrospective study of patients treated with SBRT to metastatic lymph nodes (March 2010-June 2015) was conducted. Endpoints of this study were local control (LC), chemotherapy-free survival (CFS) following SBRT, toxicities, progression free survival (PFS), and overall survival (OS).

RESULTS

Eighteen patients with a mean age of 65 years underwent SBRT to metastatic lymph nodes. Median follow-up was 33.6 months. There were four hepatocellular carcinoma, seven colorectal, four pancreatic, one esophageal, one gallbladder and one lung primary. Eleven (61%) patients had lymph node metastases at initial presentation of metastatic disease. Seven patients (39%) had systemic therapy prior to SBRT, with five patients receiving two lines of chemotherapy. Eight patients had solitary metastatic disease at the time of radiotherapy. All patients had <5 metastases. Median size of lymph node metastases was 1.95 cm (range: 0.8-6.2 cm). RT doses were 31 to 60 Gy in four to ten fractions, with 44% of patients receiving 35 Gy in 5 fractions. At 1 year, LC was 94% and CFS from SBRT was 60%. One-year PFS and OS were 39% and 89% respectively. There were no grade 3 or higher toxicities.

CONCLUSIONS

In this single institution study, SBRT to oligometastatic lymph nodes provided excellent LC and a moderate chemotherapy-free interval with minimal toxicities. Disease progression remains prominent in these patients and larger studies are warranted to identify those who benefit most from SBRT.

Improved Survival After Primary Tumor Surgery in Metastatic Breast Cancer: A Propensity-adjusted, Population-based SEER Trend Analysis

BACKGROUND

There is ongoing debate about nonpalliative primary tumor surgery in metastatic breast cancer patients. This issue has become even more relevant with the introduction of increasingly sensitive imaging modalities.

METHODS

Metastatic breast cancer patients were identified in the SEER registry between 1998 and 2009. The effect of primary tumor surgery on overall and cancer-specific mortality using risk-adjusted Cox proportional hazard regression modeling and stratified propensity score matching was assessed.

RESULTS

Overall, 16,247 women with metastatic breast cancer were included. Of those 7600 women underwent primary tumor surgery although 8647 did not have any surgery at all. Primary tumor surgery decreased from 62.0% in 1998 to 39.1% in 2009 (P < 0.001). Primary tumor surgery was associated with decreased overall mortality (hazard ratio (HR) = 0.53, 95% CI 0.50-0.55, P < 0.001) and cancer-specific mortality (HR = 0.51, 95% CI 0.48-0.54, P < 0.001) in the propensity score-matched model. The benefit of primary tumor surgery increased from 1998 to 2009 for overall mortality (1998: HR = 0.72, 95% CI 0.59-0.89, 2009: HR = 0.42, 95% CI 0.35-0.50) and cancer-specific mortality (1998: HR = 0.72, 95% CI 0.58-0.89, 2009: HR = 0.40, 95% CI 0.33-0.48).

CONCLUSIONS

The present study-the first population-based analysis using propensity score methods-provides evidence of a favorable impact of primary tumor surgery on mortality in metastatic breast cancer patients. Most importantly, the benefit of primary tumor surgery increased over time from 1998 to 2009. Although the final results of ongoing randomized studies are awaited, currently available evidence should be discussed with metastatic breast cancer patients.

乳腺癌肝转移治疗现状及射频消融的应用及前景

乳腺癌是女性发病率和死亡率最高的恶性肿瘤. 乳腺癌晚期常发生转移, 好发转移部位依次为骨、肺、肝等. 近年来, 虽然乳腺癌肝转移(breast cancer liver metastases, BCLM)治疗成功率逐渐提高, 但是BCLM的预后仍然较差. 目前, BCLM的治疗方式尚未成熟, 主要以手术切除、化疗、射频消融(radiofrequency ablation, RFA)治疗、肝动脉栓塞灌注化疗等为主. 本文回顾分析了国内外有关治疗BCLM治疗的文献, 其中重点关注BCLM局部治疗中的RFA治疗, 分析RFA治疗BCLM的应用及前景.

