Oligometastatic breast cancer

Predictive Modeling of Long-Term Survivors with Stage IV Breast Cancer Using the SEER-Medicare Dataset

IMPORTANCE

Treatment of women with stage IV breast cancer (BC) extends population-averaged survival by only a few months. Here, we develop a model for identifying individual circumstances where appropriate therapy will extend survival while minimizing adverse events.

OBJECTIVE

Our goal is to develop high-confidence deep learning (DL) models to predict survival in individual stage IV breast cancer patients based on their unique circumstances generated by patient, cancer, treatment, and adverse event variables. We previously showed that predictive DL survival modeling of potentially curable stage I-III patients can be improved by combining time-fixed and time-varying covariates. Here, we demonstrate that DL-based predictive survival modeling in stage IV patients, where treatment does not offer a cure, can generate accurate individual survival predictions by considering subsequent lines of potential treatment to guide therapy. This guidance is rarely obtainable in the nearly limitless scenarios of metastatic disease.

DESIGN, SETTING, AND PARTICIPANTS

We applied the SEER-Medicare linked dataset from 1991 to 2016 to investigate 14,312 unique stage IV patients with 1,880,153 entries. We used DeepSurv- and DeepHit-, Nnet-survival- and Cox-Time DL-based predictive models to consider the combination of time-fixed and time-varying covariates at each visit for each patient. We adopted random sampling to divide the input dataset into training, validation, and testing sets. We verified the models' implementation using the pycox package and fine-tuned the models using the open-source library Amazon SageMaker Python SDK 2.232.2 (software development kit). Our results demonstrated the proof of principle of the models by generating individual patients' survival curves.

CONCLUSIONS AND RELEVANCE

By extending the survival prediction models to consider stage IV BC patients' time-fixed and time-varying covariates, we achieved a prediction error below 10%. Based on their circumstance-specific situations, these models can predict survival in individual stage IV patients with high confidence. The models will serve as an important adjunct to treatment decisions in patients with stage IV BC and test what-if scenarios of treatment or no treatment options to optimize therapy for extending patient lives and minimizing adverse events.

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

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

Contralateral axillary lymph node metastasis in breast cancer: An oligometastatic-like disease

BACKGROUND

Contralateral axillary lymph node metastasis (CAM) is rare. It remains controversial whether CAM should be regarded as a regional or distant metastatic disease. Our study aims to investigate the accurate clinical orientation and management of CAM.

METHODS

Two hundred and ninety-nine female patients diagnosed with breast cancer from 2000 to 2014 and confirmed to develop CAM, oligometastasis (OM) or locoregional recurrence (LRR) at Fudan University Shanghai Cancer Center (FUSCC) were included in this study. Baseline information and survival outcomes were analyzed and compared among the three groups.

RESULTS

Patients with CAM exhibited similar overall survival (OS) and progression-free survival (PFS) to those with OM, but worse than those with LRR (HR: 0.47 [95 % CI: 0.27-0.85], p = 0.0097; HR:0.39 [95 % CI: 0.24-0.63], p < 0.0001, respectively). Considering the patients presented with CAM or OM as a whole, we found that local treatment combined with systemic treatment did not provide a superior survival benefit over systemic treatment alone.

CONCLUSION

CAM was similar to an oligometastatic-like disease, and patients with these diseases may benefit from systemic treatment. Adding local treatment failed to significantly improve OS.

Unravelling oligometastatic disease from the perspective of radiation and medical oncology. Part I: non-small cell lung cancer and breast cancer

Oligometastatic disease (OMD) defines a cancer status that is intermediate between localized and widely spread metastatic disease, and can be treated with curative intent. While diagnostic imaging tools have considerably improved in recent years, unidentified micrometastases can still evade current detection techniques, allowing the disease to progress. The various OMD scenarios are mainly defined by the number of metastases, the biological and molecular tumour profiles, and the timing of the development of metastases. Increasing knowledge has contributed to the earlier and improved detection of OMD, underlining the importance of early disease control. In view of increasing OMD detection rates in current real-world clinical practice and the lack of standardized evidence-based guidelines to treat this cancer status, a board of experts from the Spanish Societies of Radiation Oncology (SEOR) and Medical Oncology (SEOM) organized a series of sessions to update the current state-of-the-art on OMD from a multidisciplinary perspective, and to discuss how results from clinical studies might translate into promising treatment options. This expert review series summarizes what is known and what it is pending clarification in the context of OMD in the scenarios of non-small cell lung cancer and breast cancer (Part I), and prostate cancer and colorectal cancer (Part II), aiming to offer specialists a pragmatic framework to help improve patient management.

