The role of local therapies in metastatic breast cancer
- Michael S Sabel, MD
Michael S Sabel, MD
- Associate Professor of Surgery
- University of Michigan Medical School
- Julia White, MD
Julia White, MD
- Professor and Vice Chair
- Department of Radiation Oncology
- Klotz Sister Chair of Cancer Research
- The James CCC, Ohio State University
- Section Editors
- Daniel F Hayes, MD
Daniel F Hayes, MD
- Section Editor — Breast Cancer
- Professor of Medicine
- University of Michigan School of Medicine
- Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
- Section Editor — Breast Surgery
- Associate Professor, Department of Surgery
- Yale University School of Medicine
- David E Wazer, MD
David E Wazer, MD
- Section Editor — Radiation Therapy
- Professor of Radiation Oncology
- Tufts University School of Medicine
- Brown University School of Medicine
Patients with metastatic breast cancer are unlikely to be cured of their disease by any means. Complete remissions from systemic chemotherapy are uncommon, and only a fraction of complete responders remain progression free for a prolonged period. The median survival for patients with stage IV breast cancer is 18 to 24 months, although the range extends from only a few months to many years [1-3]. (See "Systemic treatment for metastatic breast cancer: General principles" and "Tumor, Node, Metastasis (TNM) staging classification for breast cancer".)
Although systemic therapy is the mainstay of treatment for metastatic breast cancer, local management of the primary as well as metastasis-specific local treatment (ie, metastasectomy, radiofrequency ablation, cryotherapy, and radiation therapy) may palliate symptoms and prevent cancer-related complications. Some evidence suggests a potential for prolonging survival, although prospective data are lacking . These approaches and their rationale are discussed here.
Systemic medical therapy for metastatic breast cancer, consisting of chemotherapy, endocrine therapy and/or biologic therapies, and supportive care is discussed elsewhere. (See "Systemic treatment for metastatic breast cancer: General principles".)
LOCAL MANAGEMENT OF THE PRIMARY
The primary role of local treatment to the breast in metastatic breast cancer is palliation. Patients with metastatic disease should be evaluated for possible local management of the primary if it may control local complications from the cancer (eg, bleeding, infection, or wound management). However, in general, for patients who are asymptomatic at the site of their primary, we do not offer local treatment given lack of clear evidence that it improves survival. While retrospective evidence suggests a possible benefit, prospective data have shown no overall survival benefit or only minimal survival benefit, and are limited by methodologic issues. As such, we typically do not offer surgery in such cases.
Deviations to this approach may be rarely made on a case-by-case basis in a multidisciplinary setting, although these instances are exceptional. For example, we have offered local management of the primary to patients with human epidermal growth factor receptor 2 (HER2)-positive disease who have a brisk and dramatic response to systemic therapy. However, data supporting such an approach are lacking, and the decision to proceed with local management in a similar situation should take into account the expertise and experience of the treating institution as well as patient preferences. If lumpectomy is pursued for local management of the primary, radiation therapy (RT) is not indicated, as it would be for primary curative treatment for non-metastatic disease. Similarly, if mastectomy is used, reconstruction should not be offered (unless necessary to close a large wound).
- Lee CG, McCormick B, Mazumdar M, et al. Infiltrating breast carcinoma in patients age 30 years and younger: long term outcome for life, relapse, and second primary tumors. Int J Radiat Oncol Biol Phys 1992; 23:969.
- Vogel CL, Azevedo S, Hilsenbeck S, et al. Survival after first recurrence of breast cancer. The Miami experience. Cancer 1992; 70:129.
- Leung AM, Vu HN, Nguyen KA, et al. Effects of surgical excision on survival of patients with stage IV breast cancer. J Surg Res 2010; 161:83.
- Pagani O, Senkus E, Wood W, et al. International guidelines for management of metastatic breast cancer: can metastatic breast cancer be cured? J Natl Cancer Inst 2010; 102:456.
