Metastatic breast Cancer to liver

[snowman01]

My mom has metastatic breast cancer that has spread to her lungs and liver.  She was diagnosed in 2002 and has had a mastectomy followed up by three different rounds of chemo complemented with herceptin over the past 5 years.   The liver tumors have shown up for a while but have been slow growing.  We recently found out that there is a liver tumor that has not shown up on the MRI's and CAT scans.  The oncologist described it as growing like a sheet around the outside of her liver.  It was discovered when she recently had to have her gall bladder removed.  Due to excessive bleeding the surgeon was unable to remove the gall bladder laproscopically as he had hoped and when he opened her up he saw this undetected tumor.  I questioned why they did not remove the tumor at that time since they had her open and they were right there, and was told  they feared they would do more harm than good due to the vascular nature of the tumor.  At this stage in her disease I realize that the treatments are more quality of life management than curative.  Is there any precedent for removing this type tumor in stage 4 metastatic cancer?  If the liver is able to regenerate why not remove the portion with the tumor and let the remaining liver compensate?  It's hard to accept that there is nothing to do.  I question if there are specialists that deal with these particular types of tumors or cancers that might offer other treatments?

[riley180]

Hi,
Your mom has indeed been through a lot.
You could discuss the option of using Exemestane (Aromasin) instead of Tamoxifen. The best studied hormonal drug with Herceptin is indeed Arimidex, but it seems that we have pushed it as far as benefits go. Exemestane is a drug that performs a similar metabolic goal as Arimidex using a different pathway.
Another drug you can pursue is Lapatinib (Tykerb) - which is a drug that blocks the HER2 pathway and may serve as an alternative to Herceptin.
In terms of chemotherapy - Capecitabine is a drug that is well-tolerated, and seems to behave well with either Herceptin or Tykerb.
All these options, may add some modest benefit - but all things considered I think her treatment is pretty thorough.

[snowman01]

Thanks for your explanation it was very helpful and explained why they could not just go ahead and remove the liver tumor while they had her open.  I think intuitively I was thinking along the lines of your point that if we reduce the amount of cancer then the chemo needs to fight less cancer and might be more successful.  The doctor has already told us that resection of her lungs is not an option due to the number of calcifications showing up on her scans.  I do not know how many anatomical sections of her liver are involved in this "sheetlike" tumor, but my guess would be as you suggest too much of the organ is involved to make it a viable option, but I will ask.

My mom is HER2 positive  +3.  She has been on adjuvant chemotherapy with Herceptin since her first recurrence.  Her doctor believes that using the Herceptin in addition to the chemo has made the chemos more effective at retarding and reducing the cancer.

His approach has been to stay with a particular chemo regimen until the tumors are either undetectable or it stops working and the tumors start growing.    So far her cancer has been responsive to the chemo treatments.  Her first round was a combination of Andromycin, Fluoricil, and Erubicin.  It worked and she was off chemo for about a year during which time she took Arimidex.

She had her first recurrence  and it showed up in her lungs.  They tried Faslodex (pill) I think for 30 days.  It did not work so we went to a Taxol(?) for 2 rounds  with Herceptin.  There was a dramatic reduction in size and she was off chemo for a while and back on Arimidex.  

She had her second recurrence and the cancer showed back up in her lungs as well as her liver.  They tried two rounds of Abraxane with Herceptin.  It seemed to work as far as reducing the speed of growth, but no reduction in size.  She got very weak and did not think she could handle another round.  Since the cancer  was not growing very fast, they decided to take a break from the chemo, continue the Herceptin and monitor every 6 weeks.  She was not regaining her strength like  expected which is why the doctor started looking elsewhere and decided to remove the gall bladder.  She had gall stones that were showing up on her scans, but the doctor did not want to do surgery unless it was absolutely necesary due to her weakened state.  The surgery revealed that she not only had gall stones, but also the gall bladder was infected.  It also reveled the "sheet like" tumor growing around the liver.  We knew she had several lesions in the liver, but this "sheet" had not shown up on the scans.

The plan at this point is to continue the Herceptin and start Tamoxefin (pill) while she heals from the gall bladder surgery.  As soon as she is strong enough they plan to restart chemo. I am not sure if he will restart the Abraxane or do something else.

She is a warrior and continues to fight.  Her spirit is strong as is her faith.  

Thanks for your explanation.  If you see any obvious gaps in her treatment plan, we are definitely open to suggestions.  

[riley180]

Hi.
I understand the frustration you must feel as you sense a missed opportunity.
There are some key ideas that you need to comprehend.

Is there such a thing as surgical removal of metastasis in the liver?
Yes, there is. The best successes are with liver involvement from colon cancer. There is a demonstrable proof that it makes a difference because: the pattern of metastasis for colon cancer seems to occur in a stepwise fashion in many cases – from intestine towards the liver that removing the liver metastasis can translate to being cancer-free.

Can we apply this same philosophy to your mom?

There are some supporters of performing the operation if it would mean all evidence of disease will be removed. This is controversial – meaning some doctors would, some would not – there is no science to say which is really the way to go. This also means, that there is no other site of disease outside the liver. In your mother’s case – there are metastases in the lungs, so a discussion of performing lung resection must also be discussed, before proceeding with removing the liver metastases. If the liver metastasis was a chance finding during gall bladder surgery – there wasn’t enough time to plan the lung issue.

If the goal was to reduce the total amount of cancer (not attempting to cut out all sites of cancer), such an approach has also been considered in breast cancer. The outcomes however, will depend on how well your mother will respond to chemotherapy after the operation. This strategy works well in tumors like ovarian cancer, in which the maximum amount of tumor is surgically removed, then the chemotherapy will need to fight less cancer – so overall – there is some benefit as to extension of survival. As a strategy, this is more controversial for breast cancer – especially if you have not seen any response of the cancer with chemotherapy (you didn’t mention if your mom was undergoing any chemotherapy and how well the treatment is controlling the disease – if there is dramatic response – then this plan of reducing the amount of cancer can be viable).

A third issue is your description of the liver metastasis as spreading around the surface (“growing like a sheet”). Successful liver metastasis surgery involves removal of anatomic segments, not merely sloughing off the layer with the tumor. If it is thus growing like a sheet – chances are at least 3 or 4 segments of liver will be sacrificed, removing about 3 segments would be classified as a major operation, now bear in mind that all this is usually attempted in a patient prepared for that specific purpose, not readily done as an emergency.

Other things to think about.
I’m assuming that your mom’s breast cancer is hormone receptor negative. If she was positive, it is possible to try hormonal treatment. If there is a chance to perform a biopsy, there is a chance that a prior hormone receptor negative breast cancer when it enters the metastatic stage becomes hormone receptor positive.

I hope this post helps. Happy holidays.