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PO45 SURGICAL RESECTION OF THE PRIMARY TUMOR MAY IMPROVE SURVIVAL IN PATIENTS WITH STAGE IV BREAST CANCER
Abstracts / The Breast 22 S3 (2013) S19–S63
Recommendations/action plan from 2nd audit cycle: 1. Liaise with twin hospital performing NM bone scans, where a delay is still evident, to speed up the referral system.
PO45 SURGICAL RESECTION OF THE PRIMARY TUMOR MAY IMPROVE SURVIVAL IN PATIENTS WITH STAGE IV BREAST CANCER Kenji Higaki, Mariko Kochi, Yuri Yoshimura, Yukiko Kajiwara, Miho Kono, Mitsuya Ito, Shoichiro Ohtani Hiroshima City Hospital, Hiroshima, Japan Introduction: The standard treatment of stage IV breast cancer (stage IV) has thus far mainly involved palliative care with chemotherapy, hormonal therapy and/or radiation therapy. Resection of the primary tumor is not considered as curative treatment; solely as local therapy to maintain the quality of life. However, the overall survival (OS) after the diagnosis of stage IV is largely determined by the site of metastasis, i.e. less than 6 months for visceral, approximately 18 months for nodal, and 4-5 years for bony metastasis. Several retrospective studies have that surgery for the primary tumor may improve survival in patients with stage IV. Method: We therefore examined 141 stage IV patients treated between 1992 and 2010 in our institute. The patients ranged 26 to 83 years of age, with Eastern Cooperative Oncology Group performance status 0-1. Complete resection of the primary tumor was expected to be possible by total or partial mastectomy and standard systemic therapy of the time were administered. Adequate informed consent was given to all the patients before surgery. The subjects were classified into the following 2 groups: 77 patients, who received resection of the primary tumor, and 64 patients who did not. Distributions of anatomic site of distant metastasis and number of metastatic lesions were similar in the 2 groups. Results: The median OS was longer in patients treated with surgical resection (4.8 years) compared to patients not treated with surgical resection (2.9 years). The 5-year OS was better in women treated with surgery than in women who did not receive surgery (47.7% vs. 28.3%). The 10-year OS was 23.0% in patients with surgery but undetermined in patients without surgery. Among 77 patients treated with surgery, OS was better in patients with bone metastasis and one to four metastatic lesions. There were no significant OS differences with log-rank tests, but 7 cases with surgical resection survived more than 10 years after surgery. Conclusion: Our data obviously refer to a subset of patients who were selected for favorable prognostic factors, and any comparison with surgically untreated patients is threatened by serious biases. Our results, still, indicates that surgery for the primary tumor may provide better prognosis in stage IV patients. Well-conducted prospective trials are needed to examine the potential advantages of surgery. Surgery for the primary tumor could be one of the options in multidisciplinary treatment for stage IV, may provide better prognosis with low operative morbidity and less serious adverse events.
PO46 PULMONARY RESECTION FOR LUNG OLIGOMETASTATIC DISEASE IN METASTATIC BREAST CANCER Mariko Kochi1, Yuri Yoshimura1, Yukiko Kajiwara1, Miho Kouno2, Mitsuya Ito1, Shoichiro Ohtani1, Kenji Higaki1 1 Department of Breast Surgery, Hiroshima City Hospital, Hiroshima, Japan; 2 Department of Medical Oncology, Hiroshima City Hospital, Hiroshima, Japan Debate over the local treatment for metastatic breast cancer (MBC) is controversial while the existing guidelines for patients with localized MBC include surgery, radiation, and regional chemotherapy as possible therapeutic options. We therefore examined the prognosis of 26 lung
S35
metastases patients, who underwent pulmonary resection for solitary or few lung metastases at our institute. Patients ranged in age from 28 to 73 (median 55.5) at the initial diagnosis of breast cancer. Hormonal receptor and Her2/neu status of primary tumor were available in 15 cases; 12 cases were ER(+) and/ or PgR(-) and 3 cases were ER(-) and PgR(-), and Her2/neu status was positive in 1 case and negative in 14 cases. Median DFI after primary surgery was 62 (12-200) months. All the patients achieved complete resection of detectable metastatic disease with thoracoscopic assisted surgery, and then underwent systemic therapy including chemotherapy and endocrine therapy either alone or in combination. With a median follow up of 130 (10-294) months after pulmonary resection, 5-year RFS was 51.5% and 5-year OS was 94.1%. 3 cases are now under observation without any systemic therapy and recurrent-free for 50, 53, and 135 months. In 2 cases, we performed pulmonary resection for 2 lesions, 1 lesion was metastatic disease and another was inflammatory change. We also experienced 1 case, whose subtype of primary tumor was triple negative and resected lung lesion appeared as hormonal-sensitive. She underwent endocrine therapy after pulmonary resection and is recurrent free for 30 months. Some retrospective series show an association between surgical removal of lung metastases and improved long-term outcome in patients with oligometastatic disease. The largest dataset comes from the International Registry of Lung Metastases and presents results of lung metastasectomy in 467 breast cancer patients. Complete resection was achieved in 84% of patients and led to a median survival of 37 months (5-year OS = 38%, 10-year OS = 22%). Obviously, selection bias and the retrospective nature of reported data do not allow for generalization of the results, and the use of such approaches must be individualized. Pulmonary resection in MBC patients, still, may have a potential for survival benefit, and is also an important diagnostic tool, especially in cases of a suspected first recurrence, allowing for differential diagnosis with second primary lung cancers and benign lesions. As the morbidity and mortality of pulmonary resection has decreased substantially, it could be discussed in a selected group of patients and prospective trials are needed for further examination.