Integrative competing endogenous RNA network analyses identify novel lncRNA and genes implicated in metastatic breast cancer

Competing endogenous RNAs (ceRNAs) have gained attention in cancer research owing to their involvement in microRNA-mediated gene regulation. Previous studies have identified ceRNA networks of individual cancers. Nevertheless, none of these studies has investigated different cancer stages. We identify stage-specific ceRNAs in breast cancer using the cancer genome atlas data. Moreover, we investigate the molecular functions and prognostic ability of ceRNAs involved in stage I-IV networks. We identified differentially expressed candidate ceRNAs using edgeR and limma R packages. A three-step analysis was used to identify statistically significant ceRNAs of each stage. Survival analysis and functional enrichment analysis were conducted to identify molecular functions and prognostic ability. We found five genes and one long non-coding RNA unique to the stage IV ceRNA network. These genes have been described in previous breast cancer studies. Genes acted as ceRNAs are enriched in cancer-associated pathways. Two, three, and three microRNAs from stages I, II, and III were prognostic from the Kaplan-Meier survival analysis. Our results reveal a set of unique ceRNAs in metastatic breast cancer. Further experimental work is required to evaluate their role in metastasis. Moreover, identifying stage-specific ceRNAs will improve the understanding of personalised therapeutics in breast cancer.

Outcomes of pancreatic cancer with liver oligometastasis

BACKGROUND

Liver oligometastatic pancreatic cancer (PC) may have favorable outcomes. This study aims to evaluate outcomes and factors associated with overall survival (OS) of these patients.

METHODS

We retrospectively investigated consecutive PC patients with liver metastasis treated at our institution between 2013 and 2020. Clinical characteristics and outcomes were compared and analyzed according to the extent of liver metastasis. Cox proportional hazards model was used to identify prognostic factors for OS.

RESULTS

A total of 417 patients were included (multi-organ metastasis/polymetastasis/oligometastasis 174/158/85). Oligometastasis showed a longer OS compared to other types of metastases (7.7 vs 8.2 vs 13.1 months). Age <70 years, performance status of 0, modified Glasgow prognostic score of 0, carbohydrate antigen 19-9 <1000 U/mL were identified as significant prognostic factors for OS. A prognostic index consisting of these four factors successfully stratified the prognosis of these patients (prognostic index; high vs low, 19.9 vs 8.3 months). Highly selected patients who underwent surgical resection showed a median OS of 54.6 months.

CONCLUSIONS

Oligometastasis presented a relatively favorable outcome. Our new prognostic index was useful in stratifying the prognosis of these patients. Multimodal treatment including surgery may have additional survival benefits for highly selected patients.

Oligometastatic breast cancer to parotid gland with complete response

Breast cancer metastatic to parotid gland is a very rare condition which tend to confer poor prognosis and challenging approaches. Oligometastatic breast cancer is usually defined as advanced breast cancer with less or equal than 5 metastatic lesions. We report a case of oligometastatic HER-2 breast cancer to parotid gland and lymph nodes which presented with left hemifacial swelling with erythema and enlargement of cervical and axillary lymph nodes. After 6 cycles of Docetaxel plus Trastuzumab the patient had complete response that was complemented with posterior surgical removal of primary tumor followed by radiotherapy directed to plastron, left supraclavicular and cervical drainage. The patient is still on Trastuzumab therapy and is free of disease in the last two years. We discuss the presentation and approach of a patient with metastatic breast cancer to parotid gland in the oligometastatic scenario.

