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25 maart 2018: Bron: Irish Journal of Medical Science (1971 -)

Bij ongeveer 10% van de borstkankerpatiënten worden bij de diagnose al uitzaaiingen in andere organen gevonden. Meestal in de longen of botten of de lever. En circa 25% tot 30% van de vrouwen zal na de diagnose ondanks een behandeling toch op termijn uitzaaiingen ontwikkelen in andere organen. Leveruitzaaiingen worden meestal behandeld met systemische chemotherapie en zelden weggehaald met een operatie en andere ablatietechnieken zoals RFA - Radio Frequency Ablation, MWA - Microwave Ablation, LITT - Laser-induced Interstitial Thermotherapy, en meer en meer wordt de laatste jaren de Nanoknife - Ireversible electroporation toegepast, ook bij levertumoren.

Toch blijkt uit een recent gepubliceerde reviewstudie dat in een aantal situaties het zeker zin kan hebben om de leveruitzaaiingen bij borstkanker wel weg te halen. En dan pas systemische chemo te geven of andere vormen van behandelingen, waarbij ik dan zou denken aan immuuntherapie of gerichte behandelingen binnen personalised medicine.

leveruitzaaiingen vanuit borstkanker

Source image: http://www.genetherapyhospitals.com/BreastCancer/Liver.html

Een recente systemische reviewstudie analyseerde 25 studies die gegevens van totaal 1080 patiënten verwerkte van patiënten met aan borstkanker gerelateerde leveruitzaaiingen. 

Van deze patiënten ondergingen er 280 patiënten een leverresectie, de levertumoren werden weggehaald, bv via RFA / MWA of LITT. Deze patiënten hadden een 5-jaars overleving van 24.6% tot 78% en een overall overleving van 29.5 maanden tot 116 maanden. Er ligt dus een groot verschil in die overlevingstijd en belangrijk is wel om de patiënten vooraf goed te selecteren op bepaalde kenmerken schrijven ook de onderzoekers. Van de patiënten met meerdere uitzaaiingen in meerdere organen, oligometastatische ziekte genoemd, waarbij de uitzaaiingen grotendeels waren weggehaald, varieerde de 5-jaars overleving van 21% tot 57% en de algehele overleving varieerde van 32 tot 58 maanden.

Wat mij opvalt is dat de kans om binnen 30 dagen te overlijden gerelateerd aan de operatieve ingreep m.i. hoog ligt,  14% tot 42% voor geïsoleerde en meervoudige metastasen.

Toch concluderen de onderzoekers:

Levertumoren weghalen (Hepatische resectie) kan worden overwogen bij de behandeling van borstkankerpatiënten met geïsoleerde levermetastasen en bij patiënten met oligometastatische ziekte (meerdere uitzaaiingen in meerdere organen).

Uit een andere reviewstudie uit 2011: Resection of liver metastases from breast cancer: Towards a management guideline werden min of meer gelijke resultaten gemeld. 

Zie deze grafiek van de studies die daarin werden geanalyseerd en de nieuwe reviewstudie is min of meer een vervolg daarop:

Table 1Studies on liver resection for Breast cancer liver metastases.
Author, Journal & Yearstudy periodPatient Numbers & study designComplications (m&m)Survival & outcome
Breast only
32Adam R & Aloia T et al; Ann Surg. 2006 1984–2004 85 breast ca; Single institute Nil mortality Median and 5-year overall survivals 46 months and 41%
33Pocard M et al;

Eur J Surg Oncol. 2000		 1988–1997 49 breast ca; Single, retrospective data Nil mortality, 12% morbidity Survival 86% at 12 months, 79% at 24 months and 49% at 36 months.
34Thelen A et al; J Surg Oncol. 2008 1988–2006 39 breast cancer Nil mortality & morbidity 13% overall 1-, 3-, and 5-year survival 77%, 50%, and 42%, respectively
35Sakamoto Y et al; World J Surg. 2005 1985–2003 34 breast ca No mortality Overall and disease-free 5-year survival 21% and 16%, respectively
36Raab R et al;

Anticancer Res 18 (1998)		 11 yrs 34 breast ca; R0 resection 86%. Mortality 3% Overall 5-year survival 18.4% (median 27 months)
37Vlastos G et al;

Ann Surg Oncol (2004)		 1991–2002 31 breast No post-operative mortality The median survival 63 months, Overall 2 and 5-year survival 86% and 61%, respectively
38Yoshimoto M et al; Breast Cancer Res Treat. 2000 1985–1998 25 breast Nil 2 and 5-year cumulative survival 71% and 27%, respectively
23Lubrano J et al;

