Salvage surgery for recurrence after breast conservation

Second breast-conserving surgery and interstitial brachytherapy vs. salvage mastectomy for the treatment of local recurrences: 5-year results

PURPOSE

The purpose of this study was to report the clinical outcomes of a second breast-conserving therapy (2nd BCT) with perioperative interstitial brachytherapy (iBT) vs. those of salvage mastectomy (sMT) in the treatment of ipsilateral breast tumor recurrences (IBTRs).

METHODS AND MATERIALS

Between 1999 and 2015, 195 patients with IBTR after a previous breast-conserving treatment were salvaged either with reexcision and perioperative high-dose-rate iBT (n = 39), or with sMT (n = 156). In the 2nd BCT group, a total dose of 22 Gy in five fractions of 4.4 Gy was delivered to the tumor bed with intraoperatively implanted catheters for 3 consecutive days.

RESULTS

The median followup time was 59 months (1-189) in the 2nd BCT, and 56 months (3-189) in the sMT group. The mean size of IBTR was 16 mm (2-70) vs. 24 mm (2-90), respectively (p = 0.0005), but there were no other significant differences in patient- or IBTR-related parameters between the two groups. During the followup period, 4 of 39 (10.2%) and 28 of 156 (17.9%) second local recurrences (2nd LR) occurred in the 2nd BCT and the sMT group, respectively. The 5-year actuarial rate of 2nd LR was 6% vs. 18% (p = 0.22), the 5-year probability of disease-free, cancer-specific and overall survival was 69% vs. 65% (p = 0.13), 85% vs. 78% (p = 0.32), and 81% vs. 66% (p = 0.15), respectively. In the 2nd BCT group, the rate of good to excellent cosmesis was 70%.

CONCLUSIONS

2nd BCT with perioperative high-dose-rate iBT is a safe and feasible option for the management of IBTR, resulting in similar 5-year oncological outcomes and better cosmetic results compared with sMT.

Reirradiation for locally recurrent breast cancer

The aim of this study is to review the current status of reirradiation therapy (Re-RT) for locally recurrent breast cancer. The overall outcome of breast/chest wall Re-RT is difficult to assess because of the wide range of different treatments that a patient may have undergone and the patient's individual features. The local control and complete response rates were reported to be 43-96% and 41-71%, respectively. The combination of Re-RT and hyperthermia seems to be related to improved outcomes. Toxicity rates vary between studies, and Re-RT is generally well tolerated. Re-RT may be considered an option for patients with breast cancer relapse after prior irradiation. Further studies are needed to determine the best irradiation volume and treatment modality for patients with locally recurrent disease.

Imaging of breast cancer-related changes after nonsurgical therapy

OBJECTIVE

The purpose of this article is to review both expected and unexpected thoracic CT manifestations of nonsurgical breast cancer treatment with multimodality imaging correlation. Specific topics include the spectrum of posttherapy changes attributed to chemotherapy and radiation therapy and the spread of breast cancer.

CONCLUSION

Thoracic CT is an important tool commonly used for breast cancer staging and surveillance and for diagnostic indications such as shortness of breath and chest pain. Imaging findings can be related to progression of disease or to associated conditions, such as pulmonary embolism. The hallmarks of breast cancer spread in the thorax include pulmonary nodules, enlarged lymph nodes, pleural effusions, thickening or nodularity, and sclerotic or lytic skeletal lesions. Less common findings including pulmonary lymphangitic tumor spread and pericardial metastasis. The findings also may represent the sequelae of surgery, radiation therapy, or chemotherapy for breast cancer. Knowledge of various treatment methods and their expected and unexpected CT findings is important for recognizing treatment-related abnormalities to avoid confusion with breast cancer spread and thereby minimize the risk that unnecessary further diagnostic imaging will be performed.

Current surgery for breast cancer

Surgeons retain the central role in the multidisciplinary care of the breast cancer patient. While technical details of the operations for these patients remain important, effective evidence-based decision making may be even more so. Advances in the methods of breast cancer diagnosis, localization techniques and surgical therapies, as well as the expanded role of the surgeon in breast cancer prevention, radiation therapy and the treatment of distant disease, requires surgeons to stay up to date with the available evidence. Herein, we present a review of the current surgical therapy of invasive breast cancer.

