Hepatic resection for breast cancer metastases

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.

The safety and effectiveness of liver resection for breast cancer liver metastases: A systematic review

Breast cancer liver metastases have traditionally been considered incurable and any treatment given therefore palliative. Liver resections for breast cancer metastases are being performed, despite there being no robust evidence for which patients benefit. This review aims to determine the safety and effectiveness of liver resection for breast cancer metastases. A systematic literature review was performed and resulted in 33 papers being assembled for analysis. All papers were case series and data extracted was heterogeneous so a meta-analysis was not possible. Safety outcomes were mortality and morbidity (in hospital and 30-day). Effectiveness outcomes were local recurrence, re-hepatectomy, survival (months), 1-, 2-, 3-, 5- year overall survival rate (%), disease free survival (months) and 1-, 2-, 3-, 5- year disease free survival rate (%). Overall median figures were calculated using unweighted median data given in each paper. Results demonstrated that mortality was low across all studies with a median of 0% and a maximum of 5.9%. The median morbidity rate was 15%. Overall survival was a median of 35.1 months and a median 1-, 2-, 3- and 5-year survival of 84.55%, 71.4%, 52.85% and 33% respectively. Median disease free survival was 21.5 months with a 3- and 5-year median disease free survival of 36% and 18%. Whilst the results demonstrate seemingly satisfactory levels of overall survival and disease free survival, the data are of poor quality with multiple confounding variables and small study populations. Recommendations are for extensive pilot and feasibility work with the ultimate aim of conducting a large pragmatic randomised control trial to accurately determine which patients benefit from liver resection for breast cancer liver metastases.

Surgery for liver metastases from breast cancer

INTRODUCTION

Liver metastases from breast cancer (BCLM) confer poor survival. Liver resection in BCLM patients has been increasingly employed.

AIM

We undertook a systematic review to evaluate the role of hepatic resection in patients with breast cancer metastatic to the liver.

MATERIALS & METHODS

In total, 36 studies were overviewed. Patient populations, characteristics, morbidity, mortality and survival were documented.

RESULTS

Median overall survival was 41 months. Major morbidity was rare while 30-day postoperative mortality was near nil.

CONCLUSION

Liver surgery for BCLM can be performed with low mortality, acceptable morbidity and promising survival benefit in carefully selected patients.

Screening for liver metastases in women with mammary carcinoma: comparison of contrast-enhanced ultrasound and magnetic resonance imaging

OBJECTIVE

The objective of the present study was to compare conventional B-mode ultrasound (BMU), contrast-enhanced ultrasound (CEUS), and magnetic resonance imaging (MRI) in the detection of liver metastases at the primary staging and follow-up of women with histologically confirmed mammary carcinoma.

PATIENTS AND METHODS

Included in the study were 55 women (aged 57.5 ± 11.0 years, range 27-75 years; mean disease duration 57.5 months, range 5-168 months); of these, 17 women were examined as part of primary staging (staging group) and 38 women at follow-up (follow-up group). All patients underwent BMU (Philips HDI 5000), CEUS (Philips HDI 5000; 4.8 ml SonoVue), and MRI (Siemens Avanto 1.5 T) of the liver.

RESULTS

In the staging group (n = 17), a mass was detected by BMU in 24% (n = 4), by CEUS in 29% (n = 5), and by MRI in 47% (n = 8); masses suspicious for malignancy were identified in 6% of patients with BMU and in 12% each by CEUS and MRI. Malignancy was not confirmed in any case by cytology or surgery. In the follow-up group (n = 38), masses were identified by MRI in 53% of patients with suspicion of malignancy in 18%. Malignancy was confirmed in 16% of cases identified at MRI, in 13% of cases identified with CEUS, and in 11% of cases identified with BMU. The Pearson coefficients of correlation were r = .29 (P = .03) for MRI vs. BMU; r = .42 (P = .002) for MRI vs. CEUS; and r = .75 (P ≤ .001) for BMU vs. CEUS. With respect to malignancy, the Pearson coefficients of correlation were r = .40 (P = .099) for BMU vs. MRI and r = .71 (P = .0009) for CEUS vs. MRI.

CONCLUSIONS

Beginning in tumor stage III, the use of CEUS and MRI is associated with a significantly greater benefit in the detection of malignant tumors of the liver compared with conventional BMU. BMU appears to be adequate for primary staging and the follow-up of lower tumor stages.

