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The purpose of this study was to examine our experience with hepatic resection HR in a relatively unselected group of patients with breast cancer liver metastases BCLM. Although medical therapies Liver resection for metastatic breast cancer limited survival benefit median survival, 3—15 monthsinclusion of HR into the multimodality treatment of patients with BCLM remains controversial.

Outcomes for 85 consecutive patients all female, median age, 47 years with BCLM treated with HR from to were reviewed. The Liver resection for metastatic breast cancer value of each study variable was assessed with log rank tests for univariate analysis and Cox proportional hazard models for multivariate analysis. Response to preoperative chemotherapy, resection Liver resection for metastatic breast cancer, and rehepatectomy for intrahepatic recurrence are key prognostic Liver resection for metastatic breast cancer. Importantly, favorable outcomes Liver resection for metastatic breast cancer be achieved even in patients with medically controlled or surgically resectable extrahepatic disease, indicating that surgery should be considered more frequently in the multidisciplinary care of patients with BCLM.

Although one half of stage IV breast cancer patients will develop liver metastases, there are 2 main Liver resection for metastatic breast cancer why patients with BCLM are rarely referred for surgical evaluation. First, most patients with breast cancer liver metastases also have extrahepatic metastases, 10 a finding that has traditionally been considered a contraindication to hepatic resection HR.

Second, due to the perception that BCLM are associated with a particularly poor prognosis, in many cases treatments with a minimal toxicity profile have been preferred to aggressive treatments, including systemic chemotherapy and HR. In point of fact, the literature contains only one report that examines outcomes following HR in more than 34 patients.

TABLE 1. Recognizing the limitations of other therapies to treat patients with BCLM and the possibility that the presence of BCLM does not necessarily indicate a significantly poorer prognosis than other sites of distant metastases, 2 we have taken an aggressive surgical approach to the treatment of these patients.

In addition, early in our experience, we did not view the response of intrahepatic tumors to preoperative systemic therapy as an inclusion or exclusion criteria for HR. This approach has allowed us to acquire experience with HR for the treatment of a relatively unselected group of patients with BCLM. The purpose of this study was to determine the recurrence patterns and long-term outcomes in this large cohort and to identify prognostic factors that may allow for optimal patient selection Liver resection for metastatic breast cancer the future.

A search of our prospective database identified patients with the diagnosis of hepatic metastases from breast cancer primary tumor treated surgically at our institution from to To diagnose the presence of unresectable extrahepatic disease and to confirm that resection of all radiographically apparent intrahepatic disease was feasible, each patient underwent a preoperative staging evaluation, including axial imaging brain, chest, and abdomenliver sonogram, and Kerala village girls fully nude photos scintigram.

Immunostaining was performed on a Ventana NexES platform, according to standard methods. For hormone receptor analysis, antigen retrieval was accomplished after deparaffinization by placing slides into 0. For statistical analysis, multiple clinical, operative, postoperative, and pathologic factors were recorded. To facilitate comparisons, several variables were dichotomized.

The presentation of hepatic metastases was considered synchronous when diagnosed within 6 months of primary tumor treatment and metachronous when the hepatic disease-free interval was greater than 6 months. Recurrence-free, disease-free, and overall survivals OS were Liver resection for metastatic breast cancer by the method of Kaplan and Meier. Disease-free survivals were determined by the recurrence status of the patient at the latest follow-up date. All statistical analyses were performed using SPSS software, version All patients were female with a median age of 47 years range, 27—70 years.

To be considered for HR, all patients were required to have received stage-appropriate therapy for their primary tumor. The median time from treatment of the breast primary tumor to diagnosis of liver metastases was 34 months range, 0— months.

The median maximal tumor size was 2. In anticipation of extended HR, 1 patient underwent preoperative portal vein embolization. Each of the remaining 5 patients, who underwent hepatectomy with extraabdominal disease present, had bone metastases well controlled with systemic therapy and local radiotherapy. Intrahepatic tumor response to chemotherapy was measured in all patients but was not used to determine eligibility for HR. The majority of these patients were treated with aromatase inhibitors following completion of systemic chemotherapy.

