Palliative Surgery in Breast CancerDenni Joko PurwantoSurgical Onkology, Dept Dharmais Cancer Hospital/National Cancer Center

Goals of TherapyMany patients in Breast cancer will recur not with local or regional disease, but with metastatic disease Patients with metastatic breast cancer are unlikely to be cured

Goals of therapy shift to Symptom control Improved quality of life Prolongation of survival

Breast Cancer Stadium Dharmais Cancer Center Hospital 2009STADIUMI II III IV NA Total

N13 77 81 51 21 243

Percent5.35% 31.69% 33.33% 20.99% 8.64% 100.00%

This approach centers almost exclusively on systemic therapy surgery radiation Reserved for rare situations in which they can provide palliation (such as surgery for an enlarging or ulcerating mass or radiation for bone metastases).

Some evidence that Surgical resection of metastatic disease may play a role in the treatment of breast cancer

How about current therapy ?

Patients with stage IV disease complete remissions are rare 5% - 10% survive over 5 years 2% to 5% may be cured

Data from the National Cancer Institutes Surveillance, Epidemiology, and End Results (SEER) database demonstrate a 5-year survival of 26% for patients with stage IV breast cancer

There may be a benefit to

Multimodality therapy including surgery Prevent complications improve progression free survival.

Patient Selection for SurgeryCareful assessment of the patients Medical condition Extent and biology of the cancer Feasibility and risks of complete resection is necessary Work Up Diagnostic Laboratory CT scan / MRI , Bone scan, PET Scan (if necessary)

FACTORS WHEN CONSIDERING RESECTION OF STAGE IV DISEASEPatient age Co morbidities Ability to tolerate resection Likelihood of complete resection Single organ versus multiple organ disease Solitary versus multiple lesions Disease-free interval Options for systemic therapy

Resection of Specific Metastatic SitesLung Metastases

Liver Metastases Brain MetastasesBone Metastases

Palliative Breast Surgery ( in the Face of Stage IV Disease)

Lung MetastasesWomen with breast cancer metastases will have an isolated metastatic focus in the lung or pleural space 15-25 % Five years survival ranges from 27% to 54% Median survival is 3597 months

Lung MetastasesStrongly considered resection patients with a solitary pulmonary nodule

Pulmonary metastasectomy provides an opportunity for long-term survival in patients with stage IV breast cancer

International Registry of Lung Metastases Stratification of patients Undergoing Pulmonary MetastasectomyResection DiseaseFree Survival (Months) >36 < 36 < 36 Number of Metastases 5 Year Survival Rate (%) 50 35 13 18 10-Year Survival Race (%) 26 21 13 Median Survival (Months) 59 36 2 25

Group I Group II Group III Group IV

Complete Complete Complete Incomplete

Solitary Solitary Multiple -

Liver MetastasesRare to find isolated liver disease (5% to 12% of stage IV patients) Liver involvement is a poor prognostic sign. median survival of 315 Months

With modem chemotherapy, the median survival for patients with liver only metastatic disease is approximately 22 to 27 months

The resection of breast cancer metastases to the liver is less common and more controversial.

Resection for hepatic metastases 3 and 5-year survival was 50 and 34% 3 and 5-year disease-free survival of 42 and 22% Median survival was 34.3 months

Ideal candidate has a solitary metastasis No evidence of extra hepatic metastatic disease Normal liver function Good performance statusLong DFI after treatment of the primary tumor

Multiple nodules can be resected, it may still be a consideration, but bilobar disease should be considered a contraindication to resection Unresectable primary cryotherapy radiofrequency ablation (RFA /HAIFFU)

Brain MetastasesPoor prognosis, with a median survival (untreated) of only 1 to 2 months

Whole brain radiation therapy (WBRT) provides effective palliation and increases median survival to 4 to 6 months Surgical resection will improved outcomes relative to WBRT alone and can provide rapid and more durable symptom palliation median survival durations of 16 to 37 months

Surgical resection should be considered with solitary metastases without extracranial disease

Stereotactic radiosurgery (SRS)Alternative to resection cerebral metastases. Principle of stereotactic is localization to accurate targeting with multiple convergent radiation beam.Primary treatment for single or multiple lesions.

Surgery offers the best potential forimmediate decompression of large solitary symptomatic lesions

Bone MetastasesBone is the most common site of metastatic & good response to endocrine therapy. Approximately 20% of cases are solitary Radiation therapy can provide effective pain relief and prevent fracture Surgery is used for the palliative treatment of epidural spinal cord or nerve compression syndromes reduce or prevent bone metastasis associated fractures

Palliative Breast SurgeryBreast tumor was left in place and monitored as a measure of response to therapy. Breast surgery in the presence of known metatstatic disease may improve survival Improvement in survival is seen in the women who had complete resection of their primary tumor Analysis is adjusted for age, nature of the metastatic disease and the use of systemic therapy

Surgeryprevents continued dissemination of disease from the primary increases immune recognition removed growth factors produced by the primary that influence distant metastasis

The biological rationale for an improvement in survivalPrimary tumor seed source for development of new metastases, and its removal would theoretically diminish the chances of disease progression Decreasing the tumor burden by removal of the primary could also increase the efficacy of chemotherapy by reducing the chances of a resistant clone appearing Immune modulation may be achieved by eliminating the immunosuppression associated with the presence of the primary tumor.

Chemotherapy first in this setting, and so surgery may be reserved for those with a good response to systemic therapy.

Several factors in deciding patient primary breast surgery.Age and co-morbiditi

Surgery that would be necessary for control (lumpectomy vs. mastectomy) predicted to systemic therapy (size, grade, nodal status, F,R, PR and Her-2/neu status) or the demonstrated response to systemic therapy

Several factors in deciding patient primary breast surgery (Continued)

Number and sites of the metastases (single vs. multiple, bone-only vs. visceral)Palliative benefit of resection

Primary breast surgery be appropriate in selected patients with metastatic disease

CaseFemale, 32 years old, married, children Two years ago, there was mass on right breast and after six months later, there was mass on left breast. Right breast: ulcers +, fixed to chest wall, 15 x 15 x 10 cm. Left breast: ulcers +, mobile, 5 x 5 x 2 cm. Lymph node on axillaries +, multiple, mobile Lung metastatic symptom was present

Metachronus Bilateral Breast Cancer With Lung Metastasis

Therapy ReceivedPatient received chemotherapy: Taxotere, Carboplatin, (6 x)Trastuzumab (1 year)

Bilateral Mastektomy

Skin Graft Coverage Chest Wall

One Year After Surgery