Targeting Adiponectin in Breast Cancer

Obesity and breast cancer are two major health issues that could be categorized as sincere threats to human health. In the last few decades, the relationship between obesity and cancer has been well established and extensively investigated. There is strong evidence that overweight and obesity increase the risk of postmenopausal breast cancer, and adipokines are the central players in this relationship. Produced and secreted predominantly by white adipose tissue, adiponectin is a bioactive molecule that exhibits numerous protective effects and is considered the guardian angel of adipokine. In the obesity-cancer relationship, more and more evidence shows that adiponectin may prevent and protect individuals from developing breast cancer. Recently, several updates have been published on the implication of adiponectin in regulating tumor development, progression, and metastases. In this review, we provide an updated overview of the metabolic signaling linking adiponectin and breast cancer in all its stages. On the other hand, we critically summarize all the available promising candidates that may reactivate these pathways mainly by targeting adiponectin receptors. These molecules could be synthetic small molecules or plant-based proteins. Interestingly, the advances in genomics have made it possible to create peptide sequences that could specifically replace human adiponectin, activate its receptor, and mimic its function. Thus, the obvious anti-cancer activity of adiponectin on breast cancer should be better exploited, and adiponectin must be regarded as a serious biomarker that should be targeted in order to confront this threatening disease.

Histopathological growth patterns of liver metastasis: updated consensus guidelines for pattern scoring, perspectives and recent mechanistic insights

The first consensus guidelines for scoring the histopathological growth patterns (HGPs) of liver metastases were established in 2017. Since then, numerous studies have applied these guidelines, have further substantiated the potential clinical value of the HGPs in patients with liver metastases from various tumour types and are starting to shed light on the biology of the distinct HGPs. In the present guidelines, we give an overview of these studies, discuss novel strategies for predicting the HGPs of liver metastases, such as deep-learning algorithms for whole-slide histopathology images and medical imaging, and highlight liver metastasis animal models that exhibit features of the different HGPs. Based on a pooled analysis of large cohorts of patients with liver-metastatic colorectal cancer, we propose a new cut-off to categorise patients according to the HGPs. An up-to-date standard method for HGP assessment within liver metastases is also presented with the aim of incorporating HGPs into the decision-making processes surrounding the treatment of patients with liver-metastatic cancer. Finally, we propose hypotheses on the cellular and molecular mechanisms that drive the biology of the different HGPs, opening some exciting preclinical and clinical research perspectives.

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

Purpose

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

Patients and methods

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

Results

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

Conclusions

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

Supplementary Information

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

Ways to improve breast cancer patients' management and clinical outcome: The 2020 Assisi Think Tank Meeting

We report on the third Assisi Think Tank Meeting (ATTM) on breast cancer, a brainstorming project which involved European radiation and clinical oncologists who were dedicated to breast cancer research and treatment. Held on February 2020, the ATTM aimed at identifying key clinical questions in current clinical practice and "grey" areas requiring research to improve management and outcomes. Before the meeting, three key topics were selected: 1) managing patients with frailty due to either age and/or multi-morbidity; 2) stereotactic radiation therapy and systemic therapy in the management of oligometastatic disease; 3) contralateral breast tumour prevention in BCRA-mutated patients. Clinical practice in these areas was investigated by means of an online questionnaire. In the lapse period between the survey and the meeting, the working groups reviewed data, on-going studies and the clinical challenges which were then discussed in-depth and subjected to intense brainstorming during the meeting; research protocols were also proposed. Methodology, outcome of discussions, conclusions and study proposals are summarized in the present paper. In conclusion, this report presents an in-depth analysis of the state of the art, grey areas and controversies in breast cancer radiation therapy and discusses how to confront them in the absence of evidence-based data to guide clinical decision-making.

Modern Breast Cancer Surgery 1st Central-Eastern European Professional Consensus Statement on Breast Cancer

This text is based on the recommendations accepted by the 4th Hungarian Consensus Conference on Breast Cancer, modified on the basis of the international consultation and conference within the frames of the Central-Eastern European Academy of Oncology. The recommendations cover non-operative, intraoperative and postoperative diagnostics, determination of prognostic and predictive markers and the content of cytology and histology reports. Furthermore, they address some specific issues such as the current status of multigene molecular markers, the role of pathologists in clinical trials and prerequisites for their involvement, and some remarks about the future.

The continuing conundrum in oligometastatic breast carcinoma: A real-world data

The optimal management in Oligometastatic (OM) breast carcinoma is not defined.

OBJECTIVES

To identify the prognostic factors influencing OM and the effect of Locoregional treatment (LRT) on survival in OM.

METHODOLOGY

Patients with ≤5 metastases and each with ≤ 5 cm size were defined as OM. Data of OM were extracted from the Institute Registry between 2012 and 2018. The impact of prognostic factors on survival was analysed by univariate and multivariate Cox regression. The Kaplan Meier survival curves were used to plot PFS and OS.