- Badwe R, Hawaldar R, Nair N, et al. Locoregional treatment versus no treatment of the primary tumour in metastatic breast cancer: an open-label randomised controlled trial. Lancet Oncol 2015; 16:1380.
- King TA, Lyman J, Gonen M, et al. A prospective analysis of surgery and survival in stage IV breast cancer (TBCRC 013). J Clin Oncol 2016; 34S: ASCO #1006.
- Soran A, Ozmen V, Ozbas S, et al. A randomized controlled trial evaluating resection of the primary breast tumor in women presenting with de novo stage IV breast cancer. J Clin Oncol 2016; 34S: ASCO #1005.
- Harris E, Barry M, Kell MR. Meta-analysis to determine if surgical resection of the primary tumour in the setting of stage IV breast cancer impacts on survival. Ann Surg Oncol 2013; 20:2828.
- Warschkow R, Güller U, Tarantino I, et al. Improved Survival After Primary Tumor Surgery in Metastatic Breast Cancer: A Propensity-adjusted, Population-based SEER Trend Analysis. Ann Surg 2016; 263:1188.
- Carmichael AR, Anderson ED, Chetty U, Dixon JM. Does local surgery have a role in the management of stage IV breast cancer? Eur J Surg Oncol 2003; 29:17.
- Nieto Y, Cagnoni PJ, Shpall EJ, et al. Phase II trial of high-dose chemotherapy with autologous stem cell transplant for stage IV breast cancer with minimal metastatic disease. Clin Cancer Res 1999; 5:1731.
- Juan O, Lluch A, de Paz L, et al. Prognostic factors in patients with isolated recurrences of breast cancer (stage IV-NED). Breast Cancer Res Treat 1999; 53:105.
- Khan SA, Stewart AK, Morrow M. Does aggressive local therapy improve survival in metastatic breast cancer? Surgery 2002; 132:620.
- Rapiti E, Verkooijen HM, Vlastos G, et al. Complete excision of primary breast tumor improves survival of patients with metastatic breast cancer at diagnosis. J Clin Oncol 2006; 24:2743.
- Babiera GV, Rao R, Feng L, et al. Effect of primary tumor extirpation in breast cancer patients who present with stage IV disease and an intact primary tumor. Ann Surg Oncol 2006; 13:776.
- Gnerlich J, Jeffe DB, Deshpande AD, et al. Surgical removal of the primary tumor increases overall survival in patients with metastatic breast cancer: analysis of the 1988-2003 SEER data. Ann Surg Oncol 2007; 14:2187.
- Fields RC, Jeffe DB, Trinkaus K, et al. Surgical resection of the primary tumor is associated with increased long-term survival in patients with stage IV breast cancer after controlling for site of metastasis. Ann Surg Oncol 2007; 14:3345.
- Blanchard DK, Shetty PB, Hilsenbeck SG, Elledge RM. Association of surgery with improved survival in stage IV breast cancer patients. Ann Surg 2008; 247:732.
- Hazard HW, Gorla SR, Scholtens D, et al. Surgical resection of the primary tumor, chest wall control, and survival in women with metastatic breast cancer. Cancer 2008; 113:2011.
- Cady B, Nathan NR, Michaelson JS, et al. Matched pair analyses of stage IV breast cancer with or without resection of primary breast site. Ann Surg Oncol 2008; 15:3384.
- Thomas A, Khan SA, Chrischilles EA, Schroeder MC. Initial Surgery and Survival in Stage IV Breast Cancer in the United States, 1988-2011. JAMA Surg 2016; 151:424.
- Ruiterkamp J, Ernst MF, van de Poll-Franse LV, et al. Surgical resection of the primary tumour is associated with improved survival in patients with distant metastatic breast cancer at diagnosis. Eur J Surg Oncol 2009; 35:1146.
- Ly BH, Nguyen NP, Vinh-Hung V, et al. Loco-regional treatment in metastatic breast cancer patients: is there a survival benefit? Breast Cancer Res Treat 2010; 119:537.