Surg Today. 2008		 1989–2004 16 breast No death Overall 1, 3, and 5-year survival 94%, 61%, and 33%, respectively. Median survival 42 months.
39Elias D et al;

Am J Surg. 2003		 1986–2000 Total 54 patients, 29 breast had surgery only, 25 patients had surgery as well as post-operative Hepatic arterial infusion chemotherapy (HAIC) morbidity 12.9%; no mortality 3- and 5-year overall survival 50% and 34%
24Carlini M et al;

Hepatogastroenterology 2002		 Nil available 17 breast Mortality nil and morbidity 2 Actuarial 5-year survival 46%.
25Caralt M et al;

Ann Surg Oncol. 2008		 88–2006 12 breast Nil died, 2 bile leak Median overall survival 35.9 months. Actuarial 1-, 3-, and 5-year survival 100%, 79%, and 33%, respectively
26Maksan SM et al;

Eur. J. Surg. Oncol. 2000		 1984–1998 9 pts breast No death 5-year survival 51%
27Seifert JK et al; Hepatogastroenterology 1999 1985–1997 15 breast No mortality Overall median survival following liver resection was 57 months with 1-, 2- and 3-year survival rates of 100%, 71.4% and 53.6% respectively
Breast as part of non-colorectal non-neuroendocrine (NCRNE) series
13Adam R et al;

Ann Surg. 2006		 1983–2004 Total 1452 pts

Breast 460 (32%), GI 230 (16%), urologic 206 (14%) & melanoma 148 (10%);

41 French centres; Association of French Surgeons study,

R0 resection 83%, preop chemo 42%		 60-day mortality 2.3% and a major complication 21.5% 5 years Overall and disease-free survival 36% and 21% and at 10 years 23% and 15%, respectively.

Tumour recurrence 67% of patients
15Weitz et al;

Annals of Surgery 2005		 1981–2002 Total 141 patients;

Breast 29; melanoma 17; testicular 17; gynaecological 19; (ovarian 12); renal 11; GI 12; Observational study (longitudinal type)		 Post-operative mortality 0%;

46 (33%) post-operative complications		 5 years survival 24%
40Yedibela S et al; Annals of Surgical oncology 2005 1978–2001 Total 152 patients;

Stomach 31, pancreas 21, breast 24, SB 17, kidney & GU 27, melanoma 5, sarcoma 8; Single institutional retrospective cohort studies;		 Morbidity 29%, mortality 9% Overall 2- and 5-year survival 49% and 26%, respectively; Median survival up to 23 months
41Reddy SK et al;

J Am Coll Surg 2007		 1995–2005 Total 82 patients; Breast 20, ovarian 11, renal 4, sarcoma 19, melanoma 18, gastric 1; retrospective comparative Mortality 4%, complication 30% Actuarial 5-year overall and disease-free survival 37% and 16%, respectively.
28O’Rourke TR et al; Annals of Surgical Oncology 2007 1986 to

2006		 Total 102 patients; GU 32 (Renal 16) ovarian 12) melanoma 15, breast 11, sarcoma 3;

between 2 hospitals		 Mortality and morbidity 0.8% and 21.1%, respectively Median survival 42 months and Overall Survival at 3 and 5 years 56.1% and 38.5%, respectively.
17Elias D, Lasser P et al.

J Am Coll Surg. 1998		 1984–1996 Total 147 patients. 35 breast, 27 neuroendocrine, 20 testicular, 13 sarcomas and 11 gastric, 10 melanomas and 7 gallbladder, 6 gynaecological; single centre Mortality 2%. The crude 5-year survival 36%

Five-year survival 20% for 35 breast cancers
42Ercolani G et al; Ann Surg Oncol. 2005 1990 to 2003 Total 83 cases

gastrointestinal 18, breast 21, genitourinary 15, leiomyosarcoma 10,		 No mortality, 21% morbidity The 3 and 5-year actuarial survival 49.5% and 34.3%;

3- and 5-year actuarial survival 53.9% and 24.6% from breast cancer
29Earle SA et al; J Am Coll Surg. 2006 1990–2005 Total 76 cases;

Pancreas 12, stomach 3; sarcoma 19, breast 10, kidney 10, gynaecological 10, melanoma 4;		 Mortality 2.1%, and post-operative complications 15.8% Median survival 36 months, and 5-year survival 34.9%.
30Lendoire J et al;

HPB, 2007		 1989 to 2005 Total 106,

renal 21, ovarian

14, sarcoma 23, breast 19, melanoma 6, gastric 3, other GI 4; 5 centres, Cross sectional study		 Perioperative mortality 1.8% Overall survival 1, 3 and 5 yrs is 67%, 34% and 19% respectively. 5-year survival 53% for breast origin
31Cordera F et al; J Gastrointest Surg 2005 1988–1998 Total 64 patients;

