Subdivision of M1 Stage for De Novo Metastatic Breast Cancer to Better Predict Prognosis and Response to Primary Tumor Surgery

Options for postoperative radiation therapy in patients with de novo metastatic breast cancer

BACKGROUND

Although meta-analyses have demonstrated survival benefits associated with primary tumor resection in MBC, guidelines lack consensus on the survival benefit of postoperative radiation therapy (RT).

METHODS

In this study, we included 1392 patients with de novo metastatic breast cancer (dnMBC) by integrating data from the SEER database (2010-2019) to systematically assess the efficacy of postoperative RT and develop a machine learning-driven prognostic tool. The primary endpoint was overall survival (OS).

RESULTS

Propensity score matching (PSM) results showed that postoperative RT significantly improved OS (HR = 0.573, 95 % CI = 0.475-0.693), but this survival gain showed great heterogeneity among different subgroups. It is found that patients with HR-/HER2-or HR+/HER2-subtypes gained significant OS benefit from (p < 0.001) postoperative RT, whereas patients with HER2+ subtype did not gain any survival benefit since the effect of targeted therapy overshadowed the postoperative RT. Further risk stratification by the random survival forest (RSF) model revealed that high-risk patients with T4/N3 stage, high tumor grade and poor response to chemotherapy had significantly prolonged OS after receiving RT (p < 0.001), while low-risk patients showed no additional benefit. The model had excellent predictive efficacy (training set C-index = 0.741, validation set C-index = 0.720) with key predictors including HER2 status, chemotherapy response and tumor grade. The research team developed an interactive web application (https://lee2287171854.shinyapps.io/RSFshiny/) based on this model, which can generate individualized survival risk scores in real-time to guide clinical decision-making.

CONCLUSION

This study is the first to propose a risk stratification strategy for postoperative RT in dnMBC, and innovatively integrates machine learning and clinical tools to provide a new paradigm for optimizing precision therapy.

Subdivision of M1 category and prognostic stage for de novo metastatic breast cancer to enhance prognostic prediction and guide the selection of locoregional therapy

BACKGROUND

Although de novo metastatic breast cancer (dnMBC) is acknowledged as a heterogeneous disease, the current staging systems do not distinguish between patients within the M1 or stage IV category. This study aimed to refine the M1 category and prognostic staging for dnMBC to enhance prognosis prediction and guide the choice of locoregional treatment.

METHODS

We selected patients with dnMBC from the SEER database (2010-2019), grouping them into training (N = 8048) and internal validation (N = 3450) cohorts randomly at a 7:3 ratio. An independent external validation cohort (N = 660) was enrolled from dnMBC patients (2010-2023) treated in three hospitals. Nomogram-based risk stratification was employed to refine the M1 category and prognostic stage, incorporating T/N stage, histologic grade, subtypes, and the location and number of metastatic sites. Both internal and external validation sets were used for validation analyses.

RESULTS

Brain, liver, or lung involvement and multiple metastases were independent prognostic factors for overall survival (OS). The nomogram-based stratification effectively divided M1 stage into three groups: M1a (bone-only involvement), M1b (liver or lung involvement only, with or without bone metastases), and M1c (brain metastasis or involvement of both liver and lung, regardless of other metastatic sites). Only subtype and M1 stage were included to define the final prognostic stage. Significant differences in OS were observed across M1 and prognostic subgroups. Patients with the M1c stage benefited less from primary tumor surgery in comparison with M1a stage.

CONCLUSION

Subdivision of the M1 and prognostic stage could serve as a supplement to the current staging guidelines for dnMBC and guide locoregional treatment.

Brain Radiotherapy Combined with Targeted Therapy for HER2-Positive Breast Cancer Patients with Brain Metastases

Background

Research on the sequencing of brain radiotherapy and targeted chemotherapy after brain metastasis (BM) in HER2-positive breast cancer patients is limited and inconclusive. This study investigated the efficacy of sequential delivery of radiotherapy and targeted therapy in patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer with BM.