Impact of molecular subtypes on metastatic breast cancer patients: a SEER population-based study

To investigate the significance and impact of molecular subtyping stratification on metastatic breast cancer patients, we identified 159,344 female breast cancer patients in the Surveillance, Epidemiology and End Results (SEER) database with known hormone receptor (HoR) and human epidermal growth factor receptor 2 (HER2) status. 4.8% of patients were identified as having stage IV disease, and were more likely to be HER2+/HoR−, HER2+/HoR+, or HER2−/HoR−. Stage IV breast cancer patients with a HER2+/HoR+ status exhibited the highest median overall survival (OS) (44.0 months) and those with a HER2−/HoR− status exhibited the lowest median OS (13.0 months). Patients with a HER2−/HoR+ status had more bone metastasis, whereas patients with a HER2+/HoR− status had an increased incidence of liver metastasis. Brain and lung metastasis were more likely to occur in women with a HER2−/HoR− status. The multivariable analysis revealed a significant interaction between single metastasis and molecular subtype. No matter which molecular subtype, women who did not undergo primary tumour surgery had worse survival than those who experienced primary tumour surgery. Collectively, our findings advanced the understanding that molecular subtype might lead to more tailored and effective therapies in metastatic breast cancer patients.

Liver resection for HER2-enriched breast cancer metastasis: case report and review of the literature

Liver metastasis from breast cancer usually results in the development of systemic metastasis. We report a breast cancer patient with an early isolated liver recurrence who survived more than 7 years with no recurrence. She was treated with aggressive HER2-directed chemotherapy and hepatic metastasectomy. Local hepatectomy with effective medical oncological therapy with curative intent is worth trying in patients with breast cancer liver metastasis.

The impact of local treatment of the primary tumor site in node positive and metastatic prostate cancer patients

BACKGROUND

Surgical treatment of the primary tumor in patients with metastatic prostate cancer (mPCa) is gaining traction. We discuss the biological rational and the existing literature on this approach.

METHODS

We reviewed the literature regarding surgical management of advanced and mPCa disease.

RESULTS

Surgical removal of the primary tumor despite metastases is becoming a standard in an increasing number of malignancies. Basic science data support the use of surgical removal of the prostate in metastatic PCa. In addition, durable long-term survival has been reported in patients with node-positive PCa treated with radical prostatectomy (RP) as mono or multimodal approach. Based on these data, several groups have demonstrated the feasibility and safety of RP in the metastatic setting. Retrospective series have also reported an improvement in survival for metastatic patients treated with RP in addition to systemic treatment.

CONCLUSIONS

Although no level I data exist at this time to support the use of RP in clinically node-positive or mPCa patients, retrospective data together with basic research data and experience from other malignancies suggest that treatment of the primary tumor, in form of a RP, is safe and could improve long-term quality of life and survival. However, prospective evaluations are requested to validate these findings before including in the standard clinical practice.

Primary surgical treatment of locally advanced breast cancer in low resource settings

•Optimum management of locally advanced breast cancer is multidisciplinary.•Neoadjuvant chemotherapy is mainstay of management.•Primary surgical treatment may be acceptable in selected patients.

β-catenin-independent WNT signaling and Ki67 in contrast to the estrogen receptor status are prognostic and associated with poor prognosis in breast cancer liver metastases

Liver metastasis development in breast cancer patients is common and confers a poor prognosis. So far, the prognostic significance of surgical resection and clinical relevance of biomarker analysis in metastatic tissue have barely been investigated. We previously demonstrated an impact of WNT signaling in breast cancer brain metastasis. This study aimed to investigate the value of established prognostic markers and WNT signaling components in liver metastases. Overall N = 34 breast cancer liver metastases (with matched primaries in 19/34 cases) were included in this retrospective study. Primaries and metastatic samples were analyzed for their expression of the estrogen (ER) and progesterone receptor, HER-2, Ki67, and various WNT signaling-components by immunohistochemistry. Furthermore, β-catenin-dependent and -independent WNT scores were generated and analyzed for their prognostic value. Additionally, the influence of the alternative WNT receptor ROR on signaling and invasiveness was analyzed in vitro. ER positivity (HR 0.09, 95 % CI 0.01–0.56) and high Ki67 (HR 3.68, 95 % CI 1.12–12.06) in the primaries had prognostic impact. However, only Ki67 remained prognostic in the metastatic tissue (HR 2.46, 95 % CI 1.11–5.44). Additionally, the β-catenin-independent WNT score correlated with reduced overall survival only in the metastasized situation (HR 2.19, 95 % CI 1.02–4.69, p = 0.0391). This is in line with the in vitro results of the alternative WNT receptors ROR1 and ROR2, which foster invasion. In breast cancer, the value of prognostic markers established in primary tumors cannot directly be translated to metastases. Our results revealed β-catenin-independent WNT signaling to be associated with poor prognosis in patients with breast cancer liver metastasis.

