Clinical Outcome of Neoadjuvant Radiochemotherapy in Locally Advanced Cervical Cancer: Results of an Open Prospective, Multicenter Phase 2 Study of the North-Eastern German Society of Gynecological Oncology.

OBJECTIVE: The aim of this study was to determine the response rate, toxicity, operability, and surgical complication rate of neoadjuvant concomitant radiochemotherapy (cRCH) (ifosfamide + carboplatin) followed by radical hysterectomy plus external-beam radiotherapy with curative intention in locally advanced primary inoperable stages IIB and IIIB squamous cell cervical cancer. METHODS: Patients with cervical cancer from 8 departments were enrolled. Patients received 3 cycles of ifosfamide 1.2 mg/m (+mesna 20%) plus carboplatin (area under the curve = 4), every 21 days, and concomitant external-beam radiotherapy (50.4 Gy [1.8 Gy/d]). Operability and remission were evaluated by clinical gynecological examination in general anesthesia (magnetic resonance imaging was optional), 4 weeks after the third cycle of cRCH. In case of achieved operability, a radical hysterectomy with pelvic lymphadenectomy was performed within 6 weeks after cRCH. If surgery was not performed because of incomplete remission or patient preferences, vaginal brachytherapy (15 Gy [5 Gy/d]) was given additionally. RESULTS: Forty-four patients were enrolled. Distribution of FIGO (International Federation of Gynecology and Obstetrics) tumor stage was as follows: IIB (19 patients) and IIIB (25 patients). All patients completed cRCH. Grade 3/4 hematologic toxicities (% of all cycles) were moderate: leukopenia, 7.3; thrombocytopenia, 2.4; and anemia, 3.2. In 13.8%, treatment cycles were delayed because of hematologic toxicity. Blood transfusions were given in 17.7% and granulocyte colony-stimulating factor in 39.5%. Overall, grade 3/4 nonhematologic toxicities were seldom (6.5%). Clinical overall response rate was 95.2%. Operability was achieved in 85.7%. Surgery was performed in 83.3%. Pathological response rates were as follows: pathological complete remission, 33.3%; partial remission, 63.3%; stable disease, 3.3%. CONCLUSIONS: Our study demonstrates that cRCH is an effective and tolerable regimen in locally advanced cervical cancer treatment.

Management of recurrent or metastatic endometrial cancer in Germany: results of the nationwide AGO pattern of care studies from the years 2013, 2009 and 2006.

PURPOSE: The available literature on the treatment options for recurrent or metastatic endometrial cancer (EC) is full of controversies. Therefore, we explore the results of the AGO pattern of care studies from the years 2013, 2009 and 2006. METHODS: A questionnaire was developed and sent to all 682 German gynecological departments in 2013 (775 in 2009, 500 in 2006, respectively). The results of the questionnaires were compared with each other using Fisher's exact test. RESULTS: Responses were available in 40.0 % in 2013, 33.3 % in 2009 and 35.8 % in 2006. In 2013 the most preferred endocrine drug was progestin (79.8 %), followed by tamoxifen (42.8 %), aromatase inhibitor (19.8 %), fulvestrant (16.3 %) and a combination (3.9 %) (p < 0.001). 65.3, 59.8, 51.7 and 38.2 % of the participants used platinum, taxane, a combination of cytostatic drugs, anthracycline in metastatic EC, respectively (p = 0.215). 96.2, 92.7, 49.8 and 60.9 % of the participants performed an operation, radiotherapy, endocrine therapy and chemotherapy in 2013 because of a local recurrence, respectively (p < 0.001). Compared to 2009 and 2006 these rates remained stable (no p value <0.05). Because of a distant metastasis 50.4, 64.2, 78.5 and 90.8 % of the participants performed an operation, radiotherapy, endocrine therapy and chemotherapy in 2013, respectively (p < 0.001). Compared to 2009 and 2006 more participants performed an operation or radiotherapy and less an endocrine treatment. CONCLUSIONS: Whereas progestin was the favorite drug, the participants of this study did not prefer a specific cytostatic drug for metastatic EC in 2013. This might have reflected the available literature, which did not provide a real standard of care.

