Surgery of primary tumour has survival benefit in metastatic breast cancer with single-organ metastasis, especially bone

An effective tool for predicting survival in breast cancer patients with de novo lung metastasis: Nomograms constructed based on SEER

Background & objectives

An effective tool for forecasting the survival of BCLM is lacking. This study aims to construct nomograms to predict overall survival (OS) and breast cancer-specific survival (BCSS) in breast cancer patients with de novo lung metastasis, and to help clinicians develop appropriate treatment regimens for breast cancer lung metastasis (BCLM) individuals.

Methods

We gathered clinical data of 2,537 patients with BCLM between 2010 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. Cox regression analysis was employed to identify independent prognostic parameters for BCLM, which were integrated to establish nomograms by R software. The discriminative ability and predictive accuracy of the nomograms were assessed using the concordance index (C-index), receiver operating characteristic (ROC) curves, and calibration plots. Kaplan-Meier analyses were applied to evaluate the clinical utility of the risk stratification system and investigate the survival benefit of primary site surgery, chemotherapy, and radiotherapy for BCLM patients.

Results

Two nomograms shared common prognostic indicators including age, marital status, race, laterality, grade, AJCC T stage, subtype, bone metastasis, brain metastasis, liver metastasis, surgery, and chemotherapy. The results of the C-index, ROC curves, and calibration curves demonstrated that the nomograms exhibited an outstanding performance in predicting the prognosis of BCLM patients. Significant differences in the Kaplan-Meier curves of various risk groups corroborated the nomograms' excellent stratification. Primary site surgery and chemotherapy remarkably improved OS and BCSS of BCLM patients whether the patients were at low-risk or high-risk, but radiotherapy did not.

Conclusions

We successfully developed prognostic stratification nomograms to forecast prognosis in BCLM patients, which provide important information for indicating prognosis and facilitating individualized treatment regimens for BCLM patients.

Development and validation of nomograms for predicting overall survival and cancer specific survival in locally advanced breast cancer patients: A SEER population-based study

Background

For patients with locally advanced breast cancer (LABC), conventional TNM staging is not accurate in predicting survival outcomes. The aim of this study was to develop two accurate survival prediction models to guide clinical decision making.

Methods

A retrospective analysis of 22,842 LABC patients was performed from 2010 to 2015 using the Surveillance, Epidemiology and End Results (SEER) database. An additional cohort of 200 patients from the Binzhou Medical University Hospital (BMUH) was analyzed. The least absolute shrinkage and selection operator (LASSO) regression was used to screen for variables. The identified variables were used to build a survival prediction model. The performance of the nomogram models was assessed based on the concordance index (C-index), calibration plot, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA).

Results

The LASSO analysis identified 9 variables in patients with LABC, including age, marital status, Grade, histological type, T-stage, N-stage, surgery, radiotherapy, and chemotherapy. In the training cohort, the C-index of the nomogram in predicting the overall survival (OS) was 0.767 [95% confidence intervals (95% CI): 0.751-0.775], cancer specific survival (CSS) was 0.765 (95% CI: 0.756-0.774). In the external validation cohort, the C-index of the nomogram in predicting the OS was 0.858 (95% CI: 0.812-0.904), the CSS was 0.866 (95% CI: 0.817-0.915). In the training cohort, the area under the receiver operator characteristics curve (AUC) values of the nomogram in prediction of the 1, 3, and 5-year OS were 0.836 (95% CI: 0.821-0.851), 0.769 (95% CI: 0.759-0.780), and 0.750 (95% CI: 0.738-0.762), respectively. The AUC values for prediction of the 1, 3, and 5-year CSS were 0.829 (95% CI: 0.811-0.847), 0.769 (95% CI: 0.757-0.780), and 0.745 (95% CI: 0.732-0.758), respectively. Results of the C-index, ROC curve, and DCA demonstrated that the nomogram was more accurate in predicting the OS and CSS of patients compared with conventional TNM staging.

