51 years old woman with breast cancer who underwent neoadjuvant chemotherapy with good clinical response and it was submited a radical mastectomy one year ago. Histogical evaluation showed a low grade ductal carcinoma T2N0M0, ( Her-2, progesterone and estrogen receptors are positive). At her follow-up period presented 2 hepatic metastases on left lobe (largest one presents 6 cm of diameter) . No extra-hepatic dissemination was observed. This patient underwent a new chemotherapy regimen without any response (stable disease). The questions are : Hepatic Resection or No ? Anatomic or no anatomic resection? Lap or open approach?
besides chemotherapy she received targeted and hormone therapy without response too.
I would recommend liver resection. Sometimes the liver metastases from breast cancer presents cellularity different from the original cells, meaning different clone cells. However, you must keep in mind that resection of liver metastases from noncolorectal, nonneuroendocrine origin may not be curative. I would perform a PET-CT and thorough imaging analysis to be sure that there are no other sites of disease. The golden rules for this type of resection are: longer interval from primary resection and appearance of liver metastases, response to chemotherapy, exclusive to liver, solitary metastases. She does not have these inclusive indications, therefore proceed with caution.
PET & resect, approach depends on your expertise to safely get an R0, given her biologic profile I would spare the most possible liver parenchyma she can get for the future
I agree with Dr. Machado that it is crucial to select the proper patients for local treatment of BCLM. Additional factors (to the ones mentioned by Dr. Machado) are characteristics of primary breast cancer such as small tumor size, low grade, node negativity and early stage, liver-limited disease (with the exception of isolated pulmonary and bony metastases), and PgR- and/or ER- positivity.
If you go for local treatment your aim must be complete macroscopic and microscopic eradication (R0). If you can achieve this goal (A0) by thermal ablation (MWA, RFA, SRFA, SMWA) you should apply this minimal invasive parenchyma sparing approach. The threshold for such minimal invasive treatments with low morbidity, short hospital stay and low costs may further decrease the objections to local effective treatment of BCLM.
In addition, tiny metastatic lesions should be excluded by MRI.
We treated a patient with a large BCLM (see attached image) in a very similar location 1.5 yrs ago by stereotactic radiofrequency ablation (SRFA). The patient is currently tumor-free.
I agree with Dr Machado and Dr Bale about the approach to resection of liver metastases. Have you biopsied one of these lesions to see whether it is the same as the primary breast cancer? As metastasectomy is unfortunately not a curative procedure, thermal ablation creates fewer complications for the patient.
Finally, we have decided to resect by means of an open left hepatectomy. This patient underwent a postoperative stay without any complications and was discharged at fifth postoperative day..
Great job Sergio, I have though of resection of segments 2 and 3 alone but the specimen images shows that resection of segment 4 was necessary to achieve R0 resection. I would not ablate such a large tumor. Dr Bale has a great experience with this technique and I read with interest some of his papers on the subject but in our service this size is still considered a contraindication to ablation. I would defnitively perform it by minimally invasive surgery, robotic or laparoscopy. It is a straight-forward operation and Glissonian approach would be my choice.
We have tried by means lap approach but the lesion was very bulky and presented strong adherences at both left hepatic vein and falciform ligament attaining the duomo of segment iv. This way, in our opinion would be dangerous to proceed by lap , so we have decided to convert to the open approach. We used classic hilar dissection approach because this lesion was very close to the hepatotomy areas from posterior approach.
Dear Sergio, good to know that you thought about Glissonian approach. As always, the final decision about technique and approach are made during the operation. Again, congratulations.
Nice professor marcel. We have published about this access since 2010 with initially a case series about right posterior sectioniectomy in ABCD journal and we have also cited your papers.
Greetings again, thank you for your participation in our discussions!
I would have biopsed the liver mets previous to neoadyuvance as up to 25% change the hormonal expression.In the case you expose,i would biopse them and change the type of neoadyuvance and in case of stability i will perform 2 metastasectoMies.Multimodal aggresive approach to breast liver mets can provide curation in selective cases
Congrats Prof Machado,I had a similar case of a 55-year-old woman who had a single metastasis of 4 cm at the 3rd segment at CT 3 years after the mastectomy. Intraperatively I identified another small 1 cm lump in step 2/3. I performed a segmentectomy of 3 enlarged to 2. I believe that only in the case of a favorable histological examination of the primitive and, especially when the lesions appear at least 12 months after the intervention and are limited then does the intervention make sense and in my opinion an anatomical resection is better for the risk of micrometastases near the largest nodule.
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