Reviewing Best Practices in the Surgical Management of Breast Cancer: Opportunities for Stage IV Disease

In this fourth episode of OncChats: Reviewing Best Practices in the Surgical Management of Breast Cancer, Gladys Giron, MD, FACS, and Cristina Lopez-Peñalver, MD, both of Baptist Health South Florida, discuss how to appropriately manage patients with stage IV breast cancer and outline when surgical approaches may be appropriate for this population.

Giron: [Patients with] stage IV breast cancer are not typically surgical candidates. Could you expand on the management of [these] patients, including when surgery may be appropriate?

Lopez-Peñalver: Sure. Well, let me just start out by saying that systemic therapy is the main treatment for metastatic breast cancer but local management of the primary tumor in the breast or a metastatic site may palliate symptoms, improve progression-free survival, and prevent complications.

So, let’s start with the local management of the primary tumor. The primary role of local treatment in this setting is palliation and management of symptoms, primarily with locally advanced breast cancers where the tumors are bulky and can ulcerate, bleed, cause pain, or even become infected. For patients whose primary tumor in the breast is asymptomatic, surgery and/or radiation therapy are not really considered the standard of care [SOC] because there’s no effect on systemic disease and really no clear evidence that it prolongs survival. There are exceptions to this, with surgery of the primary tumor being offered to a select group of patients with oligometastatic disease or low-volume disease, who have had a good response to systemic therapy, and also to those whose metastatic disease is well controlled with their therapy, but the primary site is progressing. There have been 4 prospective randomized trials that looked at survival after surgery of the primary tumor, and 3 of these did not show any statistical significance in overall survival.

Now, moving on to the local management of metastasis. Again, systemic therapy is the SOC, and the goal of therapy is palliation. However, local treatment with surgery or radiation is indicated in some patients who have, for example, intractable bone pain in spite of their systemic therapy. These patients are candidates for radiation, and also, in medical emergencies such as spinal cord compression, a mass effect due to a brain metastasis, and impending or present pathologic fracture due to bone metastases. Patients with asymptomatic central nervous system metastasis can have local therapy with surgical resection, stereotactic radiosurgery, or even whole-brain radiation therapy—especially if they have a good performance status if they have oligometastatic disease or less than 3 sites of disease, a long disease-free interval, and a high likelihood of completely resecting the metastasis since positive margins have been associated with worse outcomes.

In terms of lung metastasis, asymptomatic metastasis usually does not require any local intervention unless we are dealing with an undiagnosed lung nodule, and an excision of that lung nodule is used for diagnosis. Symptomatic metastasis may be treated with resection or with radiation therapy. Finally, the local management of liver metastases is indicated for those lesions that bleed [or] cause pain or biliary obstruction, and they can be treated with surgical resection with stereotactic body radiation therapy or even with radiofrequency ablation for tumors that are less than 3 centimeters.

So, thank you, Dr Giron, for that question, because as surgeons, we use local therapy of metastatic sites to eliminate disease and palliate patients.

Check back on Tuesday for the final episode in the series.