- Chua TC, Saxena A, Liauw W, et al. Hepatic resection for metastatic breast cancer: a systematic review. Eur J Cancer 2011; 47:2282.
- Friedel G, Pastorino U, Ginsberg RJ, et al. Results of lung metastasectomy from breast cancer: prognostic criteria on the basis of 467 cases of the International Registry of Lung Metastases. Eur J Cardiothorac Surg 2002; 22:335.
- Friedel G, Linder A, Toomes H. The significance of prognostic factors for the resection of pulmonary metastases of breast cancer. Thorac Cardiovasc Surg 1994; 42:71.
- Pocard M, Pouillart P, Asselain B, et al. [Hepatic resection for breast cancer metastases: results and prognosis (65 cases)]. Ann Chir 2001; 126:413.
- Yoshimoto M, Tada T, Saito M, et al. Surgical treatment of hepatic metastases from breast cancer. Breast Cancer Res Treat 2000; 59:177.
- Sofocleous CT, Nascimento RG, Gonen M, et al. Radiofrequency ablation in the management of liver metastases from breast cancer. AJR Am J Roentgenol 2007; 189:883.
- Dawood S, Broglio K, Gonzalez-Angulo AM, et al. Trends in survival over the past two decades among white and black patients with newly diagnosed stage IV breast cancer. J Clin Oncol 2008; 26:4891.
- Gennari A, Conte P, Rosso R, et al. Survival of metastatic breast carcinoma patients over a 20-year period: a retrospective analysis based on individual patient data from six consecutive studies. Cancer 2005; 104:1742.
- Miao H, Hartman M, Bhoo-Pathy N, et al. Predicting survival of de novo metastatic breast cancer in Asian women: systematic review and validation study. PLoS One 2014; 9:e93755.
- Raab R, Nussbaum KT, Behrend M, Weimann A. Liver metastases of breast cancer: results of liver resection. Anticancer Res 1998; 18:2231.
- Pastorino U, Buyse M, Friedel G, et al. Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. J Thorac Cardiovasc Surg 1997; 113:37.
- McDonald ML, Deschamps C, Ilstrup DM, et al. Pulmonary resection for metastatic breast cancer. Ann Thorac Surg 1994; 58:1599.
- Ludwig C, Stoelben E, Hasse J. Disease-free survival after resection of lung metastases in patients with breast cancer. Eur J Surg Oncol 2003; 29:532.
- Veltri A, Gazzera C, Barrera M, et al. Radiofrequency thermal ablation (RFA) of hepatic metastases (METS) from breast cancer (BC): an adjunctive tool in the multimodal treatment of advanced disease. Radiol Med 2014; 119:327.
- Briasoulis E, Karavasilis V, Kostadima L, et al. Metastatic breast carcinoma confined to bone: portrait of a clinical entity. Cancer 2004; 101:1524.
- Sherry MM, Greco FA, Johnson DH, Hainsworth JD. Metastatic breast cancer confined to the skeletal system. An indolent disease. Am J Med 1986; 81:381.
- Coleman RE, Smith P, Rubens RD. Clinical course and prognostic factors following bone recurrence from breast cancer. Br J Cancer 1998; 77:336.
- Noguchi S, Miyauchi K, Nishizawa Y, et al. Results of surgical treatment for sternal metastasis of breast cancer. Cancer 1988; 62:1397.
- Noble J, Sirohi B, Ashley S, et al. Sternal/para-sternal resection for parasternal local recurrence in breast cancer. Breast 2010; 19:350.
- Cahan WG, Castro EB. Significance of a solitary lung shadow in patients with breast cancer. Ann Surg 1975; 181:137.
- Casey JJ, Stempel BG, Scanlon EF, Fry WA. The solitary pulmonary nodule in the patient with breast cancer. Surgery 1984; 96:801.
