What is the best treatment approach for a patient with a single liver metastasis (met) from hormone receptor-positive breast cancer?

Management of Single Liver Metastasis in Hormone Receptor-Positive Breast Cancer

For patients with a single liver metastasis from hormone receptor-positive breast cancer, a multidisciplinary approach combining systemic therapy with surgical resection offers the best chance for prolonged survival and should be considered as the optimal treatment strategy. 1, 2

Initial Assessment and Referral

• All patients with breast cancer liver metastases should be referred to a tertiary center with expertise in hepatic resections and multidisciplinary management before initiating systemic therapy 1
• Early surgical consultation is critical, as chemotherapy can make metastatic lesions difficult to locate and can compromise liver function through hepatocyte damage and steatosis 1, 2
• Multidisciplinary discussion should evaluate the extent of disease, degree of disease control, and feasibility of hepatectomy 1

Patient Selection for Surgical Resection

• Ideal candidates for surgical resection meet the following criteria:
  • Good performance status 2
  • Feasibility of complete resection (R0 or R1) 1, 3
  • No uncontrolled extrahepatic disease (isolated bone metastases controlled by radiotherapy or isolated pulmonary metastases may be acceptable) 1
  • Normal liver function with ability to preserve at least 30% of liver volume 2
  • Disease stability or regression on systemic therapy 1, 3
  • Longer interval (>1-2 years) between primary diagnosis and liver metastasis 3

Systemic Therapy Considerations

• Systemic therapy remains the primary treatment approach for metastatic breast cancer, with surgery considered as an adjuvant treatment 1, 2
• For hormone receptor-positive disease, endocrine therapy options include:
  • Letrozole (2.5 mg daily) is indicated for first-line treatment of postmenopausal women with hormone receptor-positive metastatic breast cancer 4
  • Treatment should continue until tumor progression is evident 4
• First-line chemotherapy may be considered over CDK4/6 inhibitors in patients with aggressive liver metastatic disease, as it has been associated with improved overall survival in some studies 5

Surgical Approach

• In patients with normal liver function, up to 70% of liver volume can be removed safely 1
• Surgical resection has demonstrated significantly better outcomes compared to systemic therapy alone:
  • 5-year survival rates of 24.6-78% after surgical resection versus 14% with chemotherapy alone 3, 6
  • Median overall survival of 29.5-116 months with surgery versus significantly shorter with systemic therapy alone 7

Post-Surgical Management

• All patients should receive appropriate adjuvant systemic therapy based on hormone receptor status 1
• Close monitoring is essential as 60-75% of patients will experience disease relapse following hepatic resection 8

Important Considerations and Pitfalls

• Avoid prolonged chemotherapy before surgical evaluation, as this can compromise liver function and make lesions difficult to locate 1, 2
• Complete radiological remission does not mean absence of disease, as microscopic viable tumor cells often remain 8
• Surgical resection for breast cancer liver metastases differs from colorectal cancer approach - in breast cancer, systemic therapy is primary and surgery is considered adjuvant 1, 2
• Surgical intervention combined with systemic treatment has shown improved progression-free survival in patients who had good response to first-line medical treatment 9

Follow-up Recommendations

• Continue systemic therapy based on hormone receptor status after surgical intervention 1
• Regular imaging surveillance to detect early recurrence 8
• Consider additional local therapies (radiofrequency ablation, radioembolization) for limited recurrence 3, 9