Statement of the Uterus Commission of the Gynecological Oncology Working Group (AGO) on Neoadjuvant Chemotherapy Prior to Definitive Radiochemotherapy in Patients with Locally Advanced Cervical Cancer.

The presentation of the results of the prospective randomized international multicenter GCIG INTERLACE trial at the 2023 congress of the European Society of Medical Oncology (ESMO) is likely to change the therapy for locally advanced cervical cancer. In the GCIG INTERLACE trial, six cycles of neoadjuvant chemotherapy administered weekly and consisting of carboplatin AUC2 and paclitaxel 80 mg/m 2 followed by definitive radiochemotherapy with pelvic radiotherapy (40 - 50.4 Gray) and cisplatin (40 mg/m 2 once a week for 5 weeks) and brachytherapy (total dose EQD2 at least 78 Gy at point A) (experimental arm) were compared with definitive radiochemotherapy alone (standard arm) in patients with locally advanced cervical cancer (Fédération Internationale de Gynécologie et d'Obstétrique [FIGO] 2008 stage IB1/node positive, IB2, II, IIIB and IVA) and was found to be significantly superior with significantly longer recurrence-free survival (hazard ratio [HR] 0.65; 95% confidence interval [CI] 0.64 - 0.91; p = 0.013) and significantly longer overall survival rates (HR 0.61; 95% CI: 0.40 - 0.91; p = 0.04) after 5 years' follow-up. After considering the results of the GCIG INTERLACE trial published at the congress, the Uterus Commission of the AGO is of the opinion that neoadjuvant chemotherapy with carboplatin AUC2 and paclitaxel 80 mg/m 2 d1, q7, x6 may be offered to patients with locally advanced cervical cancer (FIGO stage IB1/node positive, IB2, II, IIIB and IVA) in addition to the current standard therapy after the patient has been informed about the risks, with the decision taken on a case-by-case basis. However, before this approach can be discussed at guideline level or defined as the new therapy standard, it will be necessary to wait until the data from the full publication are available.

Learning curve for laparoscopic staging of early and locally advanced cervical and endometrial cancer.

BACKGROUND: Laparoscopic staging is rapidly evolving as an important surgical approach in the field of gynecology oncology. However, the specific learning curve associated with this approach remains poorly investigated. This study aimed to evaluate the learning curve for laparoscopic staging of uterine cancers. METHODS: A series of 28 consecutive laparoscopic hysterectomies with or without pelvic and/or para-aortic lymph node sampling for the treatment of early and locally advanced endometrial or cervical cancer were performed between July 2008 and January 2011. The analyses of the learning curves of the institution were performed for 20 patients who had undergone pelvic lymphadenectomy and/or para-aortal lymph node sampling. The learning curve period has also been compared with the last 26 patients who received laparotomy staging ("open" group) due to the same diagnosis and by the same surgical team. To assess the short- and long-term outcomes, we used validated questionnaires to record the clinical and follow-up results, any complaints or subjective reports from the patients, and details of their quality of life. All data were collected prospectively in a database and reviewed retrospectively. The learning was evaluated using the cumulative sum (CUSUM) method. RESULTS: The CUSUM learning curve consisted of two distinct phases: phase 1 (the initial 9 cases) and phase 2 (the subsequent cases) which presented the mastery phase, with the operative time of 397.7 ± 63.5 versus 300.6 ± 19.4 min (p < 0.0001). The significance of the difference between the two phases and "open" group changed in terms of number of lymph nodes retrieved, intra-operative blood loss and hospital stay. The conversion rate of phase 1 was higher than phase 2 [2 (22.2 %) respectively 1 (9 %)]. CONCLUSIONS: This series confirms previous study findings concerning the feasibility and the safety of laparoscopic staging and provides information for surgeons in single centers considering adopting an endoscopic strategy to monitor the different aspects of outcomes during the implementation process for internal benchmarking. The operative outcome of laparoscopic staging intervention improves with experience. The data reported in this article suggest that after a learning curve of 9 patients, a relevant improvement at least regarding the duration of the operation can be achieved for experienced surgeons who start performing laparoscopic staging of uterine cancers. However, due to the limited number of patients as well as number of para-aortic lymph node sampling procedures, further studies are required for firm conclusions to be drawn.