Methods

Fifty-seven patients were categorized into two groups: the targeted-radiotherapy group (receiving 2-8 cycles of anti-HER2-targeted therapy followed by radiotherapy after BM) and the radiotherapy-targeted group (undergoing radiotherapy first, followed by regular anti-HER2-targeted therapy). The study endpoints were intracranial progression-free survival (iPFS) and overall survival. Factors associated with intracranial progression and mortality were assessed by univariate and multivariate Cox proportional hazards analysis.

Results

Patients in the radiotherapy-targeted group had better iPFS (P < 0.001), while there was no significant difference in overall survival between the two groups (P = 0.145). Multivariate Cox analysis showed that different sequential treatment groups were independent prognostic factors for iPFS. In patients with a modified breast graded prognostic assessment score of 3.5-4.0, the median survival time was 26 months in the radiotherapy-targeted group and 22 months in the targeted-radiotherapy group (P = 0.019).

Conclusion

Overall, radiotherapy followed by targeted therapy may improve survival in HER2-positive breast cancer patients with BM, particularly in those with a modified breast graded prognostic assessment score of 3.5-4.0.

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.

Radiotherapeutic Strategies to Overcome Resistance of Breast Cancer Brain Metastases by Considering Immunogenic Aspects of Cancer Stem Cells

Breast cancer is the most diagnosed cancer in women, and symptomatic brain metastases (BCBMs) occur in 15-20% of metastatic breast cancer cases. Despite technological advances in radiation therapy (RT), the prognosis of patients is limited. This has been attributed to radioresistant breast cancer stem cells (BCSCs), among other factors. The aim of this review article is to summarize the evidence of cancer-stem-cell-mediated radioresistance in brain metastases of breast cancer from radiobiologic and radiation oncologic perspectives to allow for the better interpretability of preclinical and clinical evidence and to facilitate its translation into new therapeutic strategies. To this end, the etiology of brain metastasis in breast cancer, its radiotherapeutic treatment options, resistance mechanisms in BCSCs, and effects of molecularly targeted therapies in combination with radiotherapy involving immune checkpoint inhibitors are described and classified. This is considered in the context of the central nervous system (CNS) as a particular metastatic niche involving the blood-brain barrier and the CNS immune system. The compilation of this existing knowledge serves to identify possible synergistic effects between systemic molecularly targeted therapies and ionizing radiation (IR) by considering both BCSCs' relevant resistance mechanisms and effects on normal tissue of the CNS.

Survival benefits of primary tumor surgery for synchronous brain metastases: A SEER-based population study with propensity-matched comparative analysis

BACKGROUND

Evidence about the prognostic value of primary tumor surgery (PTS) in patients with brain metastatic malignancies is ambiguous and controversial. This study assessed the survival benefits of primary tumor surgery in patients with brain metastases (BMs).

METHODS

Adults patients with BMs that originated from lung, breast, kidney, skin, colon, and liver diagnosed between 2010 and 2018 were derived from the Surveillance, Epidemiology, and End Results database (SEER). Propensity score matching (PSM) was used to balance the bias between patients with or without PTS. Then the prognostic value of PTS was estimated by Kaplan-Meier analysis and Cox proportional hazard regression models.

RESULTS

A total of 32,760 patients with BMs secondary to non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), breast cancer, renal cancer, melanoma, colorectal cancer, and liver cancer were identified from the database. After PSM at 1:1 ratio, PTS appeared to significantly prolong cause-specific survival (CSS) time for patients with BMs secondary to NSCLC, breast cancer, renal cancer, and colorectal cancer (hazard ratio [HR] = 0.60 [0.53-0.68], 0.56 [0.43-0.73], 0.47 [0.37-0.60], and 0.59 [0.37-0.95], respectively, all p < 0.05). Patients with earlier T and N classifications, no extracranial metastasis, and cancer-specific subtypes (adenocarcinoma in NSCLC, hormone receptor-negative breast cancer) may derive more survival benefits from PTS when suffering from BMs.

CONCLUSION

This population-based study supported PTS could provide survival benefits for patients with BMs secondary to NSCLC, breast cancer, renal cancer, and colorectal cancer. More emphasis should be put on PTS of selected patients with BMs.

