Liver metastasis from breast cancer: suitability for resection?

Abstract

s / The Breast 20 (2011) S12–S55 S48 Introduction: Women presenting with inoperable T4 tumours are often offered primary chemotherapy particularly if metastatic disease is present or suspected. Complete clinical response is uncommon, and these tumours may remain inoperable even after chemotherapy. In recent years, we have adopted the use of the vertical rectus abdominis myocutaneous (VRAM) flap to cover large post-mastectomy defects. We present our results here. Material and Methods: Retrospective review was performed of 13 patients who underwent VRAM flap cover following mastectomy from 1st January 2008 to 30th September 2009. Clinicopathological parameters and various surgical outcomes were reviewed. Results: Thirteen patients with T4 tumours underwent VRAM flap following mastectomy. 5 MBC and 8 LABC Median age was 61 years (range 33 to 86 years old). Nine were Chinese and 4 were Malays. Median tumour size at presentation was 100mm (range 30 to 150mm). Nine patients (69.2%) received primary chemotherapy, but either had no clinical response or progressively enlarging tumours. At the time of surgery, 7 patients (53.8%) had fungating tumours and 5 patients had clinical chest wall involvement. All patients underwent mastectomy and axillary clearance. In our practice, surgery is carried out concurrently by 2 separate teams, with the VRAM flap being raised simultaneously with the mastectomy. Mean time taken for the entire operation was 279 minutes. Post-operative recovery was uneventful for most. Two patients required a second surgery: one for evacuation of a flap haematoma, and another for surgical debridement for partial flap necrosis. Another 2 patients developed a superficial wound infection over the breast, which resolved with antibiotics. Median hospital stay was 10 days. One patient required inpatient rehabilitation for functional decline and stayed more than 2 weeks (40 days). Radial resection margins were clear in all 13 cases, although there was involvement of the deep margin in 3. No further radiotherapy was given. Most patients were started on further systemic therapy within 3 weeks of surgery. Three deaths occurred during the median follow-up period of 22 months. Two patients developed chest wall recurrence; one of whom also developed distant disease progression and died 21 months later. Distant disease progression occurred in another 1 patient, who died 6.5 months later. The third death was thought to be from a non-cancer related cause. Conclusions: Mastectomy often provides the best means of local control for large fungating tumours. Increasingly, surgery is being offered to patients in whom distant metastasis respond favourably to chemotherapy. The VRAM flap provides good post-mastectomy defect cover, and is associated with few complications and a short hospital stay. Importantly, further systemic therapy is not unduly delayed.