Atilla Soran1, Serdar Ozbas2, Lutfi Dogan3, Arda Isik4, Efe Sezgin5. 1. Magee-Womens Hospital Comprehensive Breast Program, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. 2. Private, Breast and Endocrine Surgeon, Ankara, Turkey. 3. Department of Surgical Oncology, University of Health Sciences, Ankara Oncology Training and Research Hospital, Ankara, Turkey. 4. Department of General Surgery, School of Medicine, Istanbul Medeniyet University, Istanbul, Turkey. Electronic address: kararda@yahoo.com. 5. Faculty of Engineering, Izmir Institute of Technology, İzmir, Turkey.
Abstract
Entities:
Keywords:
Bone Metastasis; De Novo; Metastatic Breast Cancer
Letter to the editor.We read the article entitled “Locoregional therapy in de novo metastatic breast cancer: systematic review and meta-analysis, written by Reinhorn D et al. in The Breast Journal 58 (2021) 173–181 [1]. We found this meta-analysis presentation quite interesting, but it has many points that needs to be cleared.This meta-analysis includes a not finished (early terminated because of poor recruitments; ABSCG-28 POSITIVE) trial;It has only 90 patients' data; 35% of (90/254) of estimated sample size.21% (n = 9) has R1 resection margins. Studies showed that primary breast surgery group has survival benefit when R0 margin resection is achieved.40% T3-T4 tumors (not equally distributed in Arms A and B);No visceral only met (all either bone or visceral + bone);Not all the breast conserving surgery (BCS) patients received RT to breast; all BCS patients in the MF07-01 Study patients in the surgery group received RT; standard clinical practice is RT in patients who underwent BCS.This meta-analysis includes “A randomized phase III trial of systemic therapy plus early local therapy versus systemic therapy alone in women with de novo stage IV breast cancer: A trial of the ECOG-ACRIN Research Group (E2108) presented by Khan et al. at the plenary session of ASCO 2020 virtual meeting earlier than expected. ECOG-ACRIN 2108 (Eastern Cooperative Oncology Group-American College of Radiology Imaging Network - NCT01242800)”This study has not been published yet.Although 125 patients were randomized to the early LRT group; only 109 were treated surgically.Surgical margin remained positive in approximately 20% of the early LRT group.Details of the extent of surgery for axilla and radiation volumes are not available.The distribution of patients with locally advanced disease is not specified; 44% of patients have skin involvement, skin nodules and fascia invasion; 48% of them have T4 and/or N2/N3 diseases.38% of patients had only bone metastases but subgroup analysis was not performed.No organ-specific comparison was made between the groups.The patients with 0 months follow-up were included in the analysis.Several meta-analyses including one just published including 4 RCTs and 2 prospective trails [2], and large real-life data collections such as Surveillance, Epidemiology, and End Results (SEER), National Cancer Database (NCDB), and the Epidemiological Strategy and Medical Economic (ESME) data have showed the survival benefit of LRT. The discrepancy between the current meta-analysis and literature with either meta-analyses or a huge number of patients in big data registries should be explained by the authors as they are the ones stating no survival benefit with LRT.We as the BHWGI members showed in a RCT and a prospective study that there is a group of patients, such as having low tumor burden and bone metastatic group, has a survival benefit when cautiously evaluated for primary breast surgery in de novo stage IV BC [[3], [4], [5]. LRT option should be discussed with this cohort of patients not only to control the locoregional progression but also for the prolongation of survival.