Elsevier

The Breast

Volume 32, April 2017, Pages 162-172
The Breast

Review
Systematic review of early and long-term outcome of liver resection for metastatic breast cancer: Is there a survival benefit?

https://doi.org/10.1016/j.breast.2017.02.003Get rights and content

Highlights

  • Largest review to date with 1686 patients.

  • The median overall survival was 36 months.

  • The median 1-, 3- and 5-year survival was 90%, 56% and 37%, respectively.

  • Postoperative mortality and morbidity was 0.7% and 20%, respectively.

  • Liver resection has improved survival outcomes compared to chemotherapy alone.

Abstract

Background

Isolated liver metastases occur rarely in patients with metastatic breast cancer. The success of liver resection (LR) for other metastatic disease has led centres to explore the option of LR for patients with isolated breast cancer liver metastases (BCLM). A number of small series have been published in the literature, however the evidence is conflicting. This study aimed to systematically review the literature to determine the perioperative outcome and survival of patients undergoing LR for BCLM.

Methods

An electronic search of Medline and Embase databases was performed to identify all published series. Patient demographics, management, peri-operative outcome and overall survival (OS) were obtained.

Results

A total of 1705 articles were identified of which 531 included patients with non-colorectal and non-neuroendocrine metastases. 43 articles including 1686 patients, met all the inclusion and exclusion criteria. R0 resection was achieved in 83% (683/825). Morbidity and 30-day mortality rates were 20% (174/852) and 0.7% (6/918), respectively. The median OS was 36 months (12–58 months). The median 1-, 3-and 5-year OS were 90%, 56% and 37%, respectively.

Conclusions

LR for BCLM can be carried out with acceptable peri-operative risks in selected patients with survival outcomes that appear to be superior to chemotherapy alone.

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.

References (75)

  • G.A. van Walsum et al.

    Resection of liver metastases in patients with breast cancer: survival and prognostic factors

    Eur J Surg Oncol

    (2012)
  • M. Selzner et al.

    Liver metastases from breast cancer: long-term survival after curative resection

    Surgery

    (2000)
  • S.M. Maksan et al.

    Curative liver resection for metastatic breast cancer

    Eur J Surg Oncol

    (2000)
  • M. Pocard et al.

    Hepatic resection in metastatic breast cancer: results and prognostic factors

    Eur J Surg Oncol

    (2000)
  • M.E. Brennan et al.

    Evaluation of the evidence on staging imaging for detection of asymptomatic distant metastases in newly diagnosed breast cancer

    Breast

    (2012)
  • S. Mahner et al.

    Comparison between positron emission tomography using 2-[fluorine-18]fluoro-2-deoxy-D-glucose, conventional imaging and computed tomography for staging of breast cancer

    Ann Oncol

    (2008)
  • J. Lendoire et al.

    Liver resection for non-colorectal, non-neuroendocrine metastases: analysis of a multicenter study from Argentina

    Hpb

    (2007)
  • D.D. Karavias et al.

    Liver resection for metastatic non-colorectal non-neuroendocrine hepatic neoplasms

    Eur J Surg Oncol

    (2002)
  • S. van Ruth et al.

    Metastasectomy for liver metastases of non-colorectal primaries

    Eur J Surg Oncol

    (2001)
  • N. Howlader et al.

    SEER cancer statistics review

    (2015)
  • J. O'Shaughnessy

    Extending survival with chemotherapy in metastatic breast cancer

    Oncologist

    (2005)
  • V. Guarneri et al.

    Metastatic breast cancer: therapeutic options according to molecular subtypes and prior adjuvant therapy

    Oncologist

    (2009)
  • O. Pagani et al.

    International guidelines for management of metastatic breast cancer: can metastatic breast cancer be cured?

    J Natl Cancer Inst

    (2010)
  • J. Xie et al.

    Clinical outcomes among HR+/HER2- metastatic breast cancer patients with multiple metastatic sites: a chart review study in the US

    Exp Hematol Oncol

    (2015)
  • T. Qin et al.

    Clinicopathologic characteristics and prognostic factors for HER2-positive patients with metastatic breast cancer in southern China

    Arch Med Sci

    (2015)
  • E. Viadana et al.

    Patterns of metastases in adenocarcinomas of man. An autopsy study of 4,728 cases

    J Med

    (1975)
  • E. Viadana et al.

    An autopsy study of some routes of dissemination of cancer of the breast

    Br J Cancer

    (1973)
  • O. Er et al.

    Clinical course of breast cancer patients with metastases limited to the liver treated with chemotherapy

    Cancer J

    (2008)
  • A.L. Hoe et al.

    Breast liver metastases–incidence, diagnosis and outcome

    J R Soc Med

    (1991)
  • B.M. Jaffe et al.

    Factors influencing survival in patients with untreated hepatic metastases

    Surg Gynecol Obstet

    (1968)
  • J. Alexandre et al.

    Factors predicting for efficacy and safety of docetaxel in a compassionate-use cohort of 825 heavily pretreated advanced breast cancer patients

    J Clin Oncol

    (2000)
  • G. Pentheroudakis et al.

    Metastatic breast cancer with liver metastases: a registry analysis of clinicopathologic, management and outcome characteristics of 500 women

    Breast Cancer Res Treat

    (2006)
  • X.F. Duan et al.

    Treatment outcome of patients with liver-only metastases from breast cancer after mastectomy: a retrospective analysis

    J Cancer Res Clin Oncol

    (2011)
  • B. Elsberger et al.

    Is there a role for surgical resections of hepatic breast cancer metastases?

    Hepatogastroenterology

    (2014)
  • R. Adam et al.

    Hepatic resection for noncolorectal nonendocrine liver metastases: analysis of 1,452 patients and development of a prognostic model

    Ann Surg

    (2006)
  • R. Adam et al.

    Is liver resection justified for patients with hepatic metastases from breast cancer?

    Ann Surg

    (2006)
  • F. Polistina et al.

    Aggressive treatment for hepatic metastases from breast cancer: results from a single center

    World J Surg

    (2013)
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