Conclusion

Two prediction models were developed and validated in this study which provided more accurate prediction of the OS and CSS in LABC patients than the TNM staging. The constructed models can be used for predicting survival outcomes and guide treatment plans for LABC patients.

Invasive Lobular Carcinoma Has Worse Outcome Compared with Invasive Ductal Carcinoma in Stage IV Breast Cancer with Bone-Only Metastasis

BACKGROUND

Invasive lobular carcinoma (ILC) is more likely to have bone metastasis than invasive ductal carcinoma (IDC). However, the prognosis for bone metastasis in ILC and IDC is barely known. So, the aim of this study was to investigate the difference of prognosis between ILC and IDC accompanied by bone metastasis.

METHODS

We evaluated the women with bone-only metastasis of defined IDC or ILC reported to the Surveillance, Epidemiology and End Results program from 2010 to 2016. Pearson's χ² test was used to compare the differences of clinicopathologic factors between IDC and ILC. Univariate and multivariate analyses were performed to verify the effects of histological types (IDC and ILC) and other clinicopathologic factors on the overall survival (OS) and cancer-specific survival (CSS).

RESULTS

Overall, 3,647 patients with IDC and 945 patients with ILC met the inclusion criteria and were analyzed in our study. The patients with ILC were more likely to be older and to have lower histological grade and a higher proportion of the HR*/HER2- subtype. However, less treatment was administered to ILC than IDC, such as surgery of the breast, radiation, and chemotherapy. Compared to patients with IDC, patients with ILC showed worse OS (median OS, 36 and 42 months, respectively, p < 0.001) and CSS (median CSS, 39 and 45 months, respectively, p < 0.001), especially in subgroups with HR*/HER2- subtype (OS, hazard ratio: 1.501, 95% CI 1.270-1.773, p < 0.001; CSS, hazard ratio: 1.529, 95% CI 1.281-1.825, p < 0.001), lower histological grade (I-II) (OS, hazard ratio: 1.411, 95% CI 1.184-1.683, p < 0.001; CSS, hazard ratio: 1.488, 95% CI 1.235-1.791, p < 0.001), or tumor burden, such as T_0-2 (OS, hazard ratio: 1.693, 95% CI 1.368-2.096, p < 0.001; CSS, hazard ratio: 1.76, 95% CI 1.405-2.205, p < 0.001) and N_1-2 (OS, hazard ratio: 1.451, 95% CI 1.171-1.799, p = 0.001; CSS, hazard ratio: 1.488, 95% CI 1.187-1.865, p = 0.001). Furthermore, older age, black race, unmarried status, higher tumor burden (T_3-4 and N₃), triple-negative subtype, and higher histological grade were independent risk factors for both OS and CSS. Surgery of the breast and chemotherapy could significantly improve the prognosis for patients.

CONCLUSION

Patients with ILC have worse outcomes compared to those with IDC when associated with bone-only metastasis, especially in subgroups with lower histological grade or tumor burden. More effective treatment measures may be needed for ILC, such as cyclin-dependent kinase 4/6 inhibitors, new targeted drugs, etc.

Development and Validation of Prognostic Nomogram for Elderly Breast Cancer: A Large-Cohort Retrospective Study

Purpose

Our research aims to study the bone metastatic patterns and prognostic outcomes in elderly breast cancer (BC) and to develop elder-specific nomograms.

Methods

We downloaded the data of BC patients between 2010 and 2016 from the Surveillance, Epidemiology, and End Results database. The differences in clinical features and prognosis between young (age < 65) and elderly (age ≥ 65) BC patients were compared. The univariate and multivariate Cox analyses were used to determine the overall survival (OS)- and cancer-specific survival (CSS)-related variables and establish two nomograms of BC patients with bone metastasis (BCBM). The receiver operating characteristic (ROC) curve with area under the curve (AUC), calibration curve, decision curve analysis (DCA), and Kaplan–Meier survival curve were selected to evaluate nomograms.

