The shifting landscape of metastatic breast cancer

Authors: Matthew R Quigley Olivia Fukui Brandon Chew Sanjay Bhatia Steven Karlovits

Publish Date: 2012/12/22

Volume: 36, Issue: 3, Pages: 377-382

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Abstract

The improved survival following the diagnosis of breast cancer has potentially altered the characteristics and course of patients presenting with CNS involvement We therefore sought to define our current cohort of breast cancer patients with metastatic disease to the CNS in regard to modern biomarkers and clinical outcome Review of clinical and radiographic records of women presenting to a tertiary medical center with the new diagnosis of CNS metastatic disease from breast cancer This was a retrospective review from patients identities obtained from two prospective databases There were 88 women analyzed who were treated over the period of January 2003 to February 2010 average age 569 years At the time of initial presentation of CNS disease 68  of patients had multiple brain metastases 17  had a solitary metastasis and 15  had only leptomeningeal disease LMD The median survival for all patients from the time of diagnosis of breast disease was 500 months and 97 months from diagnosis of CNS involvement The only factor related to overall survival was estrogen receptorpositive pathology 576 v 382 months p = 02 logrank those related to survival post CNS diagnosis were presentation with LMD p = 004 HR = 31 Cox regression and triplenegative hormonal/HER2 status p = 02 HR = 23 Cox regression Patients with either had a median survival of 31 months no patients in common Of the 75 patients who initially presented with metastatic brain lesions 20 26  subsequently developed LMD in the course of their disease median 104 months following which survival was grim 18 months median Symptoms of LMD were most commonly lower extremity weakness 14/33 followed by cranial nerve deficits 11/33 The recently described Graded Prognostic Assessment GPA tumor index stratified median survival at 25 59 131 and 217 months respectively for indices of 1–4 p = 004 logrank which contrasted with the nonsignificant survival difference between Radiation Therapy Oncology Group Recursive Partitioning Analysis classes one and two 131 v 132 p = 8 logrank Treatment of patients with metastatic brain disease from breast cancer should be tailored to the patient’s hormonal status and GPA index Practitioners must be vigilant for the development of LMD especially as it often presents with nondescript complaints such as back painIn this article Quigley et al present a retrospective review of 88 patients with CNS involvement of breast cancer The authors conclude that the treatment should be tailored to the patient hormonal status and GPA index Their conclusion support previous publications Their findings of the increased likelihood of active metastatic disease elsewhere in the body as well as frequent development of LMD in triplenegative disease are novel The finding that there was no increase in LMD in patients that underwent SRS with or without surgery for oligometastases when WBXRT was initially withheld is of significant importanceSurvival of breast cancer patients has significantly improved during the past decades As a consequence it is appropriate to evaluate a current cohort of patients with breast cancer brain metastases in the light of actual classifications biomarkers and clinical characteristics Quigley and colleagues have reviewed the clinical data of 88 female patients with breast cancer brain metastases treated between 2003 and 2010 They included hormonal markers/HER2 status and presented survival data according to the LUMINAL classification Geyer et al 2012 They found prognostic impact of estrogen receptor status on overall survival as well as prognostic impact of triplenegative hormonal/HER2 status on survival post central nervous system affection Additionally they evaluated their data based on the recently described Graded Prognostic Assessment Tumor Index Sperduto et al 2012 This retrospective study is a solid basis for further prospective trials concerning patients with breast cancer brain lesions including endocrine and molecular dataSperduto PW Kased N Roberge D Xu Z Shanley R Luo X Sneed PK Chao ST Weil RJ Suh J Bhatt A Jensen AW Brown PD Shih HA Kirkpatrick J Gaspar LE Fiveash JB Chiang V Knisely JP Sperduto CM Lin N Mehta M Summary report on the graded prognostic assessment an accurate and facile diagnosisspecific tool to estimate survival for patients with brain metastases J Clin Oncol 2012 Feb 1304419–25 doi  101200/JCO2011380527

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