PO47 USING LOCAL FLAPS FOR COVERAGE OF DEFECTS AFTER EXCISION OF ADVANCED MALIGNANT BREAST LESIONS Mahmoud Alhussini1, Ahmed Tarek1, Nasser Ghozlan2, Ahmed Abdelateef1, Haytham Fayed1, Hassan Kholosy2, Gamal Elhusseiny3 1 Surgical Oncology Unit, Alexandria University, Alexandria, Egypt; 2Plastic and Reconstructive Surgery Unit, Alexandria University, Alexandria, Egypt; 3Medical Oncology and Nuclear Medicine Department, Alexandria University, Alexandria, Egypt We represent a series of 18 cases with different breast malignancies which required local flaps for coverage of large defects after excision. The cases were 4 quadrant carcinoma (12 cases), cystosarcoma phylloides (3 cases), aggressive local recurrence (3 cases). All cases were subjected to multidisciplinary team meeting where the decision of mastectomy or excision of the recurrence was mandatory either for palliation of the patients symptoms - 7 cases - (e.g. bleeding, ulcerations), failure of down staging by neoadjuvant medications 8 cases - or because the proper line of treatment was mastectomy (3 cases of cystosarcoma phylloides). Reconstruction methods were either latissmus dorsi flap (LD) or transverses abdominis myocutaneous flap (TRAM). The aim of surgery was palliative rather than radical in some cases. Morbidity ranged from minor (superficial wound infection, wound dehissaence either donor or recipient) to major (severe infection or partial loss of the flap). Mortality occured in 1 case 3 months following surgery due to brain matastasis. Conclusion: local flaps as TRAM and LD are good options for covering the chest wall defects following mastectomy or excision of local recurrence.
Recommendations/action plan from 2nd audit cycle: 1. Liaise with twin hospital performing NM bone scans, where a delay is still evident, to speed up the referral system.
PO45 SURGICAL RESECTION OF THE PRIMARY TUMOR MAY IMPROVE SURVIVAL IN PATIENTS WITH STAGE IV BREAST CANCER Kenji Higaki, Mariko Kochi, Yuri Yoshimura, Yukiko Kajiwara, Miho Kono, Mitsuya Ito, Shoichiro Ohtani Hiroshima City Hospital, Hiroshima, Japan Introduction: The standard treatment of stage IV breast cancer (stage IV) has thus far mainly involved palliative care with chemotherapy, hormonal therapy and/or radiation therapy. Resection of the primary tumor is not considered as curative treatment; solely as local therapy to maintain the quality of life. However, the overall survival (OS) after the diagnosis of stage IV is largely determined by the site of metastasis, i.e. less than 6 months for visceral, approximately 18 months for nodal, and 4-5 years for bony metastasis. Several retrospective studies have that surgery for the primary tumor may improve survival in patients with stage IV. Method: We therefore examined 141 stage IV patients treated between 1992 and 2010 in our institute. The patients ranged 26 to 83 years of age, with Eastern Cooperative Oncology Group performance status 0-1. Complete resection of the primary tumor was expected to be possible by total or partial mastectomy and standard systemic therapy of the time were administered. Adequate informed consent was given to all the patients before surgery. The subjects were classified into the following 2 groups: 77 patients, who received resection of the primary tumor, and 64 patients who did not. Distributions of anatomic site of distant metastasis and number of metastatic lesions were similar in the 2 groups. Results: The median OS was longer in patients treated with surgical resection (4.8 years) compared to patients not treated with surgical resection (2.9 years). The 5-year OS was better in women treated with surgery than in women who did not receive surgery (47.7% vs. 28.3%). The 10-year OS was 23.0% in patients with surgery but undetermined in patients without surgery. Among 77 patients treated with surgery, OS was better in patients with bone metastasis and one to four metastatic lesions. There were no significant OS differences with log-rank tests, but 7 cases with surgical resection survived more than 10 years after surgery. Conclusion: Our data obviously refer to a subset of patients who were selected for favorable prognostic factors, and any comparison with surgically untreated patients is threatened by serious biases. Our results, still, indicates that surgery for the primary tumor may provide better prognosis in stage IV patients. Well-conducted prospective trials are needed to examine the potential advantages of surgery. Surgery for the primary tumor could be one of the options in multidisciplinary treatment for stage IV, may provide better prognosis with low operative morbidity and less serious adverse events.