Gestational and Non-gestational Trophoblastic Neoplasia. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 032/049, April 2022).

Purpose The aim was to develop and update a guideline which would improve the quality of care offered to women with gestational and non-gestational trophoblastic disease, a group of diseases characterized by their rarity and biological heterogeneity. Methods In accordance with the method used to compile S2k-guidelines, the guideline authors carried out a search of the literature (MEDLINE) for the period 1/2020 to 12/2021 and evaluated the recent literature. No key questions were formulated. No structured literature search with methodical evaluation and assessment of the level of evidence was carried out. The text of the precursor version of the guideline from 2019 was updated based on the most recent literature, and new statements and recommendations were drafted. Recommendations The updated guideline contains recommendations for the diagnosis and therapy of women with hydatidiform mole (partial and complete moles), gestational trophoblastic neoplasia after pregnancy or without prior pregnancy, persistent trophoblastic disease after molar pregnancy, invasive moles, choriocarcinoma, placental site nodules, placental site trophoblastic tumor, hyperplasia at the implantation site und epithelioid trophoblastic tumor. Separate chapters cover the determination and assessment of human chorionic gonadotropin (hCG), histopathological evaluation of specimens, and the appropriate molecular pathological and immunohistochemical diagnostic procedures. Separate chapters on immunotherapy, surgical therapy, multiple pregnancies with simultaneous trophoblastic disease, and pregnancy after trophoblastic disease were formulated, and the corresponding recommendations agreed upon.

Accuracy of MRI with an endorectal coil for staging endometrial cancer.

BACKGROUND: The very good results of magnetic resonance imaging (MRI) using an endorectal coil in staging prostate cancer at 1.5T suggested that this imaging technique might be able to be used to stage endometrial cancer, the most common tumor in postmenopausal women. PURPOSE: To evaluate the accuracy of MRI with an endorectal surface coil for staging primary endometrial carcinoma. MATERIAL AND METHODS: A total of 33 consecutive patients with biopsy-proven endometrial cancer underwent 1.5T MRI with an endorectal surface coil (eMRI) using sagittal and axial T2-weighted (T2w) turbo spin echo (TSE), axial T1 gradient echo 2D fat-saturated (fs), sagittal T1 gradient echo 3D with and without contrast enhancement (CE), and axial T1 TSE fs CE sequence. Evaluation of local tumor extension was based on the revised standard TNM classification for endometrial cancer. eMRI staging was compared with the histopathological results after surgery. RESULTS: A total of 33 consecutive patients underwent eMRI for staging endometrial cancer, and 21 of these underwent primary surgery. The histological stages were as follows: T1a (n = 8), T1b (n = 10), T2b (n = 2), and T3a (n = 1). Overall staging accuracy by eMRI was 71% (15 of 21). With regard to depth of myometrial invasion, eMRI correctly diagnosed stage T1a in 75% (6/8) and stage T1b in 80% (8/10). eMRI overstaged the tumor in four patients and understaged it in two. CONCLUSION: eMRI is highly accurate in staging myometrial invasion. However, eMRI at 1.5T does not seem to be significantly more accurate than pelvic MRI without an endorectal coil at 1.5T for staging primary endometrial cancer. eMRI for endometrial carcinoma therefore might not meet expectations compared with the results obtained using eMRI for staging prostate cancer at 1.5T.