- Planchard D, Soria JC, Michiels S, et al. Uncertain benefit from surgery in patients with lung metastases from breast carcinoma. Cancer 2004; 100:28.
- Yoshimoto M, Tada K, Nishimura S, et al. Favourable long-term results after surgical removal of lung metastases of breast cancer. Breast Cancer Res Treat 2008; 110:485.
- Meimarakis G, Rüttinger D, Stemmler J, et al. Prolonged overall survival after pulmonary metastasectomy in patients with breast cancer. Ann Thorac Surg 2013; 95:1170.
- Hoe AL, Royle GT, Taylor I. Breast liver metastases--incidence, diagnosis and outcome. J R Soc Med 1991; 84:714.
- Atalay G, Biganzoli L, Renard F, et al. Clinical outcome of breast cancer patients with liver metastases alone in the anthracycline-taxane era: a retrospective analysis of two prospective, randomised metastatic breast cancer trials. Eur J Cancer 2003; 39:2439.
- Zinser JW, Hortobagyi GN, Buzdar AU, et al. Clinical course of breast cancer patients with liver metastases. J Clin Oncol 1987; 5:773.
- Selzner M, Morse MA, Vredenburgh JJ, et al. Liver metastases from breast cancer: long-term survival after curative resection. Surgery 2000; 127:383.
- Maksan SM, Lehnert T, Bastert G, Herfarth C. Curative liver resection for metastatic breast cancer. Eur J Surg Oncol 2000; 26:209.
- Sadot E, Lee SY, Sofocleous CT, et al. Hepatic Resection or Ablation for Isolated Breast Cancer Liver Metastasis: A Case-control Study With Comparison to Medically Treated Patients. Ann Surg 2016; 264:147.
- Pawlik TM, Izzo F, Cohen DS, et al. Combined resection and radiofrequency ablation for advanced hepatic malignancies: results in 172 patients. Ann Surg Oncol 2003; 10:1059.
- Livraghi T, Goldberg SN, Solbiati L, et al. Percutaneous radio-frequency ablation of liver metastases from breast cancer: initial experience in 24 patients. Radiology 2001; 220:145.
- Bortolotto C, Macchi S, Veronese L, et al. Radiofrequency ablation of metastatic lesions from breast cancer. J Ultrasound 2012; 15:199.
- Wood TF, Rose DM, Chung M, et al. Radiofrequency ablation of 231 unresectable hepatic tumors: indications, limitations, and complications. Ann Surg Oncol 2000; 7:593.
- de Baere T, Elias D, Dromain C, et al. Radiofrequency ablation of 100 hepatic metastases with a mean follow-up of more than 1 year. AJR Am J Roentgenol 2000; 175:1619.
- Demopoulos RI, Touger L, Dubin N. Secondary ovarian carcinoma: a clinical and pathological evaluation. Int J Gynecol Pathol 1987; 6:166.
- Alvarado-Cabrero I, Rodríguez-Gómez A, Castelan-Pedraza J, Valencia-Cedillo R. Metastatic ovarian tumors: a clinicopathologic study of 150 cases. Anal Quant Cytopathol Histpathol 2013; 35:241.
- Quan ML, Fey J, Eitan R, et al. Role of laparoscopy in the evaluation of the adnexa in patients with stage IV breast cancer. Gynecol Oncol 2004; 92:327.
- Abu-Rustum NR, Aghajanian CA, Venkatraman ES, et al. Metastatic breast carcinoma to the abdomen and pelvis. Gynecol Oncol 1997; 66:41.
- Curtin JP, Barakat RR, Hoskins WJ. Ovarian disease in women with breast cancer. Obstet Gynecol 1994; 84:449.
- Bigorie V, Morice P, Duvillard P, et al. Ovarian metastases from breast cancer: report of 29 cases. Cancer 2010; 116:799.
- Li W, Wang H, Wang J, et al. Ovarian metastases resection from extragenital primary sites: outcome and prognostic factor analysis of 147 patients. BMC Cancer 2012; 12:278.