Is a liver biopsy recommended for a patient with advanced breast cancer, previously treated with chemotherapy and radiation, now presenting with multiple liver nodules on MRI?

From the Guidelines

A liver biopsy is generally recommended for a patient with advanced breast cancer who presents with multiple liver nodules on MRI, especially after previous chemotherapy and radiation treatment. This recommendation is based on the most recent and highest quality evidence available, which emphasizes the importance of confirming the nature of liver nodules and assessing hormone receptor and HER2 status to guide treatment decisions 1. The biopsy serves several critical purposes in this clinical scenario, including confirming whether the liver nodules represent metastatic breast cancer or potentially another condition, and allowing for assessment of biomarkers that may have changed from the primary tumor.

The procedure typically involves ultrasound or CT-guided core needle biopsy of the most accessible lesion, performed under local anesthesia. Risks include bleeding, infection, and pain, though serious complications are uncommon (occurring in less than 1% of cases) 1. If the patient has coagulopathy or ascites, these should be addressed before proceeding. The biopsy results will directly influence treatment selection, potentially including hormonal therapy, targeted agents like CDK4/6 inhibitors, or chemotherapy regimens appropriate for metastatic disease.

Some key considerations for the biopsy include:

• The information gained from the biopsy must be of value for the management of the patient 1.
• The patient must be fully informed about the indications, risks, benefits, alternatives, and follow-up plans, and must give informed consent 1.
• The procedure must be done as safely as practicable, and the operator must be competent to perform the technique 1.
• The sample(s) must be of adequate quality and size, and the biopsy must be examined by a histopathologist sufficiently competent to interpret the histology 1.

Overall, the liver biopsy is an essential diagnostic step for developing an evidence-based treatment plan tailored to the current biological characteristics of the disease, rather than relying on historical information from the primary tumor.

From the Research

Liver Biopsy Recommendation

The decision to perform a liver biopsy in a patient with advanced breast cancer and multiple liver nodules on MRI should be based on various factors, including the patient's overall health, the presence of symptoms, and the potential impact on treatment decisions.

• The study by 2 found that benign liver lesions are common in breast cancer patients suspected of having liver metastases, with 32% of patients having benign lesions only.
• However, the same study also reported a high diagnostic accuracy of MRI in evaluating hepatic lesions, with a sensitivity of 95% and a specificity of 100% for detecting malignant liver lesions.

Treatment Options

In terms of treatment, several options are available for patients with breast cancer and liver metastases.

• The study by 3 reported a case of breast cancer with multiple liver metastases successfully treated with capecitabine monotherapy after failure of combination therapy.
• The study by 4 also reported a case of a breast cancer patient with extensive liver metastases and associated impairment of liver function who was successfully treated with capecitabine.
• Additionally, the study by 5 is investigating the efficacy and safety of radioembolization as an early modality therapy for metastatic breast cancer to the liver.

Potential Complications

It's also important to consider potential complications of liver biopsy, such as bleeding or infection.

• The study by 6 reported cases of chemotherapy-related hepatotoxicity causing imaging findings resembling cirrhosis, which could potentially affect the interpretation of liver biopsy results.

Diagnostic Accuracy

The diagnostic accuracy of MRI in evaluating liver lesions is high, but it's not perfect.

• The study by 2 reported one false negative case, where no focal lesions were shown on MRI despite biopsy-proven subcentimeter breast metastases.
• Therefore, a liver biopsy may still be necessary in some cases to confirm the diagnosis and guide treatment decisions.