What treatment options are available for a patient with breast cancer and liver metastases, but no brain metastases?

Treatment Options for Breast Cancer with Liver Metastases

For patients with breast cancer and liver metastases, systemic therapy should be the primary treatment approach, with consideration of local therapy (surgery, stereotactic radiotherapy, or intra-hepatic chemotherapy) in highly selected cases with good performance status, limited liver involvement, and no extra-hepatic lesions after systemic therapy has demonstrated disease control. 1

Systemic Therapy Options

• Systemic therapy selection should be based on tumor subtype (hormone receptor status, HER2 status) and is the cornerstone of treatment for metastatic breast cancer with liver involvement 1
• For HER2-positive disease, HER2-targeted therapy (such as trastuzumab) combined with chemotherapy is recommended, with trastuzumab administered at an initial dose of 4 mg/kg as a 90-minute intravenous infusion followed by subsequent weekly doses of 2 mg/kg as 30-minute infusions until disease progression 2
• For hormone receptor-positive disease, endocrine therapy is the preferred option unless there is concern about endocrine resistance or rapidly progressive disease requiring a fast response 1
• For triple-negative breast cancer, chemotherapy remains the primary systemic approach 1
• Paclitaxel at a dose of 175 mg/m² administered intravenously over 3 hours every 3 weeks is an effective option after failure of initial chemotherapy for metastatic disease 3

Local Therapy for Liver Metastases

• Local therapy for liver metastases should only be proposed in very selected cases with:

  • Good performance status
  • Limited liver involvement
  • No extra-hepatic lesions (except for isolated bone metastases controllable with radiotherapy or isolated pulmonary metastases)
  • Disease control demonstrated with adequate systemic therapy 1

• All patients with liver metastases should be referred to tertiary centers with expertise in hepatic resections and multidisciplinary management before starting chemotherapy 1

• Surgical resection considerations:

  • Surgeons should evaluate patients before chemotherapy to properly visualize all metastases, as responsive lesions may become difficult to locate after treatment 1
  • Up to 70% of liver volume can be removed in patients with normal liver function 1
  • Prolonged survival can be obtained after resection of liver metastases from breast cancer in carefully selected patients 1
  • Surgery should be considered as an adjuvant treatment to systemic therapy, not as the primary treatment (unlike in colorectal liver metastases) 1

• Non-surgical local therapy options:

  • Stereotactic radiotherapy may be considered for patients who are not surgical candidates 1
  • Transarterial chemoembolization (TACE) and radioembolization (TARE) have shown median local control rates of 68.7% and 78.9%, respectively 4

Multidisciplinary Approach

• All cases should be discussed in multidisciplinary meetings to evaluate:

  • Extent of disease
  • Degree of disease control
  • Feasibility of local therapies
  • Patient performance status 1

• For patients who do not respond to initial systemic chemotherapy, hepatectomy may still be appropriate in selected cases 1

Common Pitfalls to Avoid

• Prolonged chemotherapy before surgical evaluation can cause liver steatosis and hepatocyte damage, compromising post-resection liver function 1
• There is a temptation to continue chemotherapy until metastatic tumors disappear, which should be avoided as it can make surgical planning more difficult 1
• Failing to refer patients to specialized centers with expertise in liver resections can limit treatment options 1
• There are currently no randomized data supporting the effect of local therapy on survival, so patients must be fully informed of this when discussing potential local therapy techniques 1

Prognosis

• Without intervention, median survival for breast cancer patients with liver metastases ranges from 3-15 months 5, 6
• Surgical resection in carefully selected patients has shown 5-year survival rates of approximately 22% 7
• The presence of multiple metastatic sites significantly reduces survival compared to single-site metastasis 5

Remember that treatment decisions should be made through multidisciplinary discussions, taking into account the extent of disease, performance status, and patient preferences, with systemic therapy remaining the foundation of treatment for metastatic breast cancer with liver involvement.