The analysis of breast cancer survival in East Azerbaijan province of Iran; prognostic impact of chemotherapy and hormone therapy protocols

BACKGROUND

The global cancer pattern indicated that there were about 2.3 million newly diagnosed breast cancer cases in 2020 worldwide, and was the most common cancer incident in the world. The aim of the study was to assess the prognostic impact of various treatment modalities and cancer-specific overall and disease-free survival rates.

METHODS

One, 5-, 10-, and 15 -years survival rates were calculated; furthermore, overall survival (OS) and disease free survival (DFS) rates were obtained using Kaplan Meier method. To assess the effects of different treatment methods and all clinico-pathological variables with OS and DFS, cox-regression method was used to achieve adjusted hazard ratios of mortality and recurrence rates.

RESULTS

During the study period, 504 primary breast cancer cases were evaluated, with mean age of 49.69(± 10.68) years. The one, 5-, 10-, and 15- year survival rates were 98.21%, 87.39%, 68.17% and, 60.60%, respectively. Tamoxifen + GnRh Agonist and Tamoxifen protocols decreased the hazard of relapse 46% and 84%, respectively. The best one-year OS was obtained for patients treated with Tamoxifen with an aromatase inhibitor (AI) for about 100% overall survival rate. The breast cancer mortality rate was lower than relapse rate in the first and 5thyears of disease, but 10- and 15- year mortality were higher than 10- and 15 -year relapse rates.

CONCLUSION

Our results revealed better overall survival and disease- free survival among primary breast cancer patients in East Azerbaijan; consequently, this underscores establishing and using better chemotherapy and hormone therapy protocols and sufficient follow-ups.

De novo metastatic lobular breast carcinoma: A population-based study from SEER database

PURPOSE

Patients with metastatic lobular breast carcinoma constitute a heterogeneous group with distinguishing features. Our aim was to describe the features and survival of them, and further subdivide them into subcategories for prognostic stratification and treatment planning.

PATIENTS AND METHODS

Patients with de novo metastatic breast cancer from 2010 to 2018 were identified using the SEER database. Multivariate logistic regression analysis was conducted to calculate odds ratios. The within-pair difference was minimized by propensity score matching. Multiple comparisons based on Cox proportional hazards model were performed to investigate the interactions of M1 subcategory and treatment modality on survival.

RESULTS

A total of 1,675 patients with de novo metastatic lobular breast carcinoma were identified, they were more likely to have HR+/HER2- subtype, low histologic grade, low T/N stage, fewer metastatic sites, but worse prognosis compared with patients with metastatic ductular breast carcinoma. The M1 stage was subdivided into 3 subcategories with significantly different prognoses. The benefits of primary tumor surgery were more pronounced in M1a/b disease, whereas the benefits of chemotherapy increased with the progression of metastatic disease.

CONCLUSION

Patients with metastatic lobular breast carcinoma have unique clinicopathological characteristics and metastatic patterns. M1 subcategory assists prognosis stratification and treatment planning for such patients.

OUP accepted manuscript

Purpose

About 10% of breast cancer (BC) is diagnosed in stage IV. This study sought to identify factors associated with time to progression (TTP) and overall survival (OS) in a cohort of patients diagnosed with de novo metastatic breast cancer (MBC), from a single cancer center in Colombia, given that information on this aspect is limited.

Methodology

An observational, analytical, and retrospective cohort study was carried out. Time to progression and OS rates were estimated using the Kaplan–Meier survival functions. Cox models were developed to assess association between time to progression and time to death, using a group of fixed variables.

Results

Overall, 175 patients were included in the study; 33.7% of patients had luminal B HER2-negative tumors, 49.7% had bone involvement, and 83.4% had multiple metastatic sites. Tumor biology and primary tumor surgery were the variables associated with TTP and OS. Patients with luminal A tumors had the lowest progression and mortality rates (10 per 100 patients/year (95% CI: 5.0-20.0) and 12.6 per 100 patients/year (95% CI: 6.9-22.7), respectively), and patients with triple-negative tumors had the highest progression and mortality rates (40 per 100 patients/year (95% CI: 23.2-68.8) and 44.1 per 100 patients/year (95% CI: 28.1-69.1), respectively). Across the cohort, the median TTP was 2.1 years (95% CI: 1.6; the upper limit cannot be reached) and the median OS was 2.4 years (95% CI: 2-4.3).