Following thorough preoperative evaluation, patients were first explored under general anesthesia through a right subcostal minilaparotomy incision. This allowed assessment for intra-abdominal spread of disease and access to the liver for ultrasound examination.

In 14 of these 22 patients, complete resection of both the intra-abdominal and intrahepatic disease appeared feasible and was performed. In the remaining 8 patients with higher volume intra-abdominal disease, the procedure was terminated.

Diagram of treatment outcome in patients undergoing abdominal exploration for breast cancer liver metastases. When no contraindication to liver resection was identified during the initial examination, the incision was enlarged and HR commenced. There was no mortality within 60 days of resection. Each fistula resolved spontaneously without need for further intervention. One patient experienced postoperative hemorrhage from the liver resection Liver resection for metastatic breast cancer, requiring urgent reoperation for control, and 1 patient experienced transient hepatic insufficiency.

The median postoperative length of inpatient hospitalization was 9 days range, 5—22 days. The median number of hepatic metastases in the resected specimen was 2. The median size of the largest metastasis was 25 mm range, 4— mm.

In each of these cases, the residual disease was addressed with postoperative hepatic Liver resection for metastatic breast cancer chemotherapy via an infusion pump placed at the end of the procedure.

Eight patients were alive 5 years after first hepatectomy and 4 of these patients were alive 10 years after first hepatectomy. Overall survival following hepatic resection for patients with breast cancer metastases. All recorded study variables were analyzed to determine associations with survivals Table 2. Overall survival following hepatic resection based on A response to preoperative chemotherapy, B status of extrahepatic disease at hepatectomy, C the margin of resection, and D repeat hepatectomy.

EHM indicates extrahepatic metastases. TABLE 2. Subsequent multivariate analysis determined that 3 of these 4 study variables were independently associated with poor outcome.

The median time to intrahepatic recurrence was 10 months range, 1—47 months. Following repeat hepatectomy, 6 of these 12 patients were disease free at Crestinine big boobs sex video full hd intervals from 1st hepatectomy ranging from 14 to months.

Of the 32 patients who were alive at latest follow-up, 19 were free of disease. In Hd nepali girl nude videos analysis, the only study factor with a significant association to recurrence was bilateral liver metastases 0.

At the conclusion of HR, 16 patients had residual metastatic disease, including 2 patients who came to the operation with extra-abdominal bone metastases, 11 patients with R2 resection, and 3 patients with both extra-abdominal disease and R2 resection. One patient with only intrahepatic disease, who initially underwent an R2 resection, was subsequently rendered disease free at rehepatectomy. Patients with metastatic breast cancer are generally considered incurable.

Treatment, therefore, frequently aims to minimize toxicity. Our group has taken an aggressive approach to these patients, offering them surgical therapy for resectable disease as part of a multimodality program. Untreated patients with BCLM have reported median survivals of approximately 3 to 6 months from the diagnosis of metastases.

In contrast, surgical Marks book mark adult measure survivals from the date of treatment. The efficacy of HR in patients with BCLM is further supported by the benefit in survival provided by repeat hepatectomy. Given the low toxicity of HR, the superior survival rates reported for patients treated with curative surgical therapy, and the efficacy of repeat hepatectomy, inclusion of HR in the multimodality treatment plan for patients with resectable BCLM appears to be justified.

However, it could be argued that the favorable survivals observed in our patients may have been related to the selection of only patients with favorable prognostic features. Patients who were referred to our institution were considered for HR based solely on general performance status, resectability of intrahepatic disease, and control of extrahepatic metastases.

Looking for am orgasm friend in liechtenstein with limited extrahepatic disease were not excluded from consideration.