The influence of the extended indications for sentinel node biopsy on the identification of metastasis-free and metastatic sentinel nodes

BACKGROUND AND OBJECTIVE

Rates of sentinel node (SN) identification and metastasis-positive SNs were compared between the group with highly selective indications for sentinel node biopsy (SNB) and the group with merely no contraindications for SNB (Groups A and B, respectively).

MATERIALS AND METHODS

We performed a single-center retrospective data analysis of 471 breast cancer patients treated during 2004-2010. Data on clinical and pathologic staging, frozen section results, radiological measurements and pathologic examination results were obtained from patient records. Patients were analyzed in two groups. Group A (n=143) had SNB performed only when the patients fulfilled to the following criteria: breast tumor no greater than 3cm in diameter, unifocal disease, no pure ductal carcinoma in situ, no history of previous breast or lymph node surgery, and no neoadjuvant chemotherapy. Indications for SNB were extended in Group B (n=328) so that inflammatory breast cancer and positive lymph nodes became the only exclusion criteria.

RESULTS

The rate of SN identification was 97.9% in Group A vs. 99.09% in Group B (P=0.29). SNs were metastasis positive and frozen sections false negative at comparable proportions in both groups.

CONCLUSIONS

The extension of indications for SNB did not reduce the rates of SN identification or did not create any impact on the rate of metastatic SNs.

Liver Ablation: Best Practice

Tumor ablation in the liver has evolved to become a well-accepted tool in the management of increasing complex oncologic patients. At present, percutaneous ablation is considered first-line therapy for very early and early hepatocellular carcinoma and second-line therapy for colorectal carcinoma liver metastasis. Because thermal ablation is a treatment option for other primary and secondary liver tumors, an understanding of the underlying tumor biology is important when weighing the potential benefits of ablation. This article reviews ablation modalities, indications, patient selection, and imaging surveillance, and emphasizes technique-specific considerations for the performance of percutaneous ablation.

Progesterone regulates the proliferation of breast cancer cells - in vitro evidence

Reports state that surgery performed at different phases of the menstrual cycle may significantly affect breast cancer treatment outcome. From previous studies, we identified differentially expressed genes in each menstrual cycle phase by microarray, then subjected them to functional in vitro analyses. Microarray studies disclosed genes that are upregulated in the luteal phase and follicular phase. TOB-1 is a tumor suppressor gene and was expressed exclusively in the luteal phase in our microarray study. Therefore, we further functionally characterized the protein product of TOB-1 in vitro. To our knowledge, no studies have yet been conducted on reactive oxygen species-regulated tumor suppressor interactions in accordance with the biphasic nature of progesterone. This work demonstrates that progesterone can produce reactive oxygen species in MCF-7 cells and that TOB-1 exerts a series of non-genomic interactions that regulate antiproliferative activity by modulating the antioxidant enzyme superoxide dismutase. Furthermore, this study implicates PTEN as an interacting partner for TOB-1, which may regulate the downstream expression of cell cycle control protein p27 via multiple downstream signaling pathways of progesterone through a progesterone receptor, purely in a time- and concentration-dependent manner. These results support the hypothesis that surgery conducted during the luteal phase of the menstrual cycle may facilitate improved patient survival.

DEGRO practical guidelines for radiotherapy of breast cancer V: Therapy for locally advanced and inflammatory breast cancer, as well as local therapy in cases with synchronous distant metastases

AIM

The purpose of this work is to give practical guidelines for radiotherapy of locally advanced, inflammatory and metastatic breast cancer at first presentation.