Conclusions

In this cohort, patients with luminal A tumors and those who underwent tumor surgery given that they presented clinical benefit (CB) after initial systemic treatment, had the lowest progression and mortality rates. Overall, OS was inferior to other series due to high tumor burden and difficulties in accessing and continuing oncological treatments.

Metastatic breast cancer: Who benefits from surgery?

BACKGROUND

We sought to identify characteristics of metastatic breast cancer (MBC) patients who may benefit most from primary tumor resection.

METHODS

Recursive partitioning analysis (RPA) was used to categorize non-surgical patients with de novo MBC in the NCDB (2010-2015) into 3 groups (I/II/III) based on 3-year overall survival (OS). After bootstrapping (BS), group-level profiles were applied, and the association of surgery with OS was estimated using Cox proportional hazards models.

RESULTS

All patients benefitted from surgery (median OS, surgery vs no surgery): 72.7 vs 42.9 months, 47.3 vs 30.4 months, 23.8 vs 14.4 months (all p < 0.001) in BS-groups I, II, and III, respectively. After adjustment, surgery remained associated with improved OS (HR 0.52, 95% CI 0.50-0.55). The effect of surgery on OS differed quantitatively across groups.

CONCLUSION

Prognostic groups may inform the degree of benefit from surgery, with the greatest benefit seen in those with the most favorable survival.

Risk Factors, Prognostic Factors, and Nomogram for Distant Metastasis in Breast Cancer Patients Without Lymph Node Metastasis

Background

Lymph node negative (N0) breast cancer can be found coexisting with distant metastasis (DM), which might consequently make clinicians underestimate the risk of relapse and insufficient treatment for this subpopulation.

Methods

The clinicopathological characteristics of N0 breast cancer patients from the Surveillance, Epidemiology, and End Results (SEER) database between January 2010 and December 2015 were retrospectively reviewed. Multivariate logistic and Cox analyses were used to identify independent risk factors in promoting DM and the 1-, 3-, and 5- year cancer-specific survival (CSS) in this subpopulation.

Result

Seven factors including age (<40 years), tumor size (>10 mm), race (Black), location (central), grade (poor differentiation), histology (invasive lobular carcinoma), and subtype (luminal B and Her-2 enriched) were associated with DM, and the area under curve (AUC) was 0.776 (95% CI: 0.763-0.790). Moreover, T1-3N0M1 patients with age >60 years at diagnosis, Black race, triple-negative breast cancer subtype, no surgery performed, and multiple DMs presented a worse 1-, 3-, and 5-year CSS. The areas under the ROC for 1-, 3-, and 5- year CSS in the training cohort were 0.772, 0.741, and 0.762, respectively, and 0.725, 0.695, and 0.699 in the validation cohort.

Conclusion

The clinicopathological characteristics associated with the risk of DM and the prognosis of female breast cancer patients without lymph node metastasis but with DM are determined. A novel nomogram for predicting 1-, 3-, 5- year CSS in T1-3N0M1 patients is also well established and validated, which could help clinicians better stratify patients who are at a high-risk level for receiving relatively aggressive management.

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

Background

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

Methods

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

Results

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

Conclusions

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

Prognostic Model for De Novo and Recurrent Metastatic Breast Cancer

PURPOSE

Metastatic breast cancer (MBC) has a heterogeneous clinical course. We sought to develop a prognostic model for overall survival (OS) that incorporated contemporary tumor and clinical factors for estimating individual prognosis.

METHODS

We identified patients with MBC from our institution diagnosed between 1998 and 2017. We developed OS prognostic models by Cox regression using demographic, tumor, and treatment variables. We assessed model predictive accuracy and estimated annual OS probabilities. We evaluated model discrimination and prediction calibration using an external validation data set from the National Comprehensive Cancer Network.

