Role of surgery in patients with synchronous metastatic breast cancer: Is there a need for axillary lymph node removal?

INTRODUCTION: About 6% of women with breast cancer present with synchronous metastases. Treatment remains palliative in international recommendations but the impact of loco-regional surgery remains controversial. OBJECTIVE: We conducted a multicentre, cohort study to evaluate the impact of axillary lymph node (ALN) surgery on overall survival in stage IV breast cancer at diagnosis. METHODS: Patients presenting with breast cancer and synchronous metastases between 2005 and 2014 were included. Follow up was conducted up to 1st June 2018. The only exclusion criterion was a history of previous malignancies. Breast surgery was defined as lumpectomy or mastectomy. Axillary surgery included full ALN dissection, and sentinel lymph node biopsy (SLNB). If the SLN was invaded on the frozen section, full axillary dissection was performed. RESULTS: 152 patients were included. 71 women had no surgery, 81 had primary site surgery of which 64 (79%) had breast and axillary surgery and 17 (21%) breast surgery only. 5-year overall survival was 59.8% (95% CI=[49.5; 69.5]) for women with breast and axillary surgery, 23.5% (95% CI=[15.6; 33]) for women with breast surgery only and 9.8% (95% CI=[4.7; 17.5]) for women without any surgery, p < 0.001. Combined with breast surgery, axillary surgery significantly added a mean of 33 months to patient overall survival. CONCLUSION: ALN surgery combined with breast surgery in metastatic breast cancer significantly increased overall survival. Thus surgical indications should not differ from those in women with breast cancer without metastases.

Survival impact of primary site surgery on metastatic breast cancer patients at diagnosis.

BACKGROUND: Stage IV breast cancer was considered to be an incurable disease. Primary site surgery used to be reserved to control local complications. In the present study, we compared the survival of women who received therapeutic breast surgery for stage IV breast cancer at initial diagnosis to the survival of those who did not. METHODS: Two French hospitals databases were retrospectively screened from 2005 to 2012. We identified all women with metastatic breast cancer at diagnosis. Patients' data were obtained by a review of their medical history. Data were analyzed according the four breast cancer subtypes (luminal A, luminal B, her 2 and triple negative). RESULTS: One hundred thirty nine women were included, of whom 69 had primary site surgery. TNM stage and phenotypes of breast cancer were comparable in the two groups but operated women were younger than women who did not (p<0.0001). Average follow-up was 31±23.3 months [1-97]. Through logistic regression, we observed that tumor resection decreased death hazard ratio vs no surgery: HR 0.33, 95% CI [0.16-0.66] p=0.001. In the surgery group, there was no survival difference if women received chemotherapy (p=0.23). There were more patients with only one metastatic site in the surgery group (p=0.002) and they had been more treated with systemic therapy. When we compared tumor phenotypes individually, surgery increased survival on luminal A breast cancer patients (p<.0001). CONCLUSION: Women with luminal A breast cancer and synchronous metastasis seemed to benefit from surgery. The development of a national reporting system or registers for outcomes would facilitate the investigation of the disease across a multitude of aspects of stage IV breast cancer.

Overall care cost comparison between robotic and laparoscopic surgery for endometrial and cervical cancer.

OBJECTIVE: The aim of our medico-economic study was to compare robotic surgery cost with conventional laparoscopic cost in endometrial and cervical cancer. STUDY DESIGN: Our study included laparoscopic and robot-assisted procedures (radical hysterectomies and lymphadenectomies) for endometrial or cervical cancer ever since first using the Da Vinci® in 2008 within a hospital setting. In the hospital perspective, direct costs were determined by examining the overall medical pathway for each type of intervention. Actual costs were calculated for 27 conventional laparoscopic procedures and for 30 robot-assisted procedures including initial cost of the robot and its maintenance. We estimated the complete medical "overall care" costs by adding the costs of consultations, surgery and post-operative hospital stay to the costs of any eventual emergency consultation and/or hospitalisation within the two months that followed surgery. A sensitivity analysis was performed to evaluate the effects of variable modulations. RESULTS: For endometrial cancer, surgical procedure cost for robotic-assisted surgery was €7402 compared to €2733 for conventional laparoscopic surgery. When considering overall medical care, the patient treatment average cost was €6666 for the laparoscopic group (with an average length of stay of 5.27 days) as compared to €10,816 for robotic group (with an average hospital stay of 4.60 days), p=0.39. For cervical cancer, average surgical cost with robotic-assisted surgery was €8501 compared to conventional laparoscopic surgery at €3239. For cervical cancer, overall care average cost was €7803 for the laparoscopic group (with an average length of stay of 5.83 days) as compared to €12,211 for the robotic group (with an average hospital stay of 4.70 days) p=0.07. Sensitivity analysis results confirmed the cost overrun with the use of robotic assisted surgery. CONCLUSIONS: Conventional laparoscopy was less expensive in our institution than robotic-assisted surgery for the surgery of endometrial (1:2.7) and cervical (1:2.6) cancers. When considering overall medical care, the use of robotic-assisted surgery was found to be 1.6 times more expensive than conventional surgery.