Results

A total of 230,177 BC patients were enrolled in our research, including 142,025 young and 88,152 elderly patients. The prognosis of elderly BCBM patients was significantly worse than young patients. Age, race, breast subtype, tumor size, tumor grade, brain metastasis, liver metastasis, surgery, and chemotherapy were independent prognostic variables for elderly BCBM patients, including OS and CSS. The AUC values at 12, 18, and 24 months were 0.750, 0.751, and 0.739 for OS nomogram and 0.759, 0.762, and 0.752 for CSS nomogram in the training cohort, which were higher than the AUC values of all single independent prognostic variables. The survival curve showed a distinct prognosis between low-, median- and high-risk groups (p < 0.001). Finally, calibration curves and DCA indicated that both nomograms have favorable performance.

Conclusion

Elderly and young patients presented with different bone metastatic frequencies, clinical features, and prognostic outcomes. Two elder-specific nomograms incorporating nine clinical variables were established and validated to be a valuable predictor for elderly BCBM patients.

Locoregional Therapy in De novo Metastatic Breast Cancer: A Retrospective Cohort Study

Objective: Whether locoregional therapy (LRT) should be performed in patients with de novo metastatic breast cancer (dnMBC) has been debated. Here we report the survival outcomes of LRT in patients with dnMBC, focusing on the association of surgical timings and surgical margins with survival in this patient population. Methods: The retrospective study included patients with dnMBC in our hospital, between March 1, 2007 and December 31, 2017. Overall survival (OS) was evaluated by means of a stratified log-rank test and summarized with the use of Kaplan–Meier methods. Results: A total of 153 patients were included, of whom 87 underwent LRT and 66 systemic therapy alone (STA). LRT showed a significant OS benefit over STA (HR, 0.62; 95% CI, 0.39 to 0.99; P  =  .043). The OS of LRT group and STA group were 39 months (95% CI, 33.6 to 44.4 months) and 24.6 months (95% CI, 20.6 to 28.6 months), respectively. The benefit was consistent across most subgroups. The OS of patients undergoing surgery was better than that of patients without surgery (HR, 0.58; 95% CI, 0.35 to 0.94; P  =  .0001), and there was difference in survival improvement at different surgical timings (surgery before chemotherapy, during chemotherapy, and after chemotherapy) (P  =  .0001). The survival benefit of surgery after chemotherapy was significantly greater than that of the other 2 options (HR, 0.77; 95% CI, 0.63 to 0.94). Moreover, compared with patients with positive margins, the OS of patients with negative margins was significantly improved (HR, 0.22; 95% CI, 0.13 to 0.37; P < .001). Conclusions: Our results suggest that LRT is associated with improved OS in women with dnMBC, and patients who had surgery after systemic chemotherapy with negative surgical margins, are expected to benefit more.

Solitary adrenal metastasis from salivary duct carcinoma of the parotid gland successfully treated by surgery: A case report

RATIONALE

Salivary duct carcinoma (SDC) is a rare and highly aggressive cancer with a poor prognosis. SDC demonstrates a potential for invasive growth with early regional and distant metastasis to organs, such as bone, lung, liver, and brain. Because, adrenal gland metastasis from SDC is rare, its treatment options are not well established. Herein, we report a case of SDC metastasis from the parotid gland to the adrenal gland, which was successfully treated by surgery.

PATIENT CONCERNS

The patient had an abnormal but painless lump on the right parotid gland. The size of the mass had increased over a period of 3 years. The patient underwent complete removal of the right parotid gland and radical neck dissection followed by adjuvant radiotherapy and chemotherapy. Two years later, a mass was identified in the left adrenal gland by computed tomography. As no local recurrence or metastasis to other organs was observed, the patient underwent adrenalectomy.

DIAGNOSES

Metastasis of SDC in the adrenal gland was confirmed by histopathological examination of the adrenalectomized specimen.