Laparoscopically assisted vaginal hysterectomy in a patient with micro-invasive cervical cancer after two liver transplantations.

BACKGROUND: Advances in surgical techniques and immunosuppressive therapy have improved graft survival in transplant recipients. However, intense long-term immunosuppression increases the incidence of cancer in these patients compared with the general population, not least because of viral infections. Cervical cancer is the third most common malignancy worldwide. In early invasive cervical cancer, surgery is the treatment of choice. CASE: In 2010, we performed a laparoscopically assisted vaginal hysterectomy (LAVH) in a 42-year-old patient with micro-invasive cervical adenocarcinoma (FIGO stage IA1) who had undergone two liver transplantations in 2006 and 2008. The patient was followed up for 18 months after surgery. Despite upper abdominal adhesions and minor difficulties in inserting the Veress needle, the pneumoperitoneum was created safely. The procedure was completed within 157 minutes without any intraoperative complications. Blood loss was less than 100 mL. Postoperative course was uncomplicated with minimal fluctuations in liver function markers. Immunosuppressive therapy was continued without modification. The patient was discharged on postoperative day 9. No complications or recurrence were reported during the 18-month follow-up. CONCLUSIONS: The laparoscopic approach is a justifiable form of surgical management in the treatment of a liver transplant recipient with early-stage cervical cancer.

Imaging of female pelvic malignancies regarding MRI, CT, and PET/CT : part 1.

AIM: The goal of this article is to provide an overview of diagnostic standard operating procedures for both clinical and imaging assessment of cervical and endometrial carcinoma, sarcoma of the uterus, and primary pelvic non-Hodgkin's lymphoma. METHODS: The literature was reviewed for methods used to diagnose malignancies in the female pelvis with a special focus on the role of MRI as the imaging method of choice. Furthermore, CT findings and staging criteria for the mentioned malignancies are also provided. CONCLUSION: Whereas ultrasound still remains the imaging modality of choice in clinical practice for the early diagnosis of female pelvic malignancies, MRI is more frequently recognized as a diagnostic tool for its accuracy in tumor identification. MRI also plays a crucial role in the 3D pretreatment planning for brachytherapy especially in cervical cancer. In the future, PET/CT might achieve an important role for staging lymph nodes or distant metastases as well as tumor recurrence.

Imaging of female pelvic malignancies regarding MRI, CT, and PET/CT: Part 2.

PURPOSE: To compose diagnostic standard operating procedures for both clinical and imaging assessment for vulvar and vaginal cancer, for vaginal sarcoma, and for ovarian cancer. METHODS: The literature was reviewed for diagnosing the above mentioned malignancies in the female pelvis. Special focus herein lies in tumor representation in MRI, followed by the evaluation of CT and PET/CT for this topic. CONCLUSION: MRI is a useful additional diagnostic complement but by no means replaces established methods of gynecologic diagnostics and ultrasound. In fact, MRI is only implemented in the guidelines for vulvar cancer. According to the current literature, CT is still the cross-sectional imaging modality of choice for evaluating ovarian cancer. PET/CT appears to have advantages for staging and follow-up in sarcomas and cancers of the ovaries.

Acceptance of oral chemotherapy in breast cancer patients - a survey study.

BACKGROUND: Oral (p.o.) chemotherapy treatments gained increasing importance in the palliative treatment of metastatic breast cancer (MBC). Aim of this survey was to evaluate the acceptance of p.o. treatment and patients' individual attitudes towards it. METHODS: A specific 14 item-questionnaire was designed. Patients suffering from breast cancer receiving a newly launched p.o. or i.v. chemotherapy treatment were prospectively evaluated during 4 months of time. 224 questionnaires using descriptive statistics, chi-square test, Spearman correlation were evaluated. RESULTS: Patients' median age was 54 years, 164 received i.v., 60 p.o therapy. 89% with p.o. and 67% with i.v. regimens would choose p.o. over i.v. therapy, if equal efficacy is guaranteed. Significant differences were especially found in terms of personal benefit (55% i.v., 92% p.o.), reduced feeling of being ill due to p.o. treatment (26% i.v., 65% p.o.), better coping with disease due to p.o. therapy (36% i.v., 68% p.o.). Side effects were significantly less often reported under p.o. treatment (19% p.o. vs. 53% i.v.) CONCLUSION: P.o. chemotherapy shows a high acceptance in MBC patients under palliative therapy. Compliance can be achieved in particular through a differentiated indication, patient education and competent support along a p.o. treatment.