One third of our patients had a history of extrahepatic disease prior to or at the time of HR. In addition, early in our experience, we did not use response to preoperative chemotherapy as a selection criterion Liver resection for metastatic breast cancer HR. By considering a wider array of disease presentation, our study group may be representative of a larger segment of patients with stage IV disease than has been examined previously; therefore, our results may be more applicable to current practice.

The lack of strict exclusion criteria used in our study also allowed determination of the prognostic significance of several previously unexamined study variables. The most important of these was the oncologic nature of the resection. Teen girl nude hairy minimal difference in observed outcomes between patients with R0 and R1 resections suggests that the microscopic margin of resection in BCLM is a less important prognostic factor.

In summary, analysis of outcomes based on the oncologic nature of the resection indicates that HR should be offered in combination with systemic therapy only to those patients with macroscopically resectable BCLM. Although our analysis Liver resection for metastatic breast cancer that the presence of extrahepatic disease was not a significant prognostic factor, the inclusion of patients with various types of extrahepatic disease allowed identification of a subset of patients with extrahepatic disease who experience poor outcomes.

Liver resection for metastatic breast cancer lower survival rates observed in patients with extrahepatic disease present at hepatectomy, long-term survivors were observed in this group; therefore, we do not recommend that patients with stable extra-abdominal metastases or patients with low-volume resectable intra-abdominal disease be excluded from consideration of HR.

Given the long median disease-free interval Liver resection for metastatic breast cancer both the Pocard et al study 12 and in our own analysis, it is unlikely that treatment decisions can reliably be based on this factor alone. Certainly, no data currently exist that support the exclusion of BCLM patients from HR based on the timing of liver metastasis diagnosis.

Finally, Liver resection for metastatic breast cancer making a detailed evaluation of presystemic and postsystemic treatment imaging, we were able to identify the response to prehepatectomy systemic therapy as a major prognostic factor. An association between prehepatectomy chemotherapy response and survivals has been identified in patients with colorectal liver Liver resection for metastatic breast cancer. In addition, there appears to be a different relationship between response and survival in patients Liver resection for metastatic breast cancer BCLM and colorectal metastases.

Given these results, we recommend that response to prehepatectomy chemotherapy be closely examined when selecting patients with BCLM for HR. During the study period, a number of advances have been made in multiple areas of breast cancer treatment.

Certainly, systemic therapies have improved, including the addition of anthracyclines and taxanes to chemotherapy regimens, aromatase inhibitors to antihormonal treatment, and the targeted biologic agent trastuzumab to the treatment of patients with Her2-neu-positive tumors. Surgical treatments Liver resection for metastatic breast cancer primary, nodal, and metastatic disease have also improved, becoming both safer and more effective. As well, radiographic staging modalities have become more sensitive.

Combined, these advances have resulted in better breast cancer patient survivals. When patient outcomes were compared in our study, the median survivals were longer in the group of patients treated from to versus tobut this difference did not reach statistical significance.

In addition, a majority of the advances in breast cancer treatments have been realized in patients with Latinas free nude ass videos disease. For patients diagnosed with visceral metastatic disease, life expectancies have been fairly constant over time, suggesting that there is significant room for improvement in the global treatment strategy for these patients and that the addition of HR to effective systemic therapies may be one means to achieve this improvement.

The dogma that surgical therapy has no role in the treatment of cancer patients with apparent systemic disease spread ie, metastatic breast cancer is no longer valid.

When included in the multimodality treatment plan, HR can be performed with low risk and can improve long-term outcomes, provided that the metastatic disease is responding to preoperative chemotherapy and that resection Liver resection for metastatic breast cancer macroscopically complete. In Liver resection for metastatic breast cancer cases, surgical therapy can act as an effective adjuvant treatment to systemic therapies, providing selected patients with a survival benefit as well as the hope for cure.

Daniel Jaeck: Thank you very much. Congratulations on this very elegant study. I enjoyed your presentation very much and I have 2 questions. The first one is concerning the predictive factors of survival.

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