ReviewSystematic review of early and long-term outcome of liver resection for metastatic breast cancer: Is there a survival benefit?
Introduction
Breast cancer is the most common cancer affecting females, with a life time risk of 12% [1]. If diagnosed early, the prognosis remains excellent. However, approximately 25–40% will develop metastatic disease [2], [3]. Metastatic breast cancer is generally regarded as a systemic disease and has historically been treated with a palliative intent. However, over the course of time, the mortality rate from metastatic breast cancer is decreasing at 1–2% every year [4] which could be associated with the development of accurate diagnostic tools, identifying metastatic diseases at an earlier stage which are more responsive to treatment and the improvement of adjuvant systemic therapies. Recent figures have shown that 70–92% of patients with metastatic breast cancer have an ECOG score of one or less meaning that the aim of treatment is no longer about palliating symptoms but rather about prolonging life [5], [6], [7].
In patients with isolated metastatic disease, it remains debatable whether surgical resection alters patient survival. Isolated breast cancer liver metastases (BCLM) are reported in 2–12% of all patients with metastatic breast cancer [8], [9], [10]. If untreated it is associated with a survival limited to a few months [11], [12]. Treatment with systemic chemotherapy leads to a prolongation of survival to 8–27 months and a 5-yr survival of 8–12% [10], [13], [14], [15], [16]. The outcome of surgical resection of BCLM is not well defined.
Improvements in patient evaluation, surgical technique and adjuvant treatments have enabled liver resection (LR) to be performed with low postoperative morbidity (22%) and mortality (2–4%) [17], [18]. LR is regarded as a standard treatment for a number of cancers, including metastatic colorectal cancer. The biology of metastatic colorectal cancer differs in that the liver is the first site of drainage of the splanchnic circulation. In contrast, liver metastases from breast cancer would have travelled through the systemic circulation to reach the liver. It is likely that the breast cancer is disseminated by the time liver metastases are diagnosed. It is therefore questionable whether LR of BCLM influences patient survival.
The current literature only reports single centered retrospective studies. The number of patients in each series is small, and the majority have included patients operated on during the infancy of LR. Earlier systematic reviews have demonstrated that LR is a suitable treatment for a specific group of patients. However, these reviews include a small number of patients and describe a narrow range of disease and treatment details [19], [20]. The aim of this study is to systematically review the literature to determine the perioperative morbidity and mortality and survival of patients undergoing LR for metastatic breast cancer.
Section snippets
Methods
This systematic review was conducted according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [21].
Results
An initial search identified 1150 and 781 citations from Medline and Embase, respectively (Fig. 1). After exclusion of duplicates, the remaining citations were screened by reviewing the title and abstract to identify relevant articles. Of the 1705 potentially relevant citations, 1174 were excluded due to content not being relevant (n = 1085; colorectal or neuroendocrine metastases, ablative treatment methods, radiological imaging), patient survival not stated (n = 76), manuscripts could not be
Discussion
This review is currently the largest to date, describing an extensive range of disease characteristics, treatment details and outcomes extracted from 1686 patients that have undergone LR of BCLM. We have demonstrated an acceptable 5-year survival (37%) with low mortality (0.7%) and morbidity rates (20%).
Recent advances in chemotherapy have opened up the potential for BCLM patients to survive for longer. Chemotherapy can be used in conjunction with LR to produce a synergistic effect. A
Conclusion
Liver resection is an effective treatment for liver metastases and can be performed with low morbidity and mortality. Although rarely indicated, LR for BCLM should be considered in patients with isolated liver metastases as the evidence suggests that their survival is improved compared to chemotherapy alone.
Conflicts of interest
None.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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