Resecting Liver Metastases in Breast Cancer?
June 1, 2000 4 minutes read
Resecting Liver Metastases in Breast Cancer?
ABSTRACT & COMMENTARY
Synopsis: Selzner and colleagues present a series of 17 patients with recurrent breast cancer who underwent resection of hepatic metastases. The median survival seemed improved compared with previous reports of similar patients treated medically. Those patients who recurred more than one year after breast surgery did better. Preoperative chemotherapy including bone marrow transplantation did not improve the outcome.
Source: Selzner M, et al. Surgery 2000;127:383-389.
Metastatic breast cancer is usually considered a systemic disease not amenable to local therapy. Therefore, localized therapy is not usually considered for hepatic metastases. Instead, patients are usually offered chemotherapy or hormonal therapy. In this report from Duke University in Durham, North Carolina, patients with resectable liver metastases from breast cancer underwent aggressive treatment to try to improve survival for this seemingly incurable situation.
Over an 11-year period, 33 patients with breast cancer and potentially resectable liver metastases underwent an exploratory laparotomy. Sixteen patients were found to be unresectable intraoperatively. The other 17 patients underwent a successful liver resection with one perioperative death. The median age was 48 years and none of the patients initially presented with stage IV disease. All specimens demonstrated infiltrating ductal adenocarcinoma.
Although no patients had extrahepatic disease at the time of surgery, three patients had been treated previously for metastatic disease with a complete response to either chemotherapy or chemoradiotherapy. The median time from breast cancer surgery to the diagnosis of liver metastases was 29 months (range, 2-84 months). Patients were studied preoperatively with either CT or MRI scans of the chest and abdomen. PET scans were performed once they became available in 1995. Intraoperative ultrasound was also used. Resectable patients had either a single lesion (71%) or two metastatic deposits (29%). Metastases ranged in size from 1.5 to 5 cm (median 2.5 cm) and all were operated on to achieve 1 cm margins with a curative approach.
In 10 patients (59%), the liver metastases were treated preoperatively with systemic chemotherapy. This consisted of doxorubicin, 5-fluorouracil, and methotrexate followed by high-dose chemotherapy with cyclophosphamide, cisplatin, and carmustine supported by hematopoietic progenitor cells. The hepatic metastases were estrogen receptor positive in three cases and these patients received postoperative hormonal therapy.
Follow-up after surgery lasted from six months to 12 years (median 17 months). The median survival was 24 months after liver resection with four patients disease-free at 6 and 17 months and 6 and 12 years postoperatively. Recurrences after liver resection occurred after 1 to 24 months (median 7 months). In two-thirds of these cases the liver was the first site of recurrence. High-dose chemotherapy had no apparent advantage in terms of overall or disease-free survival. However, survival did seem to be better if the hepatic recurrence occurred one year or more after breast surgery. Of interest, the three patients with previous extrahepatic disease did just as well as the other patients. Other factors that did not influence outcome were the type of hepatic resection performed, the number of metastases removed, or the presence of estrogen/progesterone receptors.
COMMENT by Kenneth W. Kotz, MD
Are there exceptional patients with metastatic breast cancer for whom an oncologist should consider referring to a surgeon? According to this study, patients with recurrent breast cancer and one or two resectable hepatic lesions that are diagnosed more than one year after breast surgery may achieve an improvement in survival. There may even be an occasional long-term survivor as one patient remained disease-free 12 years after surgery. Preoperative chemotherapy including high-dose chemotherapy with hematopoietic progenitor cell support does not seem to be beneficial. Despite preoperative studies suggesting resectable metastatic disease, one-half of patients will be unresectable.
Selzner et al review some of the limited data previously published on the natural history of isolated liver metastases in breast cancer. The survival in this study compares favorably with the estimated median survival of 3-6 months for medical treatment of these patients. Although there have been other series of surgically treated metastases from breast cancer reported, they are limited by small numbers and in some cases lack of follow-up information. Whether newer non surgical techniques to treat hepatic metastases, such as radiofrequency ablation, would provide a benefit for these types of patients is unknown. Preoperative chemotherapy including stem cell support does not appear to improve survival.
With the high hepatic recurrence rate after hepatic resection reported by Selzner et al, it would be interesting to know if the postoperative use of liver-directed chemotherapy via the hepatic artery or chemoembolization would be of benefit. Unfortunately, the small number of eligible patients makes the performance of any randomized trial for these patients impractical. However, based on this study, there may be exceptional patients with metastatic breast cancer for whom resection of a liver metastasis may improve the overall survival with even a chance for long-term survival. Whether these findings can be extended to solitary metastases of other sites is not known.
26. Which of the following is true regarding liver metastases in breast cancer patients?
a. Preoperative high-dose chemotherapy will improve the resection rate.
b. Preoperative high-dose chemotherapy will improve the overall survival rate.
c. After a hepatic resection, most recurrences were seen in the brain.
d. Breast cancer patients with resectable liver metastases may benefit more from liver resection if the time from breast surgery to recurrence was more than one year.
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