Phase II study evaluating consolidation whole abdominal intensity-modulated radiotherapy (IMRT) in patients with advanced ovarian cancer stage FIGO III--the OVAR-IMRT-02 Study.

BACKGROUND: The prognosis for patients with advanced FIGO stage III epithelial ovarian cancer remains poor despite the aggressive standard treatment, consisting of maximal cytoreductive surgery and platinum-based chemotherapy. The median time to recurrence is less than 2 years, with a 5-years survival rate of -20-25%. Recurrences of the disease occur mostly intraperitoneally.Ovarian cancer is a radiosensitive tumor, so that the use of whole abdominal radiotherapy (WAR) as a consolidation therapy would appear to be a logical strategy. WAR used to be the standard treatment after surgery before the chemotherapy era; however, it has been almost totally excluded from the treatment of ovarian cancer during the past decade because of its high toxicity. Modern intensity-modulated radiation therapy (IMRT) has the potential of sparing organs at risk like kidneys, liver, and bone marrow while still adequately covering the peritoneal cavity with a homogenous dose.Our previous phase I study showed for the first time the clinical feasibility of intensity-modulated WAR and pointed out promising results concerning treatment tolerance. The current phase-II study succeeds to the phase-I study to further evaluate the toxicity of this new treatment. METHODS/DESIGN: The OVAR-IMRT-02 study is a single-center one arm phase-II trial. Thirty seven patients with optimally debulked ovarian cancer stage FIGO III having a complete remission after chemotherapy will be treated with intensity-modulated WAR as a consolidation therapy.A total dose of 30 Gy in 20 fractions of 1.5 Gy will be applied to the entire peritoneal cavity including the liver surface and the pelvic and para-aortic node regions. Organ at risk are kidneys, liver (except the 1 cm-outer border), heart, vertebral bodies and pelvic bones.Primary endpoint is tolerability; secondary objectives are toxicity, quality of life, progression-free and overall survival. DISCUSSION: Intensity-modulated WAR provides a new promising option in the consolidation treatment of ovarian carcinoma in patients with a complete pathologic remission after adjuvant chemotherapy. Further consequent studies will be needed to enable firm conclusions regarding the value of consolidation radiotherapy within the multimodal treatment of advanced ovarian cancer. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01180504.

The PACOVAR-trial: a phase I/II study of pazopanib (GW786034) and cyclophosphamide in patients with platinum-resistant recurrent, pre-treated ovarian cancer.