The feasibility of a second lumpectomy and breast brachytherapy for localized cancer in a breast previously treated with lumpectomy and radiation therapy for breast cancer

PURPOSE

With accumulating evidence supporting partial-breast irradiation, we conducted a Phase I/II study to evaluate the role of a second conservative surgery and brachytherapy for patients presenting with a local recurrence/new primary in a breast who has previously undergone a lumpectomy and external radiation therapy for breast cancer.

METHODS AND MATERIALS

Fifteen patients with a localized lesion in the breast have undergone a second lumpectomy and received low-dose-rate brachytherapy on protocol. The first 6 patients received a dose of 30Gy. With no unacceptable acute toxicity observed, the brachytherapy dose was increased to 45Gy. Three patients received adjuvant chemotherapy and 8 patients are on antiestrogen therapy.

RESULTS

The median time interval between the primary breast cancer diagnosis and the second cancer event in the ipsilateral breast is 94 months (range, 28-211). With a median followup of 36 months after brachytherapy, the 3-year Kaplan-Meier overall survival, local disease-free survival and mastectomy-free survival are 100% and 89%, respectively. There was no Grade 3/4 fibrosis or necrosis observed. All patients had baseline asymmetry due to the breast volume deficit from the second lumpectomy. With breast asymmetry as a given, the cosmetic result observed in all patients has been good to excellent.

CONCLUSIONS

Early results suggest low-complication rates, high rate of local control and freedom from mastectomy. Additional studies are needed to establish whether a second lumpectomy and breast brachytherapy are an acceptable alternative to mastectomy for patients presenting with a localized cancer in a previously irradiated breast.

Lymphatic mapping and sentinel node harvesting in patients with recurrent breast cancer

AIMS

To evaluate the feasibility and consequences of lymphatic mapping and a ("repeat") sentinel lymph node (SLN) procedure in patients with breast cancer relapse after previous breast and axillary surgery.

METHODS

Review and presentation of a patient cohort. All SLN procedures included lymphoscintigraphy and blue dye injection technique.

RESULTS

Twelve cases are described: two patients after a previous SLN procedure and ten after a previous complete axillary lymph node dissection (ALND). Ten patients (83%) had a successful repeat SLN biopsy. After previous ALND, lymphoscintigraphy revealed drainage towards the internal mammary chain in three patients, and contralateral axillary drainage in four. Based on the information from the "repeat" SLN biopsy further treatment strategy was altered in seven of the 12 patients.

CONCLUSION

Lymphatic mapping and (repeat) SLN biopsy is possible and can be informative in patients who present with a relapse of breast cancer after previous surgery for primary breast cancer.

Lymphatic Mapping and Sentinel Lymph Node Biopsy for Patients With Local Recurrence After Breast-Conservation Therapy

BACKGROUND

Local recurrence (LR) after breast-conservation therapy for breast cancer occurs in 10% to 15% of cases. A subset of these represents biologically aggressive disease, yet prognostic features for identifying this high-risk category are lacking. We hypothesized that lymphatic mapping and sentinel lymph node biopsy would provide useful information regarding dominant lymphatic drainage patterns of patients with LR.

METHODS

Breast cancer case records involving surgery for LR at the University of Michigan from 2002 to 2004 were reviewed. The lymphatic drainage patterns were compared with those of 117 patients who underwent mapping for primary breast cancer.

RESULTS

Fourteen LR cases were identified (10 with initial axillary lymph node dissection, 2 with initial sentinel lymph nodes, and 2 with no axillary surgery at the time of primary cancer treatment); lymphatic mapping was performed in 10. The sentinel lymph node identification rate was 90%, the median number of lymph nodes retrieved was 3, and no metastases were detected. Significantly more cases of nonipsilateral axillary sentinel node drainage were observed in mapping procedures performed for LR compared with those for primary breast cancer (67% vs. 15%; P = .001).

CONCLUSIONS

Lymphatic mapping is feasible in patients undergoing mastectomy for LR and is likely to identify aberrantly located sentinel lymph nodes that would otherwise be overlooked with a conventional completion mastectomy.