INTERVENTIONS

After adrenalectomy, the patient was followed-up without adjuvant therapy.

OUTCOMES

The patient was well and alive during the 13-month postoperative follow-up period without any complications.

LESSONS

Surgical resection of solitary metastatic lesion may show a survival benefit with metastatic SDC.

Is there a role for locoregional treatment of the primary tumor in de novo metastatic breast cancer in the era of tailored therapies?: Evidences, unresolved questions and a practical algorithm

Improvements in systemic therapies have changed the face of de novo metastatic breast cancer (dnMBC), with a 5-year survival rate exceeding 25 %. Increasing evidence suggests that a subset of patients could benefit from a locoregional treatment (LRT) with prolonged survival, although the diversity of publications on the subject make it difficult to draw any conclusions. In this review, we summarize the available data on retrospective, prospective and current ongoing clinical trials. Since factors such as tumor biology, pattern of metastatic dissemination and the timing of the treatment are closely linked to the therapeutic strategy, we focus on papers which include these aspects. We discuss recent studies indicating that exclusive radiotherapy provides results comparable with those obtained by surgery. We will then discuss the biological rationale for LRT. Finally, we propose a decision-tree to select the optimal candidates for LRT in dnMBC patients.

Axillary surgical approach in metastatic breast cancer patients: a systematic review and meta-analysis

A systematic review and meta-analysis were conducted to evaluate the benefit of an axillary surgical approach on overall survival and secondarily of breast surgery amongst patients with metastatic breast cancer which is considered to be an incurable disease. However, an axillary surgical approach showed no association with overall survival in patients with metastatic breast cancer. The true impact of locoregional therapies on long-term outcomes remains unknown, and randomised clinical trials are needed.

Local Surgery Improves Survival in Patients with Primary Metastatic Breast Cancer: A Population-Based Study

The clinical value of local surgery in the breast cancer patients with distant metastasis is still unclear. A total of 8,922 primary metastatic breast cancer patients from the Surveillance, Epidemiology, and End Results (SEER) database were analyzed in the current study. Primary outcome variables included breast cancer-specific survival (BCSS) and overall survival (OS). Among the patients, 1,724 (19.3%) who underwent surgical treatment (ST) of primary breast tumor had increased OS (p < 0.001) and BCSS (p < 0.001) compared with those in the nonsurgical treatment (NST) group. Multivariate analysis revealed that surgery improved survival and was an independent prognostic factor for OS (hazard ratio [HR] = 0.617; 95% confidence interval [CI], 0.562-0.676, p < 0.001) and BCSS (HR = 0.623; 95% CI, 0.565-0.686, p < 0.001). Further result showed that ST tended to prolong the survival of patients with 1 or 2 distant metastatic sites (p < 0.05 for OS, p < 0.05 for BCSS). However, no differences were found in prognostic outcomes between different surgical procedure groups (p = 0.886 for OS, p = 0.943 for BCSS). In conclusion, our study suggested that local surgery appeared to confer a survival benefit, which may provide new understanding of treatment for these patients.

Breast surgery for metastatic breast cancer

BACKGROUND

Metastatic breast cancer is not a curable disease, but women with metastatic disease are living longer. Surgery to remove the primary tumour is associated with an increased survival in other types of metastatic cancer. Breast surgery is not standard treatment for metastatic disease, however several recent retrospective studies have suggested that breast surgery could increase the women's survival. These studies have methodological limitations including selection bias. A systematic review mapping all randomised controlled trials addressing the benefits and potential harms of breast surgery is ideal to answer this question.

OBJECTIVES

To assess the effects of breast surgery in women with metastatic breast cancer.

SEARCH METHODS

We conducted searches using the MeSH terms 'breast neoplasms', 'mastectomy', and 'analysis, survival' in the following databases: the Cochrane Breast Cancer Specialised Register, CENTRAL, MEDLINE (by PubMed) and Embase (by OvidSP) on 22 February 2016. We also searched ClinicalTrials.gov (22 February 2016) and the WHO International Clinical Trials Registry Platform (24 February 2016). We conducted an additional search in the American Society of Clinical Oncology (ASCO) conference proceedings in July 2016 that included reference checking, citation searching, and contacting study authors to identify additional studies.

