Pulmonary resection for metastatic breast cancer

Oligometastatic Breast Cancer: Is This a Curable Entity? A Contemporary Review of the Literature

PURPOSE OF REVIEW

Oligometastatic breast cancer (OMBC) remains a poorly understood entity for which no standard of care exists at this time. This review will focus on our biologic understanding of OMBC and provide an update on current treatment strategies.

RECENT FINDINGS

The introduction of micro RNA expression profiling has advanced our understanding of the biologic underpinnings of OMBC. Although most of the data regarding treatment have come from retrospective studies, there are now prospective randomized trials reporting progression-free survival and overall survival improvements with stereotactic ablative radiotherapy (SABR). Ongoing studies designed to evaluate addition of SABR as well as other novel agents will further develop this field and provide new treatment options. A "cure" for OMBC remains elusive. With further basic research coupled with novel prospective trials, patients will hopefully enjoy increased progression-free survival and overall survival, and ideally a delay to more toxic systemic therapy.

Hormone receptor status may impact the survival benefit of surgery in stage iv breast cancer: a population-based study

Introduction

The role of surgery in stage IV breast cancer is controversial. We used the Surveillance, Epidemiology, and End Results database to explore the impact of surgery on the survival of patients with stage IV breast cancer.

Methods

In total, 10,441 eligible stage IV breast cancer patients from 2004 to 2008 were included. They were divided into four groups as follows: R0 group (patients who underwent primary site and distant metastatic site resection), primary site resection group, metastases resection group, and no resection group.

Results

The four groups achieved a median survival time (MST) of 51, 43, 31 and 21 months, respectively, P < 0.001. The Cox proportional hazards model showed that the R0 group, primary resection group and metastases resection group had a good survival benefit, with hazard ratios of 0.558 (95% CI, 0.471-0.661), 0.566 (95% CI, 0.557-0.625) and 0.782 (95% CI, 0.693-0.883), respectively. In the hormone receptor (HR)-positive population, the R0 group (MST = 66 m, 5-year OS = 54.1%) gained an additional survival benefit compared with the primary resection group (MST = 52 m; 5-year OS = 44.9%; P < 0.001). The metastases resection group (MST = 38 m; 5-year OS = 31.7%) survived longer than the no resection group (MST = 28 m; 5-year OS = 22.0%; P < 0.001). In the HR-negative population, the R0 group and primary resection group had a similar survival (P = 0.691), and the metastases resection group had a similar outcome to that of the no resection group (P = 0.526).

Conclusion

Patients who underwent surgery for stage IV breast cancer showed better overall survival than the no resection group. Cytoreductive surgery could provide a survival benefit in HR+ stage IV breast cancer; however, in the HR- population, extreme caution should be exercised when considering surgery.

Prognostic factors for resection of isolated pulmonary metastases in breast cancer patients: a systematic review and meta-analysis

BACKGROUND

Lung is a common organ of metastases in patients with primary breast cancer. Pulmonary metastasis of primary breast cancer is usually considered as a systemic disease, however, the systemic approaches have achieved little progress in terms of prolonging survival time. In contrast, some studies revealed a probable survival benefit of pulmonary metastasectomy for such patients. However, the prognostic factor for pulmonary metastasectomy in breast cancer patients is still a controversial issue. The aim of this study was to conduct a systematic review and meta-analysis of cohort studies to assess the pooled 5-year overall survival (OS) rate and the prognostic factors for pulmonary metastasectomy from breast cancer.

METHODS

An electronic search in MEDLINE (via PubMed), EMBASE (via OVID), CENTRAL (via Cochrane Library), and Chinese BioMedical Literature Database (CBM) complemented by manual searches in article references were conducted to identify eligible studies. All cohort studies in which survival and/or prognostic factors for pulmonary metastasectomy from breast cancer were reported were included in the analysis. We calculated the pooled 5-year survival rates, identified the prognostic factors for OS and combined the hazard ratios (HRs) of the identified prognostic factors.

RESULTS

Sixteen studies with a total of 1937 patients were included in this meta-analysis. The pooled 5-year survival rates after pulmonary metastasectomy was 46% [95% confidence interval (95% CI): 43-49%]. The poor prognostic factors were disease-free interval (DFI) (<3 years) with HR =1.70 (95% CI: 1.37-2.10), resection of metastases (incomplete) with HR =2.06 (95% CI: 1.63-2.62), No. of pulmonary metastases (>1) with HR =1.31 (95% CI: 1.13-1.50) and the hormone receptor status of metastases (negative) with HR =2.30 (95% CI: 1.43-3.70).