RESULTS

There were 170 patients with OM. The median follow-up was 61 months. Median OS was 43.3 months. The median OS was 74 months in OMD vs 22.7 months in Oligorecurrent disease (ORD) with 5year OS rate of 55.3% vs 16.5% respectively. In the multivariate analyses of OMD both Ki67 ≤ 50% and hormone therapy (HT) showed significant favourable survival outcome. While premenopausal status and HT showed significant survival benefits in ORD. The worse survival outcome in ORD could be because of their aggressive biology and deficit in LRT compared to literature review. The prognostic factors were swayed by the uneven distribution of HR status, grade and Ki67.

CONCLUSION

The survival of OM was influenced by OMD, Ki67 ≤ 50%, premenopausal status and HT. The lesser survival rates of OM in the long term suggest the need for curative LRT to metastatic sites and primary tumor. The potential role of HT and targeted therapy with or without LRT need to be assessed in future randomised trials.

Analysis of Clinical Characteristics, Treatment, and Prognostic Factors of 106 Breast Cancer Patients With Solitary Pulmonary Nodules

Objective

The clinical features of solitary pulmonary nodules (SPN) in breast cancer patients were retrospectively analyzed, and the clinical features of primary lung cancer (PLC) and metastatic pulmonary breast cancer (MBC) in breast cancer patients were compared, and the treatment plan, curative effect and influencing factors were analyzed.

Methods

The clinical data of 106 patients of SPN combined with breast cancer surgery in our hospital from January 2015 to June 2020 were analyzed. There were 65 patients of PLC and 41 patients of MBC. Record the characteristics of the primary breast cancer lesion in our patient, the interval between the initial diagnosis of breast cancer and the appearance of SPN, the previous treatment history of our patient, and the characteristics and surgical method of SPN. The survival status of all patients during the follow-up period was recorded.

Results

The onset age, interval, maximum nodule diameter, ER expression positive rate and radiotherapy history ratio of PLC patients were higher than those of MBC patients, and the lymph node positive rate and triple negative rate were lower than those of MBC patients (P < 0.05). Median survival was 51 months in patients with PLC and 37 months in patients with MBC. The 1, 3, and 5 year overall survival rates in patients with PLC were higher than those in patients with MBC (P < 0.05). Vascular tumor thrombus, SPN type and chemotherapy were all independent factors affecting the prognosis of patients with breast cancer combined with SPN (P < 0.05).

Conclusion

PLC patients and MBC patients have significant differences in pathological characteristics, like the onset age, interval, maximum nodule diameter, ER expression positive rate, radiotherapy history ratio, the lymph node positive rate, and triple negative rate. Septum, vascular tumor thrombus, SPN type, and chemotherapy are all independent factors that affect the curative effect of breast cancer patients with SPN. Based on the nature of SPN, it can provide reference for clinicians to decide the treatment plan, improve patients' quality of life and prolong their survival time.

Diagnostic Performance of [18F]FDG PET in Staging Grade 1-2, Estrogen Receptor Positive Breast Cancer

Positron emission tomography using [¹⁸F]fluorodeoxyglucose (FDG PET) potentially underperforms for staging of patients with grade 1–2 estrogen receptor positive (ER+) breast cancer. The aim of this study was to retrospectively investigate the diagnostic accuracy of FDG PET in this patient population. Suspect tumor lesions detected on conventional imaging and FDG PET were confirmed with pathology or follow up. PET-positive lesions were (semi)quantified with standardized uptake values (SUV) and these were correlated with various pathological features, including the histological subtype. Pre-operative imaging detected 155 pathologically verified lesions (in 74 patients). A total of 115/155 (74.2%) lesions identified on FDG PET were classified as true positive, i.e., malignant (in 67 patients) and 17/155 (10.8%) lesions as false positive, i.e., benign (in 9 patients); 7/155 (4.5%) as false negative (in 7 patients) and 16/155 (10.3%) as true negative (in 14 patients). FDG PET incorrectly staged 16/70 (22.9%) patients. The FDG uptake correlated with histological subtype, showing higher uptake in ductal carcinoma, compared to lobular carcinoma (p < 0.05). Conclusion: Within this study, FDG PET inadequately staged 22.9% of grade 1–2, ER + BC cases. Incorrect staging can lead to inappropriate treatment choices, potentially affecting survival and quality of life. Prospective studies investigating novel radiotracers are urgently needed.

