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A Role for Hepatic Metastasectomy in Stage IV Melanoma and Breast Cancer: Reestablishing the Surgical Modality

A Role for Hepatic Metastasectomy in Stage IV Melanoma and Breast Cancer: Reestablishing the Surgical Modality

Historically, liver-related metastases associated with melanoma or breast cancer have portended a poor prognosis. Many affected patients are not considered for surgical resection based on the extent and multifocal nature of their disease. For this patient population, treatment includes systemic and/or regional therapy, local destruction (ablation/radiation), and embolization. Despite the best therapeutic regimens, prognosis remains poor. Advances in surgical technique and postoperative care have led to a resurgence in the use of metastasectomy, most notably seen in patients with colorectal-related liver metastases. With the potential for therapeutic durability and a small chance of cure, surgical resection may offer improved survival compared to other therapeutic modalities. This review summarizes the existing literature that addresses the topic of metastasectomy in patients with melanoma and breast cancer.

Introduction

Advances in perioperative planning, surgical technique, and postoperative care over the past two decades have allowed the indications for hepatic resection to be potentially broadened to include histologies and/or disease burdens previously felt to be contraindications for this treatment modality. This trend has been seen most notably with respect to resection of colorectal-related liver metastases.[1,2] Historically, colorectal liver metastases have been treated with palliative chemotherapy. The improvements seen with surgical resection have made this the gold standard for treatment; expected 5-year survival rates are 50% to 65%, and resection offers the only potential for cure.[3] Hepatic resection for neuroendocrine-related liver metastases is likewise now accepted as appropriate.[4] However, while retrospective reports have demonstrated long-term survival in some highly selected patients with other histologies, including melanoma and breast cancer, the application of hepatectomy in these patients remains controversial.

There are a number of arguments against the use of hepatectomy in the management of metastatic disease. First and foremost is the lack of randomized data to support its utilization, even in patients with neuroendocrine and colorectal histologies. Hepatectomy is associated with severe morbidity rates—20% to 30%—and with 90-day mortality rates of 1% to 5%.[5] Disease recurs in the overwhelming majority of patients following hepatectomy, and the prospect of recurrence exceeds 80% even in the most favorable of histologies.[6] However, similar statements can be made to argue against surgical resection of pancreatic cancer, gastric cancer, esophageal cancer, and primary liver cancer. Ultimately, patients and their oncologists are drawn to the small to modest possibilities of cure that are associated with hepatectomy and other complicated oncologic resections in the face of what would be a near-zero possibility of cure without resection. For young, healthy patients, it is a relatively easy decision, although for older and/or infirm patients the decisions are more complex.

For the vast majority of patients with liver metastases who are not candidates for surgical resection, treatment options include systemic and/or regional therapy, local destruction (ablation/radiation), and embolization. Systemic therapy options have evolved, and there are now a multitude of agents available for metastatic disease. However, response rates have been low and the effect on overall survival is still unclear. Regional therapy, including the use of isolated hepatic artery treatment, has been shown to achieve partial remission, although it has no significant effect on long-term survival. Lastly, embolization techniques have been promising, with reports showing better survival rates than those associated with the best chemotherapy, with minimal toxicity.[7] Still, even this therapy is palliative at best; surgical resection offers the only real opportunity for cure.

The aim of this review is to present an analysis of the existing literature that addresses the topic of metastasectomy in patients with melanoma and breast cancer. Despite improvements in systemic chemotherapy for these diseases, the prognosis for metastasized disease in both cases remains poor.[8,9] With proper patient selection, the added modality of surgical resection may allow for improved survival and, as with colorectal and neuroendocrine cancers, may be the only possibility of cure.

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