METHODS

A comprehensive survey of the literature using the search phrases "locally advanced breast cancer", "inflammatory breast cancer", "breast cancer and synchronous metastases", "de novo stage IV and breast cancer", and "metastatic breast cancer" and "at first presentation" restricted to "clinical trials", "randomized trials", "meta-analysis", "systematic review", and "guideline" was performed and supplemented by using references of the respective publications. Based on the German interdisciplinary S3 guidelines, updated in 2012, this publication addresses indications, sequence to other therapies, target volumes, dose, and fractionation of radiotherapy.

RESULTS

International and national guidelines are in agreement that locally advanced, at least if regarded primarily unresectable and inflammatory breast cancer should receive neoadjuvant systemic therapy first, followed by surgery and radiotherapy. If surgery is not amenable after systemic therapy, radiotherapy is the treatment of choice followed by surgery, if possible. Surgery and radiotherapy should be administered independent of response to neoadjuvant systemic treatment. In patients with a de novo diagnosis of breast cancer with synchronous distant metastases, surgery and radiotherapy result in considerably better locoregional tumor control. An improvement in survival has not been consistently proven, but may exist in subgroups of patients.

CONCLUSION

Radiotherapy is an important part in the treatment of locally advanced and inflammatory breast cancer that should be given to all patients regardless to the intensity and effect of neoadjuvant systemic treatment and the extent of surgery. Locoregional radiotherapy in patients with primarily distant metastatic disease should be prescribed on an individual basis.

Surgical resection of a liver metastasis from breast cancer

We report a case of a solitary liver metastasis from breast cancer in a 65-year-old woman. The patient underwent a mastectomy and axillary lymph node clearance for right breast cancer in 1990. A solitary metastasis was found in the left lobe of the liver by ultrasonography, 20 years after the initial mastectomy. A left lateral segmentectomy was performed in January 2011 and adjuvant hormonal therapy was also initiated. At present, she remains disease free. This case demonstrates the implementation of liver resection to provide an effective treatment for metachronous metastatic breast cancer. We encourage surgeons to offer suitable patients this surgical treatment option, which is shown to provide a survival benefit.

Is Stereotactic Body Radiotherapy (SBRT) in lymph node oligometastatic patients feasible and effective?

OBJECTIVES

To review the available data about stereotactic body-radiotherapy (SBRT) for oligometastatic lymph node cancer recurrence.

METHODS

The inclusion criteria for this study were as follows: Medline search for the (1) English language (2) full paper (abstracts were excluded) on (3) adult oligometastatic solid cancer recurrence limited to lymph node that underwent SBRT (4) outcome data available and (5) published up to the 30th April 2014.

RESULTS

38 papers fulfilling the inclusion criteria have been found: 7 review articles and 31 patient series (20 and 11 retrospective and prospective studies, respectively) including between 1 and 69 patients (636 lymph nodes). Twelve articles reported only lymph node SBRT while in 19 - all types of SBRT including lymph node SBRT were presented. Two-year local control, 4-year progression free survival and overall survival was of up to 100%, 30% and 50%, respectively. The progression was mainly out-field (10-30% of patients had a recurrence in another lymph node/nodes). The toxicity was low with mainly mild acute events and single grade 3-4 late events. When compared to SBRT for any oligometastatic cancer, SBRT for lymph node recurrence carried better prognosis and showed lower toxicity.

CONCLUSIONS

SBRT is a feasible approach for oligometastatic lymph node recurrence, offering excellent in-field tumor control with low toxicity profile. The potential abscopal effect has been hypothesized as a basis of these findings. Future studies are warranted to identify the patients that benefit most from this treatment. The optimal combination with systemic treatment should also be defined.

Radiotherapy in patients with distant metastatic breast cancer

Background

The study evaluates frequency of and indications for disease-related radiotherapy in the palliative breast cancer (BC) situation and analyzes in which phase of the palliative disease course radiotherapy was applied.

Patients & methods

340 patients who developed distant metastatic disease (DMD) and died (i.e. patients with completed disease courses) were analyzed.