PO46 PULMONARY RESECTION FOR LUNG OLIGOMETASTATIC DISEASE IN METASTATIC BREAST CANCER Mariko Kochi1, Yuri Yoshimura1, Yukiko Kajiwara1, Miho Kouno2, Mitsuya Ito1, Shoichiro Ohtani1, Kenji Higaki1 1 Department of Breast Surgery, Hiroshima City Hospital, Hiroshima, Japan; 2 Department of Medical Oncology, Hiroshima City Hospital, Hiroshima, Japan Debate over the local treatment for metastatic breast cancer (MBC) is controversial while the existing guidelines for patients with localized MBC include surgery, radiation, and regional chemotherapy as possible therapeutic options. We therefore examined the prognosis of 26 lung
S35
metastases patients, who underwent pulmonary resection for solitary or few lung metastases at our institute. Patients ranged in age from 28 to 73 (median 55.5) at the initial diagnosis of breast cancer. Hormonal receptor and Her2/neu status of primary tumor were available in 15 cases; 12 cases were ER(+) and/ or PgR(-) and 3 cases were ER(-) and PgR(-), and Her2/neu status was positive in 1 case and negative in 14 cases. Median DFI after primary surgery was 62 (12-200) months. All the patients achieved complete resection of detectable metastatic disease with thoracoscopic assisted surgery, and then underwent systemic therapy including chemotherapy and endocrine therapy either alone or in combination. With a median follow up of 130 (10-294) months after pulmonary resection, 5-year RFS was 51.5% and 5-year OS was 94.1%. 3 cases are now under observation without any systemic therapy and recurrent-free for 50, 53, and 135 months. In 2 cases, we performed pulmonary resection for 2 lesions, 1 lesion was metastatic disease and another was inflammatory change. We also experienced 1 case, whose subtype of primary tumor was triple negative and resected lung lesion appeared as hormonal-sensitive. She underwent endocrine therapy after pulmonary resection and is recurrent free for 30 months. Some retrospective series show an association between surgical removal of lung metastases and improved long-term outcome in patients with oligometastatic disease. The largest dataset comes from the International Registry of Lung Metastases and presents results of lung metastasectomy in 467 breast cancer patients. Complete resection was achieved in 84% of patients and led to a median survival of 37 months (5-year OS = 38%, 10-year OS = 22%). Obviously, selection bias and the retrospective nature of reported data do not allow for generalization of the results, and the use of such approaches must be individualized. Pulmonary resection in MBC patients, still, may have a potential for survival benefit, and is also an important diagnostic tool, especially in cases of a suspected first recurrence, allowing for differential diagnosis with second primary lung cancers and benign lesions. As the morbidity and mortality of pulmonary resection has decreased substantially, it could be discussed in a selected group of patients and prospective trials are needed for further examination.
PO47 USING LOCAL FLAPS FOR COVERAGE OF DEFECTS AFTER EXCISION OF ADVANCED MALIGNANT BREAST LESIONS Mahmoud Alhussini1, Ahmed Tarek1, Nasser Ghozlan2, Ahmed Abdelateef1, Haytham Fayed1, Hassan Kholosy2, Gamal Elhusseiny3 1 Surgical Oncology Unit, Alexandria University, Alexandria, Egypt; 2Plastic and Reconstructive Surgery Unit, Alexandria University, Alexandria, Egypt; 3Medical Oncology and Nuclear Medicine Department, Alexandria University, Alexandria, Egypt We represent a series of 18 cases with different breast malignancies which required local flaps for coverage of large defects after excision. The cases were 4 quadrant carcinoma (12 cases), cystosarcoma phylloides (3 cases), aggressive local recurrence (3 cases). All cases were subjected to multidisciplinary team meeting where the decision of mastectomy or excision of the recurrence was mandatory either for palliation of the patients symptoms - 7 cases - (e.g. bleeding, ulcerations), failure of down staging by neoadjuvant medications 8 cases - or because the proper line of treatment was mastectomy (3 cases of cystosarcoma phylloides). Reconstruction methods were either latissmus dorsi flap (LD) or transverses abdominis myocutaneous flap (TRAM). The aim of surgery was palliative rather than radical in some cases. Morbidity ranged from minor (superficial wound infection, wound dehissaence either donor or recipient) to major (severe infection or partial loss of the flap). Mortality occured in 1 case 3 months following surgery due to brain matastasis. Conclusion: local flaps as TRAM and LD are good options for covering the chest wall defects following mastectomy or excision of local recurrence.