ReviewsLocally recurrent breast cancer after conservation therapy
Section snippets
Characteristics of local-regional recurrences
Although all LRR after BCT generally are grouped together, it is important to appreciate that there are several different types of recurrences that may reflect both cause and patient prognosis. The types of LRR are categorized by location of the breast recurrence in comparison with the primary treated breast carcinoma.
The most common type of LRR, present in 57% to 88% of patients [11], [12], [13], [14], [15], appears at the site of the primary breast cancer and probably represents incomplete
Margin status
One of the most important predictors of increased risk for LRR is pathologic margin status after BCT. Margin status typically is described as negative, close, or positive. Controversy exists in the literature regarding the meaning of a close surgical margin, with definitions ranging from less than 1 cm to less than 1 mm. According to the NSABP, a margin is positive only if tumor cells are present at the inked surface. A close margin requires cancer cells to be within 1 mm of the inked margin
Detection of local recurrence
Patients should be screened for the early detection of LRR by breast imaging and clinical examination. LRRs are detected by mammography alone 42% to 75% of the time, by physical examination alone 10% to 33% of the time, by a combination of the physical examination and mammography in 12% to 25% of the time, and by other imaging techniques such as magnetic resonance imaging (MRI) 5% of the time (Fig. 2)[18], [20], [42]. Some data suggest that MRI may be a sensitive and specific test, in addition
Management of local recurrence
Unlike chest wall recurrences after mastectomy, LRR after BCT typically is not associated with distant metastases [11], [34]. Because it would alter overall treatment decisions, it is reasonable to perform an extent of disease work-up with a computerized tomography scan and bone scan at the time of LRR. Between 5% and 12% of patients will be found to have inoperable disease at the time of diagnosis of LRR [11], [53], [54]. The treatment of choice for LRR historically has been salvage
Prognosis with local recurrence
In contrast to chest wall recurrence after mastectomy in which the incidence of simultaneous metastatic disease is between 25% and 50%, LRR after BCT typically is not associated with distant metastases [11], [34]. The overall survival at 5 years for patients with LRR after BCT is between 76% and 92% [13], [20], [55], [56]. The median time to second relapse after LRR is 97 months, and the median survival time is 103 months [55].
The prognosis at LRR is dependent on several factors, including the
Status of axillary lymph nodes
The status of the axillary lymph nodes at the initial BCT as well as at the time of the LRR are important prognostic factors [17], [35], [56], [60]. Patients with negative nodes at the primary BCT have an 8% incidence of distant metastases at the LRR, compared with 36% for those with 1 to 3 positive nodes, and 50% for those with 4 of more positive nodes [60]. The status of the axillary lymph nodes at the time of salvage surgery also has an impact on outcome. Patients with negative axillary
Conclusions
The majority of small invasive and noninvasive breast cancers are treated today by BCT, which includes wide local excision with negative surgical margins and radiation treatment to the breast. Studies have shown the incidence of LRR after BCT for stage 0, I, and II patients to range from 5% to 22%. The factors increasing the risk for LRR are positive margins, the presence of high-grade DCIS, young patient age, and the absence of radiation therapy at the time of the initial BCT.
Patients who are
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