Results

165 patients (48.5%) received palliative radiotherapy (255 series, 337 planning target volumes) as a part of palliative care. The most common sites for radiotherapy were the bone (217 volumes, 64.4% of all radiated volumes) and the brain (57 volumes, 16.9%). 127 series (49.8%) were performed in the first third of the metastatic disease survival (MDS) period; 84 series (32.8%) were performed in the last third. The median survival after radiotherapy was 10 months. Patients who had received radiation were younger compared to those who had no radiation (61 vs. 68 years, p < 0.001) and had an improved MDS (26 vs. 14 months, p < 0.001). Compared to rapidly progressive disease courses with short survival times, in cases where effective systemic therapy achieved a longer MDS (≥24 months), radiotherapy was significantly more often a part of the multimodal palliative therapy (52.1% vs. 37.1%, p = 0.006).

Conclusions

In a cohort of BC patients with DMD, nearly one half of the patients received radiotherapy during the palliative disease course. In a palliative therapy approach, which increasingly allows for treatment according to the principles of a chronic disease, radiotherapy has a clearly established role in the therapy concept.

Management of primary metastatic breast cancer in elderly patients--an international comparison of oncogeriatric versus standard care

BACKGROUND

An oncogeriatric approach may affect management of elderly patients with breast cancer. However, little is known about oncogeriatric care in the metastatic setting. Therefore, we performed an international comparison of management of elderly patients with primary metastatic disease who were treated in two different care settings.

MATERIALS AND METHODS

Patients who were ≥70years at diagnosis of primary metastatic disease were eligible. The first cohort comprised a population-based cohort of 104 patients (Comprehensive Cancer Center West, The Netherlands), who all received standard care. The second cohort comprised a hospital-based cohort of 42 patients (H. Lee Moffitt Cancer Center, Florida, United States), who all received oncogeriatric care.

RESULTS

No large differences in patient and tumor characteristics were observed between both cohorts. Most patients in the standard care cohort received systemic therapy as primary therapy, whereas most patients in the oncogeriatric cohort received a combination of systemic and local therapy. Patients in the standard care cohort received fewer lines of treatment (mean number of treatments 2.1 vs. 3.6, p<0.001), and particularly received less breast surgery, chemotherapy, and trastuzumab. Three-year overall mortality was 71% (95% CI: 61-83%) as compared to 58% (95% CI: 42-75%) among patients in the oncogeriatric care cohort (multivariable HR: 1.59 [95% CI: 0.88-2.87], p=0.125).

CONCLUSIONS

In primary metastatic breast cancer, oncogeriatric care intensifies treatment and might improve survival in elderly patients. Future studies on a larger scale should investigate the potential for improved survival, and whether this is accompanied by a better (preservation of) quality of life and functional status.

Primary 4T1 tumor resection provides critical "window of opportunity" for immunotherapy

It is believed that primary tumor resection modulates host-tumor immune interaction, but this has not been characterized in a stringent breast cancer tumor model. This report, using the 4T1 murine mammary tumor model, characterizes for the first time the dynamic longitudinal changes in immunosuppressive and effector components of the immune system after resection of an established orthotopic primary tumor with a defined natural history of developing lung metastases. More specifically, we analyzed changes of absolute numbers and frequencies of MDSC, regulatory T cells (Treg), as well as activated CD4 and CD8 positive T cells in spleens and, in some studies, lungs of 4T1 tumor-bearing mice and mice after primary tumor resection. Importantly, using mathematical analyses we established that primary resection of an orthotopic tumor had created a "window of opportunity" with decreased tumor-associated immune suppression that existed for approximately 10 days. Although tumor resection did slightly prolong survival, it did not affect the ultimate development of metastatic disease since animals with resected tumors or intact primary tumors eventually died by day 47 and 43, respectively. This window of opportunity likely occurs in humans providing a rationale and parameters for integration and testing of immunotherapeutic strategies in this critical "window of opportunity" to combat the development of metastatic disease.

Radiofrequency thermal ablation (RFA) of hepatic metastases (METS) from breast cancer (BC): an adjunctive tool in the multimodal treatment of advanced disease

PURPOSE

The study was done to analyse the results of a series of radiofrequency ablation (RFA) procedures performed on hepatic metastases (METS) from breast cancer in order to evaluate the clinical impact of this therapy.