Inflammatory local recurrence after breast-conservation therapy for noninflammatory breast cancer

Inflammatory local recurrence after breast-conserving therapy for noninflammatory breast cancer is uncommon and carries a poor prognosis. Over a 5-year period, 7 such cases were treated at the New York-Presbyterian Hospital/Weill-Cornell Medical Center. The characteristics of these 7 patients were compiled and are reviewed along with a discussion of inflammatory recurrence. Tumor size, location, histologic type, grade, stage, margin status, lymphovascular invasion (LVI), estrogen receptor (ER) status, progesterone receptor (PgR) status, adjuvant therapy, and/or radiation therapy at the time of primary treatment and at recurrence were analyzed. The median survival time was 79 months (range, 26-130 months) for patients initially ER-positive, compared with 23 months (range, 0-67 months) for initially ER-negative patients. The median survival for patients without lymph node involvement was 78 months (range, 26-130 months) compared with 41 months (range, 0-79 months) for those with nodal metastases. Survival time in this series of inflammatory local recurrences correlated with the ER status and lymph node involvement of the primary lesion. The optimal management for inflammatory local recurrence is a multimodality approach combining preoperative chemotherapy and surgery.

Locally recurrent breast cancer after conservation therapy

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.

New trends in breast conservation therapy

Breast conservation therapy for early-stage invasive breast cancer provides survival equivalent to mastectomy. Careful patient selection and surgical technique are necessary to minimize local recurrence. Extensive studies of breast conservation therapy over the past 15 years have identified risk factors for local recurrence, and have proven that certain cases previously thought to be ineligible for lumpectomy (such as occult breast cancer, locally advanced breast cancer, macromastia, and cancer in pregnant patients), can be safely managed with modified BCT approaches. Recent trends in breast cancer management, such as expanded applications of induction chemotherapy, use of magnetic resonance imaging and ultra sound, and touch-prep cytology for intraoperative margin evaluation, can improve success rates for BCT. New developments with brachytherapy may also improve BCT availability by shortening duration of treatment. Innovations with minimally invasive tumor ablation techniques are investigational at present, but may obviate the need for surgical resections in selected patients in the future. Local recurrences that develop after breast conservation therapy should be managed aggressively, as long-term survival can frequently be achieved.

Treatment choices and response rates in African-American women with breast carcinoma

BACKGROUND

Breast cancer mortality rates are higher among African-American women compared with white American women, yet little is known regarding ethnicity-related variation in patterns of primary surgical treatment, locoregional recurrence rates, and response to induction chemotherapy.

METHODS

The available literature was reviewed to evaluate outcome from breast-conservation therapy in African-American women and response rates to systemic therapy.

RESULTS

Breast-conservation therapy appears to be underused among African-American women, a pattern that is noted also among white women with breast carcinoma. Higher rates of locoregional recurrence are seen among African-American women regardless of whether they receive breast-conserving treatment or undergo mastectomy, and this appears to be a function of primary tumor biology. Response rates to appropriately delivered systemic therapy are similar for African-American patients and white patients.

CONCLUSIONS

Despite the apparent increased aggressiveness of disease seen in African-American women with breast carcinoma, patterns of response to local and systemic therapy are similar to the patterns seen in white women with breast carcinoma.

Prognosis after treatment for loco-regional recurrence after mastectomy or breast conserving therapy in two randomised trials (EORTC 10801 and DBCG-82TM). EORTC Breast Cancer Cooperative Group and the Danish Breast Cancer Cooperative Group