BACKGROUND: The prognosis of patients with recurrent, platinum-resistant epithelial ovarian cancer (EOC) is poor. There is no standard treatment available. Emerging evidence suggests a major role for antiangiogenic treatment modalities in EOC, in particular in combination with the metronomic application of low dose chemotherapy. The novel, investigational oral antiangiogenic agent pazopanib targeting vascular endothelial growth factor receptor (VEGFR), platelet-derived growth factor receptor (PDGFR) and c-kit is currently being studied in different tumour types and is already used as first line therapy in recurrent renal cell carcinoma. A combined therapy consisting of pazopanib and metronomic oral cyclophosphamide may offer a well-tolerable treatment option to patients with recurrent, pretreated EOC. METHODS/DESIGN: This study is designed as a multicenter phase I/II trial evaluating the optimal dose for pazopanib (phase I) as well as activity and tolerability of a combination regimen consisting of pazopanib and metronomic cyclophosphamide in the palliative treatment of patients with recurrent, platinum-resistant, pre-treated ovarian cancer (phase II). The patient population includes patients with histologically or cytologically confirmed diagnosis of EOC, cancer of the fallopian tube or peritoneal cancer which is platinumresistant or -refractory. Patients must have measurable disease according to RECIST criteria and must have failed available standard chemotherapy. Primary objectives are determination of the optimal doses for pazopanib (phase I) and the overall response rate according to RECIST criteria (phase II). Secondary objectives are time to progression, overall survival, safety and tolerability. The treatment duration is until disease progression or intolerability of study drug regimen (with a maximum of 13 cycles up to 52 weeks per subject). DISCUSSION: The current phase I/II trial shall clarify the potential of the multitargeting antiangiogenic tyrosinkinaseinhibitor GW 786034 (pazopanib) in combination with oral cyclophosphamide as salvage treatment in patients with recurrent, pretreated ovarian cancer.

Long-term remission of an advanced recurrent endometrial cancer in a heavily pretreated patient using a combined regimen with bevacizumab and metronomic cyclophosphamide.

The treatment of advanced endometrial cancer remains a challenge and the range of valuable treatments remains limited. Recently, the monoclonal vascular endothelial growth factor--antibody bevacizumab as a single-agent regimen or in combination with different chemotherapeutic approaches has been approved as a therapeutic option for several solid tumors. First, clinical trials evaluating the use of bevacizumab in endometrial cancers have been completed, but the results have not been published yet. A 59-year-old patient with advanced recurrent endometrial cancer presented at our institution suffering from increasing abdominal discomfort. She had been extensively pretreated using radiotherapeutic approaches and multiple chemotherapeutic regimens. The level of cancer antigen 125 (CA 125) was rising and a cystic pelvic mass was detected, consistent with a persistent local tumor relapse. As several cytotoxic treatment attempts had failed, we decided to induce a combined therapy with bevacizumab (intravenously) and metronomic cyclophosphamide (orally) as an individual treatment option. After 6 weeks of treatment, the patient's abdominal complaints had completely disappeared, CA 125 had decreased significantly to nearly baseline levels, and the previously detected cystic pelvic mass could no longer be seen. No significant side effects could be observed besides a mild fatigue. During the following weeks, CA 125 levels continued to decrease, and the patient experienced a long-time remission in fine condition for 10 months before PD. Bevacizumab in combination with metronomic cyclophophamide can be a well-tolerated salvage treatment option for patients with advanced, heavily pretreated recurrent endometrial cancer that exacts further evaluation within clinical trials.

Long-term remission in a patient with heavily pretreated, advanced ovarian cancer achieved by bevacizumab and metronomic cyclophosphamide treatment.

Vascular endothelial growth factor seems to be a promoter of tumor progression for epithelial ovarian cancer. New drugs such as bevacizumab, either alone or in combination with metronomic chemotherapy, suppress tumor growth and have proved to be effective in various tumor types. We present a 60-year-old patient with heavily pretreated, recurrent epithelial ovarian cancer, who received bevacizumab (10 mg/m(2)) every 2 weeks in combination with metronomic administered low-dose cyclophosphamide (50 mg/day orally) after failing four explorative laparotomies and multiple chemotherapy regimes. At the time of writing, February 2011, she was being treated with this combination therapy for 24 months and the progression-free survival still continues. Treatment of advanced, refractory epithelial ovarian cancer with bevacizumab in combination with low-dose cyclophosphamide could be a very effective salvage treatment option in heavily pretreated patients.

One life ends, another begins: Management of a brain-dead pregnant mother-A systematic review-.