MATERIALS AND METHODS

We analysed 45 patients (mean age 55 years) with 87 METS (mean size 23 mm), in terms of adverse events (AE), complete ablation (CA) at initial follow-up assessment and during the subsequent follow-up (mean 30 months), time to progression, and survival. The correlation between local effectiveness and METS size was investigated. Possible predictors of 3-year survival, including the local effectiveness of RFA (complete ablation maintained at 1-year versus treatment failure) were analysed.

RESULTS

Nine AE occurred (two major complications, 2.3 %). CA at initial follow-up was obtained in 90 %; 19.7 % CA relapsed, with a time to progression of 8 months. The difference between the mean diameter of maintained CA (22 mm) and that of the treatment failures (30 mm) was highly significant (p = 0.0005), as was the 30 mm threshold (p = 0.0062). Overall survival at 1-3 years was 90, 58 and 44 %. At univariate analysis, the local effectiveness of RFA did not reach statistical significance.

CONCLUSION

RFA of hepatic METS from breast cancer has high local effectiveness in tumours up to 30 mm, but it is not relevant in determining survival.

Thyroid metastasectomy

Metastases to the thyroid gland are uncommon. Renal, lung, breast, and colon cancer and melanoma are the most common primary diseases implicated. Few retrospective series have been reported. Treatment decisions must be individualized, and will depend on the state of systemic disease. Selected patients could benefit from surgical treatment. Although most patients selected for surgery will not be cured, the aim of surgery is to avoid the complications of uncontrolled central neck disease.

Disease-related surgery in patients with distant metastatic breast cancer

INTRODUCTION

This study evaluates the frequency of and indications for disease-related surgical procedures in the palliative breast cancer (BC) situation.

PATIENTS & METHODS

Based on a cohort of women who were treated for newly diagnosed BC during a 20-year period (1990-2009), we analyzed 340 patients who developed distant metastatic disease (DMD) until 2011 and died (i.e. still ongoing palliative disease courses were not included).

RESULTS

One hundred and twenty-seven surgical procedures were performed in 100 patients (29.4% of all patients with metastatic disease). The most common site for surgery was breast (n = 60, 47.2%). The primary tumor was removed at first diagnosis of DMD in 43 patients (33.9%); sixteen operations (12.6%) were performed for local recurrence. In 37 patients, 50 surgical procedures (39.4%) were necessary to stabilize osseous structures due to metastases. Procedures were rarely performed on other common metastatic sites: lung: n = 1 (0.8%); liver: n = 1 (0.8%), brain: n = 4 (3.1%). When excluding surgery for primary breast tumors at initial diagnosis of DMD from analysis, 34 of 84 surgeries (40.4%) were performed in the first third of survival follow-up (i.e. period of metastatic disease survival); operations in the last two-thirds each totaled 29.8% (n = 25). The median survival after surgery was 16 months (range: 0.5-89 months).

CONCLUSIONS

In a cohort of BC patients who had primary or developed secondary DMD, nearly one third of the patients received disease-related surgical procedures during their palliative disease course. This high rate of operations shows that surgery has a clearly established role in the palliative therapy concept.

A genetic variant in pre-miR-27a is associated with a reduced breast cancer risk in younger Chinese population

Accumulating evidence has indicated that single nucleotide polymorphisms (SNPs) in miRNA precursors may have an effect on miRNA expression levels. Recently, an important A to G transition SNP in pre-mir-27a (rs895819) was identified. Previous studies have investigated the role of rs895819 in cancer risk, but the results remain contradictory, rather than conclusive. The present study aimed to evaluate the association of rs895819 with sporadic breast cancer susceptibility, clinicopathological characteristics and prognosis. We first analyzed the influence of rs895819 on the miR-27a expression level and determined that miR-27a expression was significantly lower in samples with the AG/GG genotype compared to samples with the AA genotype (p=0.022). Further investigation revealed that subjects with the G allele exhibited a significantly decreased risk of breast cancer relative to subjects carrying the A allele among the younger population (adjusted OR=0.628, 95% confidence interval 0.410-0.961; p=0.032). Moreover, significant associations between the presence of rs895819 and the histological grade and estrogen status of breast cancers were observed among the older group. However, the SNP did not influence the survival rate of patients with breast cancer. In conclusion, our results suggest that the SNP rs895819 may serve as a risk factor for breast cancer in younger Chinese populations; however, larger population-based studies are needed to validate these findings.