The aim of this study was to investigate and compare the prognosis after treatment for loco-regional recurrences (LR) after (modified) radical mastectomy (MRM) or breast conserving therapy (BCT), in terms of overall survival and time to subsequent LR, in patients originally treated in two European randomised trials. In EORTC trial 10801 and DBCG trial 82-TM, 1,807 patients with stage I and II breast cancer were randomised to receive MRM or BCT from 1980 to 1989. All patients with a LR in these trials were analysed for survival and time to subsequent LR after salvage treatment. Of these, 133 patients had their LR as a first event, the majority within 5 years after initial treatment. The prognostic significance for survival and time to subsequent LR after salvage treatment was analysed in uni-, and multivariate analyses for a number of original tumour- and recurrence-related variables. After salvage treatment of LR after MRM or BCT, actuarial survival curves and the actuarial locoregional control curves were similar. The 5-year survival rates were 58% and 59% and the 5-year subsequent loco-regional control rates 62% and 63%, respectively. In a multivariate analysis, pN category (P = 0.03), pT category (P = 0.01) and vascular invasion (P = 0.02) of the primary tumour were the only independent prognostic factors for survival, whereas extensive LR (P < 0.001), interval < or = 2 years (P < 0.002) and pN+ at primary treatment (P = 0.004) were significant predictive factors for time to subsequent LR. The type of original treatment (MRM or BCT) did not have any prognostic impact. It is concluded that the survival and time to subsequent LR after treatment for an early loco-regional recurrence after MRM or BCT was similar in these two European randomised trials. This suggests that both after MRM and BCT an early LR is an indicator of a biologically aggressive tumour; early loco-regional relapse carries a poor prognosis and salvage treatment only cures a limited number of patients, whether treated by MRM or BCT originally.

Presentation, treatment, and outcome of local recurrence afterskin-sparing mastectomy and immediate breast reconstruction

BACKGROUND

The local recurrence (LR) rate with skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) has been reported as comparable to the LR rate after conventional mastectomy. However, limited data are available on the prognostic significance and management of LR following SSM.

METHODS

A prospective database maintained at the University of Texas M. D. Anderson Cancer Center identified 437 SSMs performed for 372 invasive T1/T2 breast cancers between 1986 and 1993.

RESULTS

Twenty-three LRs were identified, with a LR rate of 6.2% (23/372). Twenty-two of these (96%) presented as palpable skin-flap masses. The median time to recurrence was 25 months (range, 3 to 98 months). Fourteen patients were treated with a combination of surgery and systemic therapy. Resection of the reconstructed breast was performed in only three patients. Complete local control of the recurrent disease was achieved in 17 patients (74%). Nine patients (39%) developed distant metastatic disease. At a median follow-up of 26 months, 14 of 23 patients (61%) are alive without evidence of disease, and 7 (30%) have died from breast cancer.

CONCLUSIONS

Because LR rate with SSM is low and likelihood of local control and survival is high, SSM and IBR is an acceptable treatment option for early stage breast cancer.

[Influence of locoregional irradiation on local control and survival in breast cancer]

Locoregional control is a crucial step in the achievement of breast cancer cure. In ductal carcinoma in situ, breast irradiation significantly reduces the rates of local recurrence whatever the histological subtypes, as demonstrated by the NSABP-B17 trial (25.8% of local recurrences without radiotherapy vs. 11.4% with radiotherapy). In infiltrating breast carcinomas, complementary breast irradiation has been shown to significantly improve the local control and slightly the overall survival in five randomized trials. Following mastectomy, locoregional irradiation clearly reduces the chest wall and nodal relapse rates, especially in case of lesions more than 5 cm or with nodal involvement and/or large lymphatic or vascular emboli. Two recent randomized trials confirmed the benefit of well-adapted locoregional irradiation in all subgroups, especially in patients with one to three axillary involved nodes. In the Danish trial (including premenopausal high-risk women), radiotherapy reduced locoregional relapses from 32 to 9% (p < 0.001) and increased the 10-year survival rate from 45 to 54% (p < 0.001). In the Canadian trial, locoregional relapse rate decreased from 25 to 13% and the 10-year survival rate increased from 56 to 65%. The meta-analysis published in 1995 by the EBCTCG showed only a modest benefit due to locoregional irradiation in breast cancer. However, when small or old trials were excluded due to imperfect methodology or inadequate irradiation techniques, the benefit of modern radiotherapy became much more evident in a population of 7,840 patients. Locoregional irradiation appears to be able to reduce the risk of metastatic evolution occurring after local or nodal relapse and must be integrated in a multidisciplinary strategy. Treatment toxicity (especially toxicity due to irradiation of internal mammary nodes) is of special concern, as anthracycline-based chemotherapy is prescribed more often. The use of a direct field, with at least 60% of the dose delivered by electrons alternating with photons is recommended to protect the heart and lungs.