Improvement of survival and prospect of cure in patients with metastatic breast cancer

Patients with metastatic breast cancer have traditionally been considered incurable with conventional treatment. However, 5-10% of those patients survive more than 5 years, and 2-5% survive more than 10 years. Recent studies suggest that the survival of patients with metastatic breast cancer has been slowly improving. In this review, we examine the possible curative approach for a certain group of patients with metastatic breast cancer. We identify that patients most likely to benefit from such an aggressive approach are young and have good performance status, adequate body functional reserve, long disease-free interval before recurrence, oligometastatic disease, and low systemic tumor load. An aggressive multidisciplinary approach including both local treatment of macroscopic disease and systemic treatment of microscopic disease can result in prolonged disease control in certain patients with metastatic breast cancer. Whether patients with prolonged disease control are "cured" remains controversial.

Surgical management of breast cancer liver metastases

INTRODUCTION

Selected patients with isolated breast cancer liver metastases (BCLM) may benefit from surgical management; however, indications remain unclear and the risks may outweigh the benefits in patients with a generally poor prognosis.

METHODS

Between 1998 and 2006, 17 patients diagnosed with BCLM were considered for surgical management (<4 tumours, tumour <4 cm in diameter and no/stable extrahepatic metastases). Peri-operative and outcomes data were analysed and compared.

RESULTS

Eight patients were found to have extensive or untreatable disease on staging laparoscopy and intra-operative ultrasound (SL/IOUS). The remaining nine patients underwent surgical management [seven laparoscopic radiofrequency ablations (RFA) and two hepatic resections]. Median length of follow-up for patients treated surgically was 40.0 months, median disease-free survival (DFS) was 32.2 months and median time to disease progression was 17.7 months. Of the eight patients not amenable to surgery, median length of follow-up was 21.8 months.

CONCLUSION

SL/IOUS prevented unnecessary laparotomy in half of the patients taken to the operating room for surgical treatment of BCLM. In patients with BCLM, SL/IOUS should be considered standard of care before surgical intervention. The small number of patients and short follow-up may be inadequate to determine the true value of surgical management in this group of patients with BCLM.

Palliative hepatic intraarterial chemotherapy (HIC) using a novel combination of gemcitabine and mitomycin C: results in hepatic metastases

To evaluate repeated hepatic intraarterial chemotherapy (HIC) as a palliative treatment option for unresectable cholangiocarcinoma and liver metastases of various origins that were progressive under systemic chemotherapy. Between 2002 and 2006, 55 patients were treated in 4-week intervals (mean five sessions). Combined gemcitabine/mitomycin was administered intraarterially within 1 h. Tumor response was evaluated after the third session according to RECIST. Treated tumor entities were colorectal carcinoma (CRC) (n = 12), breast cancer (BC) (n = 12), cholangiocarcinoma (CCC) (n = 10), pancreatic (n = 4), ovarian (n = 3), gastric, cervical, papillary (each n = 2), prostate, esophageal carcinoma, leiomyosarcoma (each n = 1), cancer of unknown primacy (CUP) (n = 5). All patients tolerated the treatment well without any major side effects or complications. In total, there were 1 complete response (CR), 19 partial responses (PR), 19 stable (SD) and 16 progressive diseases (PD). We observed 5 PR, 3 SD and 4 PD in CRC; 1 CR, 4 PR, 6 SD in BC; and 2 PR, 2 SD and 6 PD in CCC. Median survival after first HIC was 9.7 months for CRC, 11.4 months for BC and 6.0 months for CCC. HIC with gemcitabine/mitomycin is a safe, minimally invasive, palliative treatment for hepatic metastases that are progressive under systemic chemotherapy. The treatment yields respectable tumor control rates in CRC and BC patients.

Trace element concentration in metastatic liver disease: a systematic review

BACKGROUND

There are conflicting reports about the levels of trace elements in secondary liver cancers. This review summarises the evidence associating secondary liver tumours with trace elements.

METHODS

MEDLINE, EMBASE and CENTRAL databases were searched for the period up to January 2006 using a formal search strategy. Various inclusion and exclusion criteria were applied to select the articles for inclusion. Data extraction was performed using a custom designed data extraction form.

RESULTS

A total of 6917 references were identified. About 1359 duplicates were excluded using EndNote. About 5529 clearly irrelevant references were excluded through reading titles and abstracts. Of these 24 references were excluded by applying the exclusion criteria. Five studies including 239 patients and measuring iron content (2), copper content (4) and zinc (3) qualified for the review. Both studies on iron, three studies on copper and all the studies on zinc used quantitative methods to determine mineral content. A meta-analysis was performed using the random effects model.

CONCLUSION

Copper and zinc content are lower in secondary liver cancer compared to livers from healthy patients. Iron, copper and zinc content are lower in liver secondaries compared to the normal tissues surrounding the secondaries. Reasons and implications for the trace element alterations should be further investigated.