SELECTION CRITERIA

The inclusion criteria were randomised controlled trials of women with metastatic breast cancer at initial diagnosis comparing breast surgery plus systemic therapy versus systemic therapy alone. The primary outcomes were overall survival and quality of life. Secondary outcomes were progression-free survival (local and distant control), breast cancer-specific survival, and toxicity from local therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted trial selection, data extraction, and 'Risk of bias' assessment (using Cochrane's 'Risk of bias' tool), which a third review author checked. We used the GRADE tool to assess the quality of the body of evidence. We used the risk ratio (RR) to measure the effect of treatment for dichotomous outcomes and the hazard ratio (HR) for time-to-event outcomes. We calculated 95% confidence intervals (CI) for these measures. We used the random-effects model, as we expected clinical or methodological heterogeneity, or both, among the included studies.

MAIN RESULTS

We included two trials enrolling 624 women in the review. It is uncertain whether breast surgery improves overall survival as the quality of the evidence has been assessed as very low (HR 0.83, 95% CI 0.53 to 1.31; 2 studies; 624 women). The two studies did not report quality of life. Breast surgery may improve local progression-free survival (HR 0.22, 95% CI 0.08 to 0.57; 2 studies; 607 women; low-quality evidence), while it probably worsened distant progression-free survival (HR 1.42, 95% CI 1.08 to 1.86; 1 study; 350 women; moderate-quality evidence). The two included studies did not measure breast cancer-specific survival. Toxicity from local therapy was reported by 30-day mortality and did not appear to differ between the two groups (RR 0.99, 95% CI 0.14 to 6.90; 1 study; 274 women; low-quality evidence).

AUTHORS' CONCLUSIONS

Based on existing evidence from two randomised clinical trials, it is not possible to make definitive conclusions on the benefits and risks of breast surgery associated with systemic treatment for women diagnosed with metastatic breast cancer. Until the ongoing clinical trials are finalised, the decision to perform breast surgery in these women should be individualised and shared between the physician and the patient considering the potential risks, benefits, and costs of each intervention.

The impact of surgical excision of the primary tumor in stage IV breast cancer on survival: a meta-analysis

Introduction

Approximately 5% of primary breast cancer patients present de novo stage IV breast cancer, for whom systematic therapy is the mainstream treatment. The role of surgical excision of the primary tumor has been controversial due to inconsistent results of relevant studies. Recently, with the reports of some relevant preclinical data, retrospective studies and randomized clinical trials, we've got more evidence to reexamine the issue. Based on those above, a literature review and meta-analysis was performed to determine whether surgery of the primary tumor could improve overall survival in the setting of stage IV breast cancer.

Materials and Methods

A comprehensive search of PubMed, OVID, American Society of Clinical Oncology (ASCO) symposium documents, European Society for Medical Oncology (ESMO) symposium documents and San Antonio Breast Cancer Symposium (SABCS) symposium documents was performed to identify published literature that evaluated survival benefits from excision of the primary tumor in the setting of stage IV breast cancer. Data were extracted in review of appropriate studies by the authors independently. The primary endpoint was overall survival following surgical removal of the primary tumor. Secondary endpoints were the impacts of surgery on progression free survival (PFS) and time to progression (TTP).

Results

Data from 19 retrospective studies showed a pooled hazard ratio of 0.65 (95% confidence interval (95% CI), 0.60-0.71, P < 0.01= for overall survival (OS), indicating a 35% reduction in risk of mortality in patients who underwent surgical excision of the primary tumor. Nevertheless, the analysis of 3 randomized clinical trials revealed a pooled hazard ratio of 0.85 (95% CI, 0.59–1.21, P = 0.359) for OS in the surgical group. According to the meta-regression, the survival benefit was independent of age, tumor size, site of the metastases, and PR or HER-2 status, acceptance of systematic therapies and radiotherapy and inversely correlated with the ER+ status of the population included.