BACKGROUND: An accident or a catastrophic disease may occasionally lead to brain death (BD) during pregnancy. Management of brain-dead pregnant patients needs to follow special strategies to support the mother in a way that she can deliver a viable and healthy child and, whenever possible, also be an organ donor. This review discusses the management of brain-dead mothers and gives an overview of recommendations concerning the organ supporting therapy. METHODS: To obtain information on brain-dead pregnant women, we performed a systematic review of Medline, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). The collected data included the age of the mother, the cause of brain death, maternal medical complications, gestational age at BD, duration of extended life support, gestational age at delivery, indication of delivery, neonatal outcome, organ donation of the mothers and patient and graft outcome. RESULTS: In our search of the literature, we found 30 cases reported between 1982 and 2010. A nontraumatic brain injury was the cause of BD in 26 of 30 mothers. The maternal mean age at the time of BD was 26.5 years. The mean gestational age at the time of BD and the mean gestational age at delivery were 22 and 29.5 weeks, respectively. Twelve viable infants were born and survived the neonatal period. CONCLUSION: The management of a brain-dead pregnant woman requires a multidisciplinary team which should follow available standards, guidelines and recommendations both for a nontraumatic therapy of the fetus and for an organ-preserving treatment of the potential donor.

Liver resection for multimodal treatment of breast cancer metastases: identification of prognostic factors.

BACKGROUND: Liver resection (LR) within a multimodal treatment concept of hepatic metastases (HM) that results from breast cancer has been controversially discussed. The aim of this study was to evaluate the outcome of LR in patients with hepatic breast cancer metastases. METHODS: Prospectively collected data from 41 consecutive patients who underwent LR for HM between 1999 and 2008 were analyzed retrospectively. Univariate and multivariate analyses were performed to assess potential prognostic factors. RESULTS: Segmental resection was performed in 46% and major hepatectomy in 54% of patients. The postoperative mortality rate was 0%. At a median follow-up of 34 months, 26 patients were alive. The median and 5-year overall survival rates after LR were 58 months and 48%, respectively. The median and 5-year disease-free survivals were 34 months and 31%, respectively. The intrahepatic recurrence-free 5-year survival was 62%. The median survival from time of diagnosis of HM was 79 months. The positive resection margin as well as a disease-free interval between the treatment of the primary tumor and the diagnosis of HM < 1 year were independent predictors of overall survival. CONCLUSIONS: LR of hepatic breast cancer metastases within a multimodal treatment concept is a safe procedure in well-selected patients. Both a short time interval to the development of HM and positive resection margins after LR are strongly associated with worse long-term survival.

Successful remission of extensive liver metastases in a breast cancer patient with acute liver failure using a combined chemotherapy regimen with mitomycin, folinate, and 5-fluorouracil (Mi/Fo/FU).

BACKGROUND: Liver failure due to disseminated hepatic secondaries represents a therapeutic dilemma in patients with metastatic breast cancer (MBC). Reduced liver function and non-assessable toxicity are limiting factors in the selection of chemotherapeutic agents. Currently, there is no standard treatment after failure of anthracycline-and taxane-based first-line therapies, although there is a variety of well evaluated drugs such as capecitabine. CASE REPORT: We report on a 45-year-old breast cancer patient with disseminated hepatic metastases. She presented in markedly poor condition, showing substantial ascites and extensive jaundice. Blood chemistry analysis showed increased serum levels of liver enzymes (aspartate aminotransferase 271 U/l, alanine transaminase 101 U/l), bilirubin (7.9 mg/dl), and CA 15-3 (1,459 U/l). We induced a palliative chemotherapy with mitomycin, folinate, and 5-fluorouracil (Mi/Fo/FU). The patient improved impressively after the first cycle of systemic therapy. Liver enzymes stabilized continuously, CA 15-3 returned to normal. The patient was discharged 2 weeks after the treatment start. Chemotherapy was well tolerated under dose escalation, no grade 3/4 toxicity was observed. The progression-free interval was 5 months. CONCLUSIONS: A combination therapy with Mi/Fo/FU appears to be a reasonable and tolerable alternative salvage strategy for patients with liver failure due to hepatic breast cancer metastases.