Breast cancer patients with isolated bone metastases and oligometastatic bone disease show different survival outcomes

In this study, we planned to investigate the clinical course of patients with breast cancer with oligometastatic bone disease (OMBD). The patients were grouped according to the characteristics and the sites of metastases. Group I included 928 patients without metastasis. Group II, the OMBD group, included 68 patients. Group III, the widespread metastasis group, comprised 185 patients with multiple bone metastases and/or solid organ metastases. The mean overall survival of the groups was 16.7 ± 0.3 years in group 1, and 7.8 ± 0.8 and 5.9 ± 0.4 years in groups 2 and 3, respectively (p < 0.001 for the comparison of all three groups together; p < 0.001 for group 1 vs. 2 and 3) and (p = 0.037 for group 2 vs. group 3). In the subgroup survival analysis of patients in group 2 (OMBD), the mean and median survival was 5.5 ± 0.8 and 4.0 ± 0.8 years vs. 9.2 ± 0.98 and 9.0 ± 1.05 years in patients with more than one bone metastasis and single bone metastasis, respectively (p = 0.019). OMBD seems to be a different disease than breast cancer with isolated bone metastases. The high risk of developing OMBD, especially following locoregional recurrence, increases the importance of locoregional therapy in large T and N stage tumors.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

3a.

The role of loco-regional treatment in long-term quality of life in de novo stage IV breast cancer patients: protocol MF07-01Q

BACKGROUND/OBJECTIVE

Since more solid evidence has emerged supporting the effectiveness of loco-regional treatment (LRT), clinicians consider LRT a treatment option for selected de novo stage IV breast cancer (BC) patients. This is the first report on long-term quality of life (QoL) in a cohort of patients who were randomized to receive either LRT and then systemic treatment (ST) or ST alone in the protocol MF07-01. We aimed to evaluate QoL in patients living at least 3 years since randomization using scores from the SF-12 health survey.

METHODS

SF-12 (V2) forms were completed during visits of patients who were living 36 months after the randomization. We first calculated PCS-12 (Physical Health Composite Scale) and MCS-12 (Mental Health Composite Scale) scores from de novo stage IV BC patients and compared them with the scores of patients diagnosed with stage I-III BC who lived more than 3 years. Further, PCS-12 and MCS-12 scores were compared between the LRT and ST groups with de novo stage IV BC. Additionally, general health, physical functioning, role functioning, bodily pain, vitality, mental health, and social functioning were evaluated and compared between the groups. Considering age-related changes in QoL, we also compared PCS-12 and MCS-12 scores of patients below or above 55 and 65 years of age. Responses to four additional questions (compare your physical health, mental health, daily activities, and energy currently vs. at diagnosis of BC) were recorded, considering cultural differences.

RESULTS

There were 81 patients in this analysis; 68% of patients (n = 55) had LRT, and 32% (n = 26) received ST. General health was good or very good in 62% (n = 34) in the LRT group and 66% (n = 17) in the ST-only group (p = 0.63). Mean PCS-12 score was 40.8 + 1.6, and mean MCS-12 score was 43.4 + 2.0 (p = 0.34 and p = 0.54, respectively). PCS-12 and MCS-12 score difference was lower than that of the general Turkish population (PCS-12 = 49.3 + 12.8 and MCS-12 = 46.8 + 13.0) and stage I-III BC patients (PCS-12 = 51.1 ± 0.5, MCS-12 = 45.7 ± 0.6). PCS-12 and MCS-12 scores were similar between the LRT and ST-only groups in patients younger and older than 55 and 65, but QoL scores were much better in stage I-III BC patients younger than 65 when compared to the scores of those with de novo stage IV BC. Although treatment with or without LRT did not affect physical health, mental health, daily activities, and energy at 3 years vs. at diagnosis of BC in de novo stage IV BC patients (p > 0.05), these variables were significantly better in stage I-III BC patients (p < 0.001).

CONCLUSION

The current MF07-01Q study demonstrates that patient who had LRT has similar physical and mental health outcomes compared to ST only in a cohort of patients who lived longer than 3 years. Trial registration This study is registered on clinicaltrials.gov with identifier number NCT00557986.

