Locoregional Recurrence After Early-Stage or Early Invasive Breast Cancer
When a patient develops a local failure after BCT for early invasive cancer or ductal carcinoma in situ (DCIS), it is generally in the region of the initial primary tumor. The risk of ipsilateral breast tumor recurrence (IBTR) after conservative treatment in patients with early invasive cancer ranges from 0.5% to 2% per year, with long-term local failure rates that plateau at 15% to 20%. Local failure rates after wide excision alone for DCIS vary from 10% to 63%, as compared with rates between 7% and 21% after wide excision plus radiation therapy. Most patients whose disease recurs after conservative treatment for DCIS can be treated with salvage mastectomy. In one study, 14% of patients who developed local recurrence had synchronous distant metastatic disease.
The optimal treatment of a local or regional recurrence after mastectomy has yet to be defined. Locoregional recurrences are associated with initial nodal status and primary tumor size. Appropriate treatment may result in long-term control of locoregional disease. In many instances, these patients develop simultaneous distant metastasis, or distant disease develops some time after the locoregional recurrence manifests itself.
A retrospective study (Meyers MO et al Ann Surg Oncol 2011) investigated the impact of subtypes on locoregional recurrence (LRR) after neoadjuvant chemotherapy for locally advanced breast cancer. The impact of subtypes on LRR after neoadjuvant chemotherapy for locally advanced breast cancer is unknown. A total of 149 patients with stage II and III breast cancer with known estrogen receptor (ER), progesterone(Drug information on progesterone) receptor (PR), and human epidermal growth factor receptor 2 (HER2,HER2/neu) status who underwent neoadjuvant chemotherapy from 1991 to 2005 were analyzed. Clinical assays to distinguish luminal A (ER/PR+, HER2−, n = 55), luminal B (ER/PR+, HER2+, n = 25), HER2 (ER/PR−, HER2+, n = 20), and basal-like (ER/PR/HER2−, n = 49) subtypes were performed. With a median follow-up of 55 months, 49 (33%) patients had BCT with radiation, 82 (55%) had a mastectomy with radiation, and 18 (12%) had a mastectomy alone. A total of 88 (59%) were clinically node positive. A pCR was seen in 39 (26%) patients. LRR was identified in 11 (7%) patients: 2 after BCT (4%) and 9 after mastectomy (9%). LRR rates by subtype are as follows: luminal A, 2 of 55 (4%); luminal B, 1 of 25 (4%); HER2, 1 of 20 (5%); and basal-like, 7 of 49 (14%). Compared with all other subtypes, basal-like patients were more likely to have a LRR (7/49 (14%) vs 4/100 (4%), P = .03).
After wide excision and breast irradiation. Some studies with limited follow-up have reported acceptable results with repeated wide local excision for IBTR following conservative surgery and radiation therapy. Selection criteria for this approach are unclear, however, and use of this salvage procedure remains controversial. Although the use of limited-field reirradiation has been reported, selection criteria for this management option and long-term follow-up data are lacking. The Radiation Therapy Oncology Group is currently investigating re-irradiation with accelerated partial breast irradiation (APBI) in patients with a recurrence after whole breast irradiation and breast-conserving surgery.
After wide excision alone. In patients initially treated with wide local excision alone who sustain an IBTR, small series with limited follow-up suggest that wide local excision followed by radiation therapy to the intact breast at the time of local recurrence may be a reasonable treatment alternative. In this situation, standard radiation doses would be employed.
Recurrent disease in the chest wall after mastectomy or breast-conserving surgery
When possible, disease recurring in the chest wall or axillary nodes should be resected and radiation therapy should be considered to aid in local control. Patients should be also evaluated for possible treatment with adjuvant chemotherapy.
Radiation treatment techniques are generally similar to those employed for patients treated with standard postmastectomy irradiation and consist of photon- and/or electron-beam arrangements directed at the chest wall and adjacent lymph node regions. Treatment planning should strive for homogeneous dose distributions to the target areas while minimizing the dose to the underlying cardiac and pulmonary structures.
Radiation dose and protocol. Conventional fractionation of 180 to 200 cGy/d to the area of locoregional recurrence and immediately adjacent areas at risk, to a total dose of 4,500 to 5,000 cGy, is indicated. A boost to the area of recurrence or gross residual disease, to a dose of approximately 6,000 cGy, results in acceptable long-term locoregional control.
Radical chest wall resection. A select group of patients with local chest wall recurrence secondary to breast cancer may be candidates for a radical chest wall resection, which may include resection of skin, soft tissue, and bone. Flap coverage or prosthetic chest wall reconstruction is required. Appropriate candidates would include patients who do not have distant metastases and who have persistent or recurrent chest wall disease after chest wall irradiation and those who present with a chest wall recurrence after a long disease-free interval.
Ipsilateral breast tumor recurrence. The data suggest that women whose tumors recur in the ipsilateral breast within the first few years following the original diagnosis may be considered for adjuvant systemic therapy. Given the lack of prospective, randomized data, specific treatment recommendations for these women remain highly individualized.
Regional nodal recurrence and postmastectomy recurrence in the chest wall. Although there are limited data addressing the use of adjuvant systemic therapy at the time of locoregional relapse following mastectomy, given the high rate of systemic metastasis in this population, these patients may be considered for adjuvant systemic therapy. A randomized trial demonstrated a disease-free survival benefit with the use of adjuvant tamoxifen(Drug information on tamoxifen) following radiation therapy at the time of postmastectomy recurrence in the chest wall in patients with ER-positive tumors. The 5-year disease-free survival was increased from 36% to 59%, and the median disease-free survival was prolonged by > 4.5 years.
Patients with ER-negative tumors and aggressive locoregional recurrences may also be considered for systemic cytotoxic chemotherapy, given their relatively poor prognosis and the high rate of metastasis.