Oligometastatic Disease in Breast Cancer

A subset of patients with stage IV breast cancer have limited distant metastatic disease that is often confined to a solitary lesion. This is termed oligometastatic disease (note that the term initially referred to restricted locoregional tumor load), and has been described in other malignancies, such as lung cancer, soft tissue sarcoma, osteosarcoma, renal cell carcinoma, and melanoma.

Management of the oligometastatic state is controversial. If it is thought of as the tip of the iceberg, with more widespread micrometastases escaping clinical detection, the treatment strategy would focus on systemic chemotherapy. However, several studies have shown improved survival after surgical resection of the metastasis followed by systemic therapy. Another potential benefit is an improvement in the quality of life because of discontinuation of chemotherapy.

The management of the primary tumor in this setting is also controversial, with some studies showing improved survival after resection of the primary tumor.

Definitive answers will require large, multicenter, randomized trials.

The MIP image above is from a patient with left-sided invasive ductal carcinoma with a solitary metastasis to the left T2 pedicle, who was treated with neoadjuvant chemotherapy, modified radical mastectomy, and stereotactic radiation therapy to T2. There is multicentric uptake in the left breast with multiple FDG-avid left axillary and infraclavicular lymph nodes. The lesion in the left T2 pedicle is indicated by the arrow.

References

• Pockaj BA, Wasif N, Dueck AC, Wigle DA, Boughey JC, Degnim AC, Gray RJ, McLaughlin SA, Northfelt DW, Sticca RP, Jakub JW, Perez EA. Metastasectomy and surgical resection of the primary tumor in patients with stage IV breast cancer: time for a second look? Ann Surg Oncol. 2010 Sep;17(9):2419-26.
• Tait CR, Waterworth A, Loncaster J, Horgan K, Dodwell D. The oligometastatic state in breast cancer: hypothesis or reality. Breast. 2005 Apr;14(2):87-93.