Oligometastatic Breast Cancer: How to Manage It?

Breast cancer (BC) is the most frequent cancer among women and represents the second leading cause of cancer-specific death. A subset of patients with metastatic breast cancer (MBC) presents limited disease, termed 'oligometastatic' breast cancer (OMBC). The oligometastatic disease can be managed with different treatment strategies to achieve long-term remission and eventually cure. Several approaches are possible to cure the oligometastatic disease: locoregional treatments of the primary tumor and of all the metastatic sites, such as surgery and radiotherapy; systemic treatment, including target-therapy or immunotherapy, according to the biological status of the primary tumor and/or of the metastases; or the combination of these approaches. Encouraging results involve local ablative options, but these trials are limited by being retrospective and affected by selection bias. Systemic therapy, e.g., the use of CDK4/6 inhibitors for hormone receptor-positive (HR+)/HER-2 negative BC, leads to an increase of progression-free survival (PFS) and overall survival (OS) in all the subgroups, with favorable toxicity. Regardless of the lack of substantial data, this subset of patients could be treated with curative intent; the appropriate candidates could be mostly young women, for whom a multidisciplinary aggressive approach appears suitable. We provide a global perspective on the current treatment paradigms of OMBC.

Optimal management of oligometastatic nasopharyngeal carcinoma

PURPOSE

Oligometastatic nasopharyngeal carcinoma (NPC) is a distinctive subset of metastatic NPC. Imaging examinations and biomarkers can screen out NPC patients with limited number of sites showing metastasis. Past studies have demonstrated the survival advantages of oligometastatic NPC over multiple metastatic NPC. The treatment strategies of de-novo oligometastatic NPC differ owing to the heterogeneity of this disease. This study aims to systematically review the characteristics and treatments of oligometastatic NPC.

METHODS

PubMed, EMBASE, the Web of Science, and the Cochrane Library were used to search for publications with an emphasis on oligometastatic NPC.

RESULTS

We have presented the current advances on the management of oligometastatic NPC, including the definition, diagnosis, biomarkers, classification, prognosis, subtype, especially systematic therapy, locoregional radiotherapy to the primary tumor, and treatments of the metastatic lesions.

CONCLUSIONS

More well-designed prospective clinical trials that are exclusive for oligometastatic NPC are warranted to determine the best treatment paradigm.

Long-Term Non-progression in Metastatic Breast Cancer Beyond 5 Years: Case Series and Review

Purpose of review

Metastatic breast cancer (MBC) was traditionally viewed as homogeneously progressive and incurable among all comers, but there is new evidence that MBC harbors a range of tumor molecular/immune subtypes and degrees of aggressiveness. Thus, MBC is not rapidly fatal in all affected patients.

Recent findings

A small subset of patients will attain long-term disease control, or undetectable disease, and will enjoy a prolonged survival with little disability from their disease or treatment. Though the term is controversial, some patients with long-term non-detectable disease may effectively be considered “cured”. To best advise treatment options in these patients, it is imperative to identify patients most likely to benefit from aggressive treatment.

Summary

In this review, we delineate the clinical, pathologic, and disease characteristics associated with long-term non-progression in MBC. We include a single institution case series of long-term non-progressive MBC patients and their characteristics as an example of the frequency of this sub-population of MBC. Future prospective trials are warranted to examine the utility of clinical characteristics as predictors of long-term survival in MBC.

Can we cure oligometastatic disease? A practical point of view

PURPOSE OF REVIEW

To critically analyze the available evidence on oligometastatic breast cancer and to suggest therapeutic approaches for optimal management of these patients.

RECENT FINDINGS

Unlike metastatic breast cancer, which remains incurable, patients with a limited number and extent of metastatic lesions, that is, oligometastatic disease, might achieve disease control and long-term survival when radical therapy of the primary tumor, if present, and metastatic disease is added to standard systemic therapy. However, the lack of a clear definition, variety of presentations, and the absence of biomarkers makes oligometastatic breast cancer a poorly understood clinical entity for which there is no standard treatment.