RESULTS

We identified 10,655 patients. A model using age at diagnosis, race or ethnicity, hormone receptor and human epidermal growth factor receptor 2 subtype, de novo versus recurrent MBC categorized by metastasis-free interval, Karnofsky performance status, organ involvement, frontline biotherapy, frontline hormone therapy, and the interaction between variables significantly improved predictive accuracy (C-index, 0.731; 95% CI, 0.724 to 0.739) compared with a model with only hormone receptor and human epidermal growth factor receptor 2 status (C-index, 0.617; 95% CI, 0.609 to 0.626). The extended Cox regression model consisting of six independent models, for < 3, 3-14, 14-20, 20-33, 33-61, and ≥ 61 months, estimated up to 5 years of annual OS probabilities. The selected multifactor model had good discriminative ability but suboptimal calibration in the group of 2,334 National Comprehensive Cancer Network patients. A recalibration model that replaced the baseline survival function with the average of those from the training and validation data improved predictions across both data sets.

CONCLUSION

We have generated and validated a robust prognostic OS model for MBC. This model can be used in clinical decision making and stratification in clinical trials.

Breast Subtypes and Prognosis of Breast Cancer Patients With Initial Bone Metastasis: A Population-Based Study

Background

Metastatic breast cancer (MBC) is a highly heterogeneous disease and bone is one of the most common metastatic sites. This retrospective study was conducted to investigate the clinical features, prognostic factors and benefits of surgery of breast cancer patients with initial bone metastases.

Methods

From 2010 to 2015, 6,860 breast cancer patients diagnosed with initial bone metastasis were analyzed from Surveillance, Epidemiology, and End Results (SEER) database. Univariate and Multivariable analysis were used to identify prognostic factors. A nomogram was performed based on the factors selected from cox regression result. Survival curves were plotted according to different subtypes, metastatic burdens and risk groups differentiated by nomogram.

Results

Hormone receptor (HR) positive/human epidermal growth factor receptor 2 (HER2) positive patients showed the best outcome compared to other subtypes. Patients of younger age (<60 years old), white race, lower grade, lower T stage (<=T2), not combining visceral metastasis tended to have better outcome. About 37% (2,249) patients received surgery of primary tumor. Patients of all subtypes could benefit from surgery. Patients of bone-only metastases (BOM), bone and liver metastases, bone and lung metastases also showed superior survival time if surgery was performed. However, patients of bone and brain metastasis could not benefit from surgery (p = 0.05). The C-index of nomogram was 0.66. Cutoff values of nomogram point were identified as 87 and 157 points, which divided all patients into low-, intermediate- and high-risk groups. Patients of all groups showed better overall survival when receiving surgery.

Conclusion

Our study has provided population-based prognostic analysis in patients with initial bone metastatic breast cancer and constructed a predicting nomogram with good accuracy. The finding of potential benefit of surgery to overall survival will cast some lights on the treatment tactics of this group of patients.

Breast Cancer-Specific Mortality in Small-Sized Tumor with Stage IV Breast Cancer: A Population-Based Study

BACKGROUND

Small-sized primary tumor does not always indicate a better prognosis. We hypothesized that very small primary breast tumors with extensive lymph node (LN) metastases represented an aggressive biologic behavior in stage IV disease.

MATERIALS AND METHODS

Data between 2010 and 2015 were retrieved retrospectively from the Surveillance, Epidemiology, and End Results database with inclusion criteria of female sex, unilateral, metastatic, and T1/2 invasive ductal carcinoma. Primary study variables included T stage, N stage, grade, metastatic sites, number of involved sites, estrogen receptor status, progesterone receptor status, and human epidermal growth factor receptor 2 status. Kaplan-Meier and adjusted Cox proportional hazards models with interaction terms were used. One-, 2- and 3-year breast cancer-specific mortality (BCSM) was examined according to tumor size.