GI 12, GU 28, soft tissue 15 (Breast 10), 3 lung; retrospective study at Mayo clinic		 Mortality 1.5% Actual 1-, 3-, and 5-year survivals 81%, 43%, and 30%, respectively
Studies not included: having less than 10 patients of breast ca
19Harrison et al; Surgery 1997 1980–1995 Total 96 patients; sarcoma 27, melanoma 7, breast 7, testicular 9, adrenal 7, renal 5, ovary 7, gastric 5, 8 unknown;

Cross Sectional study		 No post-operative complications, but no details given on death Survival at 1, 3 and 5 yrs 80%, 45% and 37% respectively
20Karavias et al;

European Journal of Surgical Oncology 2002		 1994–2000 Total 18 patients;

Breast 4, kidney 6; gastric 4; intestinal leomyosarcoma 2;

Observational (longitudinal type)		 3 cases: pulmonary atelectasis and bile leakage Median survival 3.2 years
21Benevento A et al; J Surg Oncol. 2000 1988–1998 Total 18 patients; breast 4, gastric 5 Nil mortality, 8 complications Overall actuarial survival 54% at 1 year, 42% at 2 years, and 21% at 5 years
22Goering JD et al; Am J Surg. 2002 1991–2001 Total 42 (13 neuroendocrine); 3 renal, 8 ovarian, sarcoma 10, breast 3, melanoma 2 1 operative mortality (2%) Overall survival rates at 1, 3, and 5 years are 82%, 55%, and 39%, respectively (median survival, 45 months).
16Laurent C et al;

World J Surg. 2001		 1980–1997 Total 39;

gastrointestinal 15, genitourinary 12, breast 2, sarcoma 3		 No mortality Survival at 1, 3, and 5 years 81, 40, and 35%, respectively;
14Hemming et al;

Liver transplantation 2000		 1978–

1998		 Total 37 patients; 7 pts GI,

7 sarcoma, 7 renal, 5 melanoma; 2 pancreas; breast 1; Observational study (longitudinal type)		 No surgical deaths.

No complications mentioned		 Survival at 1, 3 and 5 yrs is 85%, 55% and 45% respectively; average survival 46 months
View Table in HTML

Het volledige studierapport The role of liver resection in patients with metastatic breast cancer: a systematic review examining the survival impact is tegen betaling en door artsen en chirurgen werkzaam in een ziekenhuis gratis in te zien. Het abstract met referentielijst staat hieronder.

Hepatic resection can be considered in the management of breast cancer patients with isolated liver metastases as well as those with oligometastatic disease.

Irish Journal of Medical Science (1971 -)

Tasleem, S., Bolger, J.C., Kelly, M.E. et al. Ir J Med Sci (2018). https://doi.org/10.1007/s11845-018-1746-9

The role of liver resection in patients with metastatic breast cancer: a systematic review examining the survival impact

  • Sadia Tasleem
  • Jarlath C. Bolger
  • Michael E. Kelly
  • Michael R. Boland
  • Dermot Bowden
  • Karl J. Sweeney
  • Carmel Malone
  1. 1.Department of Breast Surgery, University Hospital GalwaySaolta University Hospital GroupGalwayIreland
Review Article
First Online: 01 February 2018

Abstract

Introduction

Approximately 10% of breast cancer patients will present with solid organ metastases, while up to 30% will develop metastatic disease during their treatment course. Liver metastases are usually treated with systemic chemotherapy. Although colorectal liver metastases are routinely resected, this is not yet the standard of care for breast cancer-related liver metastases. This review examines the evidence for resection of breast cancer-related liver metastases.

Methods

A systematic review identified 25 articles for inclusion, 12 papers concerning patients with isolated liver metastases, and 13 papers concerning patients with extrahepatic metastases. Data from 1080 patients were included.

Results

Two hundred eighty patients underwent hepatic resections for breast cancer-associated metastases with no extrahepatic metastases. Reported 5-year survival ranged from 24.6 to 78%. Median overall survival ranged from 29.5 to 116 months. For patients with oligometastatic disease undergoing resection, 5-year survival ranged from 21 to 57%, with median overall survival ranging from 32 to 58 months. Reported 30-day morbidity ranged from 14 to 42% for isolated and multiple metastases.

Conclusion

Hepatic resection can be considered in the management of breast cancer patients with isolated liver metastases as well as those with oligometastatic disease.

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© Royal Academy of Medicine in Ireland 2018

borstkanker, RFA, operatie, levertumoren, overall overleving, ziektevrije tijd, in lever uitgezaaide borstkanker


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