Reviews
Locally recurrent breast cancer after conservation therapy

https://doi.org/10.1016/j.amjsurg.2004.07.039Get rights and content

Abstract

Background

Today, the majority of small invasive and noninvasive breast cancers are treated with breast conservation therapy (BCT). The incidence of local-regional recurrence (LRR) after BCT for stage 0, I, and II patients ranges between 5% and 22%.

Methods

A literature search for BCT, local recurrence, and regional recurrence was performed. Data from over 50 articles pertaining to the characteristics, risk factors, detection, management, and prognosis of these patients with LRR after BCT were collected and analyzed.

Results

Positive margins, high-grade ductal carcinoma in situ (DCIS), young age, and the absence of radiation therapy after BCT increase the risk for LRR. Prognosis at LRR is impacted by invasive versus noninvasive histology, size and stage, method of detection, and involvement of skin and/or axillary lymph nodes. The standard treatment is salvage mastectomy.

Conclusions

The prognosis for LRR after BCT is favorable compared with patients with postmastectomy chest wall recurrence.

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

References (61)

  • J.P. Julien et al.

    Radiotherapy in breast conserving treatment for ductal carcinoma in situFirst results of the EORTC randomised phase III trial 10853

    Lancet

    (2000)
  • M.J. Silverstein et al.

    Duct carcinoma in situ227 cases without microinvasion

    Eur J Cancer

    (1992)
  • A. Recht et al.

    Prognosis following local or regional recurrence after conservative surgery and radiotherapy for early stage breast carcinoma

    Int J Radiat Oncol Biol Phys

    (1989)
  • E.R. Port et al.

    Reoperative sentinel lymph node biopsyA new option for patients with primary or locally recurrent breast carcinoma

    J Am Coll Surg

    (2002)
  • L.A. Newman et al.

    Presentation, management and outcome of axillary recurrence from breast cancer

    Am J Surg

    (2000)
  • J. Kurtz et al.

    The prognostic significance of late local recurrence after breast-conserving therapy

    Int J Radiat Oncol Biol Phys

    (1990)
  • B. Fisher et al.

    Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer

    N Engl J Med

    (1989)
  • M.C. Christian et al.

    The national cancer institute audit of the national surgical adjuvant breast and bowel project protocol B-06

    N Engl J Med

    (1995)
  • B. Fisher et al.

    Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer

    N Engl J Med

    (1995)
  • B. Fisher et al.

    Five year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer

    N Engl J Med

    (1996)
  • Fisher et al.

    Fifteen year prognostic discriminants for invasive breast carcinoma

    Cancer

    (2001)
  • E.R. Fisher et al.

    Pathologic findings from the National Surgical Adjuvant Breast Project protocol B-06

    Cancer

    (1993)
  • U. Veronesi et al.

    Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast

    N Engl J Med

    (1981)
  • B. Fisher et al.

    Lumpectomy and radiation therapy for the treatment of intraductal breast cancerFindings from national surgical adjuvant breast and bowel project B-17

    JCO

    (1998)
  • B. Fisher et al.

    Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer

    N Engl J Med

    (1993)
  • E.R. Fisher et al.

    Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) protocol B-17

    Cancer

    (1995)
  • J.M. Kurtz et al.

    Local recurrence after breast-conserving surgery and radiotherapy

    Cancer

    (1989)
  • M.P. Osborne et al.

    Salvage surgery for recurrences after breast conservation

    World J Surg

    (1994)
  • M.J. Kennedy et al.

    Management of locally recurrent breast cancer

    Cancer

    (1993)
  • C.C. Cajucom et al.

    Results of salvage mastectomy for local recurrence after breast-conserving surgery without radiation therapy

    Cancer

    (1993)
  • Cited by (0)

    View full text