Conclusions

This is the first meta-analysis that includes both retrospective and prospective studies regarding the impact of surgery of the primary tumor on survival in stage IV breast cancer patients. According to the analytical results, we do not recommend surgery of the primary tumor as routine therapy for stage IV breast cancer. However, for those who are supposed to have long life expectancy, physicians could discuss it with these patients, put forward surgery as a therapy choice and perform the operation under deliberation.

MicroRNA-140-5p inhibits invasion and angiogenesis through targeting VEGF-A in breast cancer

MicroRNAs (miRNAs) have been proven to be involved in cell metastasis and angiogenesis by interaction with the target mRNAs. Evidence has been confirmed that miR-140-5p is a tumor suppressor in human cancers such as breast cancer. However, the potential molecular mechanism of miR-140-5p in breast cancer invasion and angiogenesis is still poorly understood. According to our study, we reported that miR-140-5p inhibited the tumor invasion and angiogenesis of breast cancer cells both in vitro and in vivo by targeting VEGF-A. The mRNA amount of miR-140-5p was decreased in the breast cancer clinical samples and breast cancer with metastasis compared with the corresponding adjacent normal tissues and cancer without metastasis. MiR-140-5p mimics and a negative control were transfected into human MCF-7 and MDA-MB-231 cells. Transwell chambers were used to detect the invasive ability of the cells, and the angiogenic ability was assessed by tube-formation assay. The markers of invasion and angiogenesis, VEGF-A, CD31 and MMP-9, were detected by using immunohistochemistry and western blot analysis in vivo. VEGF-A was verified as a possible target gene of miR-140-5p, and corroborated by dual-luciferase reporter and ELISA. Taken together, the study elucidates the molecular mechanisms by which miR-140-5p inhibits breast cancer metastasis and angiogenesis, and provides a potent evidence for the development of a novel microRNA-targeting anticancer strategy for breast cancer patients.

Locoregional Treatment of the Primary Tumor in Patients With De Novo Stage IV Breast Cancer: A Radiation Oncologist's Perspective

BACKGROUND

The aim of this study was to assess the outcomes of patients with de novo stage IV breast cancer after locoregional treatment (LRT) of primary site.

PATIENTS AND METHODS

We studied 245 patients diagnosed with de novo stage IV breast cancer. LRT of the primary tumor (+ systemic therapy) was performed in 82 (34%) patients (surgery, 27; surgery + radiotherapy (RT), 46; and RT, 9). Among those undergoing surgery, 64 (88%) patients underwent mastectomy, and 9 (12%) patients underwent breast-conserving surgery (BCS). Local recurrence-free survival (LRFS) and overall survival (OS) were investigated, and propensity score matching was used to balance patient distributions.

RESULTS

The 5-year LRFS and OS rates were 27% and 50%, respectively. Advanced T stage (T4), liver or brain metastasis, ≥ 5 metastatic sites, and absence of hormone therapy were significant adverse factors for LRFS, whereas T4 stage and absence of hormone therapy were significant for OS. The LRT group demonstrated significantly more favorable outcomes (5-year LRFS, 61%; 5-year OS, 71%), especially after surgery. After matching, survival rates remained significantly higher for patients who received LRT (5-year LRFS, 62% vs. 20%; P < .001; 5-year OS, 73% vs. 45%; P = .02). BCS + RT was superior to mastectomy ± RT, which can be attributed to more patients with a low tumor burden undergoing BCS + RT. Outcomes were better with post-mastectomy RT in selected patients (≥ N2, ≥ T3, or T2N1).

CONCLUSIONS

Upfront LRT including RT is an important option together with systemic therapies for de novo stage IV breast cancer.