The Role of Surgery in Soft Tissue Metastasis
Several SHARE volunteers, support group participants and I attended the MBCN annual conference in Baltimore, MD last month. The conference sponsored by MBCN and Johns Hopkins and provided a full day of programming, much of it relating directly to metastatic breast cancer. Many of the sessions presented will be available on line at the MBCN website: Mbcnetwork.org later this month. One break out session I attended is described below. A few of our volunteers have had this type of treatment. If you have any questions, feel free to call me or the hotline, and we will be happy to connect you with someone who has been there...
The Role of Surgery in Soft Tissue Metastasis lecture by Kenzo Hirose, MD, focused on the use of surgery (resection), radiofrequency ablation, microwave ablation, cryo ablation and laser ablation to treat specific tumors. These types of local treatment aim to improve quality of life, reduce pain, disability, and disfigurement.
There are strict criteria which must be met in order for a patient to be eligible for this treatment. First, doctors evaluate the tumor and consider the following:
- Is the tumor aggressive vs. indolent?
- Are there a low number of mets or a high number of mets?
- Is the tumor estrogen and progesterone positive or negative?
- What is the her2 status?
- What has been the response to chemo,?
- Is the tumor resistant to chemotherapy?
Patients are selected by a number of criteria as well.
- The general health of the patient.
- Number of mets.
- Location of the tumor.
- Is it resectable with acceptable risk?
- Age of the patient.
- How has the tumor responded to chemo?
Although there is no evidence that shows that resection improves survival time, Dr. Hirose states many patients do survive long term with an aggressive approach. He also contends that the patient is the one who can determine if resection has been successful.
Liver Mets
5% of all mets are liver mets. Most patients receive chemotherapy before and after resection. Liver resection is never palliative. There are usually no symptoms with liver mets unless the tumor has grown to a size where resection will be extremely difficult. Location of the tumor plays a major role in deciding if a patient is eligible for resection. If a tumor is too close to inside ducts, surgery may not be an option. There is a 1% mortality rate during or just after resection. The surgery requires a 5-7 day hospital stay and 4-6 weeks recovery time at home.
Laparoscopic Liver Resection is another method of surgery that is less invasive and has a shorter recovery time. Dr. Hirose does not feel it is as good as open surgery but may be an appropriate alternative for some.
Radiofrequency Ablation (RFA)
A needle is placed into the tumor and "cooked" using radiofrequency energy. This is an effective treatment for tumors 3 cm or less. Some areas of the liver are less well suited for RFA. If the tumor is near a large blood vessel, main bile duct, or adjacent to other organs, it is not well suited for RFA.
There are other forms of ablation including microwave, cryoablation and laser ablation. There are no trials to support these types of ablation and RFA is the most frequently used. Johns Hopkins does however perform some microwave ablation procedures.
TACE - Trans Arterial Chemoembolization
A catheter is inserted into the artery of the tumor on the liver. Chemo and a drug to block the blood vessel are injected directly into the tumor. This blocks the blood supply to the tumor as well as supplies chemotherapy directly into the tumor with the hope of reducing its size. In addition, radio active beads can be inserted into the tumor. Studies show this treatment might be more effective than chemoembolization.
Sterotactic Radiosurgery (SRS)
Stereotactic radiosurgery (SRS) is a highly precise form of radiation therapy initially used to treat tumors and other abnormalities of the brain. Now the principles developed for cranial SRS are also being used to treat cancer in other parts of the body in a procedure called stereotactic body radiotherapy (SBRT). The Gamma Knife is the equipment used for this procedure.
Bone Mets
Bone mets often respond to hormonal and chemotherapy as well as radiation. Bisphosphanate therapy prevents the loss of bone. Surgery is sometimes recommended for bone mets. Dr. Hirose sited a study that claimed whole brain radiation and surgery increased survival in patients compared to whole brain radiation alone.
In summary:
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- Resection of mets is recommended for some select patients.
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- Johns Hopkins supports aggressive resection.
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- Goal of resection is palliative or to prolong life or both.
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- Tumor biology is the most important factor to consider.
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- Tumor location is also important to consider.
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- Surgery is one of many options for local therapy.
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- Only the patient can say if resection is successful.
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- Many doctors do not offer resection or ablation to patients as a treatment option.
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- Patients must sometimes advocate for the treatment they want.
Posted November 15, 2011.
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