SUMMARY

Improvements in systemic therapies along with radical treatment of the primary tumor and metastatic lesions, together with optimization in the use of imaging tools, may help to increase the percentage of patients with metastatic breast cancer who achieve no-evidence-of-disease status or, at least, chronification of the disease. However, the fundamental question remains: which patients may benefit the most from a radical therapeutic approach? In this article, we propose strategies for the appropriate selection and comprehensive management of these patients.

Association between the histopathological growth patterns of liver metastases and survival after hepatic surgery in breast cancer patients

Currently, there are no markers to identify patients with liver-only or liver-dominant metastases that would benefit from hepatic surgery. Here we characterized histopathological growth patterns (HGPs) of liver metastases in a consecutive series of 36 breast cancer patients who underwent hepatic surgery. Survival analyses showed that the presence of a desmoplastic HGP in the liver metastases (a rim of fibrous tissue separating cancer cells from the liver parenchyma, present in 20 (56%) patients) is independently associated with favorable progression-free and overall survival when compared with the replacement HGP (cancer cells growing into the liver parenchyma, present in 16 (44%) patients).

Development and validation of a nomogram in survival prediction among advanced breast cancer patients

BACKGROUND

The overall survival (OS) among patients with advanced breast cancer (ABC) varies greatly. Although molecular subtype is known as the most important factor in OS differentiation, significant differences in OS among patients with the same molecular subtype still occur, leading to the need for a more accurate prognostic prediction model. This study aimed to develop a prediction model (nomogram) based on current diagnosis and treatment to predict the OS of newly diagnosed ABC patients in China.

METHODS

From the institution's database, we collected data of 368 ABC patients from Sun Yat-sen Memorial Hospital (national hospital) as a training set to establish a nomogram with prognostic risk factors that calculated the predicted probability of survival. Nomograms were independently validated with 278 patients with ABC from two other institutions using the concordance index (C-index), calibration plots and risk group stratifications.

RESULTS

The initial primary tumor stage, molecular subtype, disease-free survival (DFS), presence of brain metastasis, and the tumor burden of metastasis disease (local recurrence, oligo-metastatic disease, or multiple-metastatic disease) were included in the prognostic nomogram. The nomogram had a C-index of 0.77 and 0.71 in the training and the validation sets, respectively. The nomogram was able to stratify patients into different risk groups, respectively (HR 6.81, 95% CI: 4.69 to 9.89, P<0.001). In the lower risk score group (risk score <11), there was no significant difference between the OS with chemotherapy and hormone therapy (HR 0.81, 95% CI: 0.44 to 1.47, P=0.48).

CONCLUSIONS

We have constructed a novel prediction nomogram that can guide the physicians to select personalized treatment options. Furthermore, our study is the first to add oligo-metastatic disease and primary endocrine/trastuzumab resistance into the prognostic models.

Diagnosis and Treatment of Bone Metastases in Breast Cancer: Radiotherapy, Local Approach and Systemic Therapy in a Guide for Clinicians

The standard care for metastatic breast cancer (MBC) is systemic therapies with imbrication of focal treatment for symptoms. Recently, thanks to implementation of radiological and metabolic exams and development of new target therapies, oligometastatic and oligoprogressive settings are even more common-paving the way to a paradigm change of focal treatments role. In fact, according to immunophenotype, radiotherapy can be considered with radical intent in these settings of patients. The aim of this literature review is to analyze available clinical data on prognosis of bone metastases from breast cancer and benefits of available treatments for developing a practical guide for clinicians.

Extracranial Stereotactic Body Radiotherapy in Oligometastatic or Oligoprogressive Breast Cancer