RESULTS

We identified 5,340 eligible patients with breast cancer. In multivariate analysis, race, age, grade, molecular subtype, surgery, brain metastases, and liver metastases were found to be independently associated with BCSM. For T1 tumors, the N0, N1, and N2+ groups had the same BCSM. In tumors smaller than 50 mm, the 1-, 2-, and 3-year BCSM did not decline with the decrease of tumor size. For triple-negative breast cancers (TNBCs), the T1a/T1bN2+ group had significantly worse BCSM than any other group did.

CONCLUSION

Patients with stage IV cancer with small-sized tumors may have BCSM as high as those with larger tumors. In TNBCs, very small tumors with severe LN involvement are associated with the worst BCSM. Continued efforts are needed to further investigate Ta1/T1bN2 + M1 TNBCs and individualize the treatment for affected patients.

IMPLICATIONS FOR PRACTICE

This study revealed that for stage IV breast cancer, smaller primary tumors were not always associated with better breast cancer-specific mortality. This study illustrated that very small triple-negative breast cancers (TNBCs) with extensive regional lymph node involvement may be a surrogate for biologically aggressive disease. Because of poor prognosis of T1a/T1bN2+ TNBCs, there might be an urgent need of more individualized treatment for affected patients. Future correlative studies ought to focus on the genetic and molecular differences in Ta1/T1bN2+ TNBCs that contribute to the biological behavior. Clarification of the regulation mechanism of very small-sized primary TNBCs with metastatic outgrowth in nodes and distant sites will play an integral role in developing targeted therapies.

Role of Locoregional Treatment in De Novo Stage IV Breast Cancer

It is estimated that approximately 154000 women in the United States have stage IV breast cancer (BC). A subset of this group has metastatic disease at presentation, known as de novo stage IV disease. De novo stage IV BC accounts for approximately 6% of all BC diagnoses in the United States. Traditionally, stage IV BC patients are treated with primary systemic therapy with a palliative intent reserving possible locoregional treatment (LRT) as last resort. There has been a lot of interest in the role of LRT in de novo stage IV BC for the past decade with mixed conclusions. Although this review is not intended to be a comprehensive overview of all literature regarding this topic to date, we will review the recent findings in literature focusing on the studies with larger sample sizes to investigate the role of LRT in de novo stage IV BC.

Analysis of Prognostic Factors Affecting the Brain Metastases Free Survival and Survival After Brain Metastases in Breast Cancer

This study aimed to analyze the factors affecting brain metastases free survival (BMFS) and the survival after brain metastases (SABM). The data of 215 patients with breast cancer brain metastases (BCBM) in Sun Yat-sen University Cancer Center from January 2000 to August 2017 were retrospectively analyzed. The clinicopathological features of BCBM were analyzed, and their effects on BMFS and SABM were analyzed by univariate and multivariate COX regression. Finally, it was analyzed whether the receptor status of the brain metastases and the primary lesions were consistent. The median age of the entire cohort was 46 years old. The median BMFS, SABM and overall survival were 31, 9 and 44.2 months, respectively. Clinical stage, molecular subtypes and bone metastasis were independent prognostic factors affecting BMFS. TNM stage IV (HR, 4.99 [95% CI, 2.13-11.7]) and triple negative subtype (HR, 2.06 [95% CI, 1.35-3.14]) was significantly associated with shorter BMFS, but the presence of bone metastases (HR, 0.63 [95% CI, 0.45-0.88]) was a favorable factor for BMFS. Molecular subtypes, resection of BCBM and whole brain radiotherapy (WBRT) were independent factors for SABM. The triple negative subtype (HR, 2.02[95% CI, 1.12-3.64]) was significantly associated with shorter SABM. However, resection of BCBM (HR, 0.31 [95% CI, 0.15-0.65]) and WBRT (HR, 0.57 [95% CI, 0.35-0.93]) were independent factors in improving SABM. The conversion rate of ER was 11.1%, PR was 29.6%, and HER2 was 3.7% between paired breast cancer and brain metastases. BMFS and SABM have different influencing factors. Resection of BCBM and WBRT can significantly improve SABM. The frequency of HER2 status changes between the paired BCBM and the primary lesions is low.