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Palliative Surgery

in
Breast Cancer
Denni Joko Purwanto
Surgical Onkology, Dept
Dharmais Cancer Hospital/National Cancer Center
Goals of Therapy
•Many 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
2009
STADIUM N Percent

I 13 5.35%

II 77 31.69%

III 81 33.33%

IV 51 20.99%

NA 21 8.64%

Total 243 100.00%


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
Institute’s 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 Surgery
Careful 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 DISEASE
Patient 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 Sites
Lung Metastases

Liver Metastases

Brain Metastases

Bone Metastases

Palliative Breast Surgery


( in the Face of Stage IV Disease)
Lung Metastases
Women 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 35–97 months


Lung Metastases
Strongly 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 Metastasectomy

Resection Disease- Number of 5 – Year 10-Year Median


Free Metastases Survival Survival Survival
Survival Rate (%) Race (%) (Months)
(Months)
Group I Complete >36 Solitary 50 26 59

Group II Complete < 36 Solitary 35 21 36

Group III Complete < 36 Multiple 13 13 2

Group IV Incomplete - - 18 - 25
Liver Metastases
•Rare to find isolated liver disease (5% to 12% of
stage IV patients)

• Liver involvement is a poor prognostic sign.


median survival of 3–15
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 status

Long 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 Metastases
Poor 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 for


immediate decompression of large solitary
symptomatic lesions
Bone Metastases
Bone 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 Surgery

Breast 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
Surgery
prevents 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 survival
Primary 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
Case
Female, 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 Received
Patient received chemotherapy:

Taxotere, Carboplatin, (6 x)

Trastuzumab (1 year)
Bilateral Mastektomy
Skin Graft Coverage Chest Wall
One Year After Surgery