Purpose/Objective: Oligometastatic disease (OMD) and oligoprogressive disease (OPD) describe tumor states with a limited metastasization. In contrast to other disease states, treatment of OMD or OPD has not yet become common for breast cancer. We sought to understand the outcomes and toxicities of this treatment paradigm. Material/Methods: We retrospectively analyzed female breast cancer patients with OMD (≤3 metastases) or OPD (1 progressive lesion) who received stereotactic body radiotherapy (SBRT) for their respective extracranial metastatic lesions between 01/2002 and 07/2019. Survival analysis was performed using the Kaplan-Meier method with log-rank test being used for evaluation of significance. Cox regression was used to detect prognostic outcome factors. Toxicity was evaluated using the Common Terminology Criteria for Adverse Events (CTCAE v. 5.0). Results: Forty-six patients (70% OMD; 30% OPD) with 58 lesions met criteria for inclusion. The majority of treatments (34 out of 58; 58.6%) were delivered from 2017 to 2018. Treatment sites were bone, liver, lung [n = 19 (33%) for each site], and adrenal gland [n = 1 (1%)]. Median biologically effective dose (BED at α/β = 10) was 81.6 Gy (range: 45-112.5 Gy) and median planning target volume was 36.60 mL (range: 3.76-311.00 mL). At 2 years, local control (LC) was 89%, distant control (DC) was 44%, progression free survival (PFS) was 17% and overall survival (OS) was 62%. Multivariate analysis identified the diagnosis of a solitary metastasis as an independent prognostic factor for superior DC (HR = 0.186, CI [0.055; 0.626], p = 0.007) and PFS (HR = 0.363, CI [0.152; 0.863], p = 0.022). OS was independently inferior for patients treated at a higher age (HR = 5.788, CI [1.077; 31.119] p = 0.041). Nine (15.5%) grade I° and one (1.7%) grade II° toxicities were recorded, with no grade III° or higher toxicities. Conclusion: Extracranial SBRT in breast cancer patients with OMD or OPD was well-tolerated with excellent LC. SBRT should especially be offered to younger OMD and OPD breast cancer patients with only one metastasis. The increase in utilization since 2017 points toward a growing acceptance of SBRT for OMD and OPD in breast cancer.

Systemic Treatments in Pregnancy-Associated Breast Cancer

Available data on systemic treatments in pregnancy-associated breast cancer (PABC) is reviewed in this section. These treatments include chemotherapy, endocrine therapy (ET), small molecule inhibitors, monoclonal antibodies against human epidermal growth factor receptor 2 (EGFR-2) also known as HER2; and human epidermal growth factor receptor 3 (EGFR-3), also known as HER3.In local disease, systemic treatment can be delivered as neoadjuvant (before surgery) or adjuvant (after surgery) treatment. In metastatic disease, systemic therapy is the main modality of treatment.Approach to PABC is based on available data in the general population, limited only by safety issues for use of medications during gestation and lactation. Therefore, treatments are similar to non-PABC patients while trying to minimize the risk to the fetus. Available data on different chemotherapies, anti-HER2 monoclonal antibodies, ET and small molecule inhibitors are discussed in detail.

A Case of Locally Advanced Breast Cancer Successfully Treated with Multidisciplinary Therapy

A 42-year-old woman with locally advanced luminal breast cancer was referred to our hospital. Ultrasonography showed marked skin thickening with obscured breast mass. Positron emission tomography showed bilateral swelling in the axillar, parasternal, and supraclavicular lymph nodes in addition to the primary breast cancer. Following the patient's request, we treated her with primary bevacizumab-containing chemotherapy followed by radiotherapy to the breast due to the histologically proven widely spreading cancer remnants in the skin after chemotherapy. Thereafter, the patient underwent mastectomy and axillary dissection with a vertical rectus abdominis musculo-cutaneous flap to cover the skin defect. Pathological examination showed no viable cancer cells both in the breast and lymph nodes but imperceptible cytokeratin AE1 + 3-positive cells in the skin. Although wound healing needed 3 months due to the influence of preoperative radiotherapy, the patient has been well on endocrine therapy without any recurrence for more than 7 years.

Redrawing the Lines: The Next Generation of Treatment in Metastatic Breast Cancer

Although not considered curative in nature, new therapeutic advances in metastatic breast cancer (MBC) have substantially improved patient outcomes. This article discusses the state-of-the-art and emerging therapeutic options for management of MBC. BC systemic therapy targets multiple key pathways, including estrogen receptor signaling, HER2 signaling, and phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) signaling. Other therapeutic strategies include targeting DNA repair, inhibiting immune checkpoints, and developing antibody-drug conjugates. Although surgery historically was reserved for palliation of symptomatic, large, or ulcerating masses, some data suggest a possibly expanding role for more aggressive locoregional therapy in combination with systemic therapy. As technology develops, biomarker-specific, line-agnostic, and receptor-agnostic treatment strategies will redraw the current lines of MBC care. However, tumor heterogeneity remains a challenge. To effectively reshape our approach to MBC, careful consideration of the patient perspective, the costs and value of novel treatments, and accessibility (especially in developing countries) is paramount.