CONCLUSIONS

Surgery with a relatively high 5-year OS rate after pulmonary metastasectomy (46%), may be a promising treatment for pulmonary metastases in the breast cancer patients with a good performance status and limited disease. The main poor prognostic factors were DFI (<3 years), resection of metastases (incomplete), No. of pulmonary metastasis (>1) and hormone receptor status of metastases (negative). And prospective randomized trials will be needed to address these issues in the future.

Efficacy of computer-aided detection system and thin-slab maximum intensity projection technique in the detection of pulmonary nodules in patients with resected metastases

OBJECTIVES

To evaluate the efficacy of the computer-aided detection (CAD) system and thin-slab maximum intensity projection (MIP) technique in the detection of pulmonary nodules at multidetector computed tomography (CT) in patients who underwent metastatectomy.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board and patients' informed consent was waived. Forty-nine consecutive patients who underwent pulmonary metastatectomy were enrolled. Four chest radiologists analyzed preoperative 1-mm section CT images and recorded the locus of each nodule candidate. Afterward, they reevaluated the images once using CAD software and once with thin-slab MIP given the results of 1-mm section CT alone. The reference standard for nodule presence was established by a consensus panel and pathologic records for malignant nodules.

RESULTS

A total of 514 nodules were identified by a consensus panel. Of 212 nodules surgically removed, 121 nodules were malignant. The sensitivity of each observer in detecting malignant nodules with thin-section CT scans alone was 91%, 88%, 87%, and 86% for observers A- to D, respectively. With CAD, sensitivity increased significantly to 95%, 95%, 94%, and 95% (P< 0.05 for observer B-D), and using MIP increased to 94%, 96%, 91%, and 92% (P < 0.05 for observer B-D), respectively. There were no significant differences in sensitivity between CAD and MIP for the detection of malignant nodules. The average number of false-positive findings per patient was 0.8 with thin-section CT alone, 1.1 with CAD, and 1.4 with MIP.

CONCLUSIONS

In candidates for metastatectomy, reading with the aid of either CAD or MIP significantly improved the detection of malignant nodules compared with using thin-section CT alone.

A role for curative surgery in the treatment of selected patients with metastatic breast cancer

Although metastatic breast cancer is widely believed to carry a grim prognosis, treatment developments over the past 25 years have greatly improved survival outcomes in these patients. In selected cases, aggressive treatment approaches may occasionally result in long-term survival of 15 years or more. This review considers the role of surgery in the treatment of single or multiple metastatic lesions restricted to one site. For each site, available literature from 1992-2002 was assessed to determine the role of surgery on survival outcomes and to determine appropriate criteria for selecting the best candidates for surgery. For lung, liver, brain, and sternum metastases, the use of surgery with or without adjuvant therapy resulted in greater median survival times and 5-year survival rates. The best candidate for surgery had no evidence of additional metastatic disease, good performance status, and a long disease-free interval after treatment of the primary tumor. Current treatment standards for breast cancer follow-up do not include imaging studies other than mammography. The addition of chest x-rays as part of routine follow-up should be considered as a cost-effective approach for early assessment of metastases to the lung or sternum that may be appropriate for surgical excision.

Surgical treatment of hepatic and pulmonary metastases from non-colorectal and non-neuroendocrine carcinoma

BACKGROUND

Surgical resection is standard treatment for colorectal and neuroendocrine liver metases provided the tumor can be removed completely. The same is true for isolated pulmonary metastases. To date, only few reports have addressed the value of surgical resection of organ metastases from other solid tumors.

METHODS

The literature was searched by Medline, conference proceedings and cross-referencing of published articles for information pertaining to the long-term results of surgical treatment of non-colorectal and non-neuroendocrine (NCNN) liver or lung metastases.

RESULTS

Resection of hepatic and pulmonary metastases is increasingly performed in non-colorectal and non-neuroendocrine malignancies. Mortality and morbidity of hepatic and pulmonary resection are low and 5 year survival can be expected to reach some 20-30 percent, irrespective of the histological type of the primary tumor.

CONCLUSION

Resection of hepatic or pulmonary metastasis should be considered in all patients with low operative risk provided that complete resection is possible.

A case of pulmonary metastasis from breast cancer following an 18-year disease-free interval that responded to tamoxifen treatment

A 61-year-old woman was admitted to our hospital with an abnormal shadow on chest roentgenogram. She had undergone a radical mastectomy for right breast cancer 18 years previously. Since pleural dissemination was noted at the time of thoracotomy, only tumor biopsy was performed. Although a decisive diagnosis could not be obtained histologically, the tumor resembled breast cancer and the estrogen receptor status was positive. She underwent post-operative chemotherapy and tamoxifen treatment. After tamoxifen treatment, complete response was observed. The patient is now doing well without recurrence about 10 years after thoracotomy. Based on the clinical course, we obtained both a definitive diagnosis and complete remission.