Long-term results of local recurrence after breast conservation treatment for invasive breast cancer

Prognostic Factors and Surgery for Breast Cancer Patients With Locoregional Recurrence: An Analysis of 5,202 Consecutive Patients

Purpose

With the application of “less extensive surgery” in breast cancer treatment, the pattern of locoregional recurrence (LRR) has significantly changed. This study aims to evaluate the risk and prognostic factors of LRR in a recent large breast cancer cohort.

Methods

Consecutive early breast cancer patients who received surgery from January 2009 to March 2018 in Shanghai Ruijin Hospital were retrospectively analyzed. LRR was defined as recurrence at the ipsilateral breast (IBTR), chest wall, or regional lymph nodes and without concurrent distant metastasis (DM). Patients’ characteristics and survival were compared among these groups.

Results

Among 5,202 patients included, 87 (1.7%) and 265 (5.1%) experienced LRR and DM as first event after a median 47.0 (3.0–122.5) months’ follow-up. LRR was significantly associated with large tumor size and positive lymph node status (p < 0.05). Forty (46.0%) patients received further salvage surgery after LRR and had a significantly better 3-year post-recurrence overall survival than those who did not (94.7% vs. 60.7%, p = 0.012). Multivariate analysis showed that salvage surgery for LRR was independently associated with better survival (HR = 0.12, 95% CI 0.02–0.93, p = 0.043) along with estrogen receptor (ER) positivity (HR = 0.33, 95% CI 0.12–0.91, p = 0.033).

Conclusion

LRR rate was relatively low in recent era of breast cancer treatment. Tumor size and lymph node status were associated with risk of LRR, and salvage surgery for selected LRR patients achieved an excellent outcome.

Proton reirradiation for recurrent or new primary breast cancer in the setting of prior breast irradiation

BACKGROUND AND PURPOSE

Late local recurrences and second primary breast cancers are increasingly common. Proton beam therapy (PBT) reirradiation (reRT) may allow safer delivery of a second definitive radiotherapy (RT) course. We analyzed outcomes of patients with recurrent or new primary breast cancer who underwent reRT.

MATERIALS AND METHODS

In an IRB-approved retrospective study, patient/tumor characteristics, treatment parameters, outcomes, and toxicities were collected for all consecutive patients with recurrent or new primary non-metastatic breast cancer previously treated with breast or chest wall RT who underwent PBT reRT.

RESULTS

Forty-six patients received reRT using uniform (70%) or pencil beam (30%) scanning PBT. Median first RT, reRT, and cumulative doses were 60 Gy (range 45-66 Gy), 50.4 Gy(RBE) (40-66.6 Gy(RBE)), and 110 Gy(RBE) (96.6-169.4 Gy(RBE)), respectively. Median follow-up was 21 months. There were no local or regional recurrences; 17% developed distant recurrence. Two-year DMFS and OS were 92.0% and 93.6%, respectively. Nine of 13 (69.2%) patients who underwent implant or flap reconstruction developed capsular contracture, 3 (23.1%) requiring surgical intervention. One (7.7%) patient developed grade 3 breast pain requiring mastectomy after breast conserving surgery. No acute or late grade 4-5 toxicities were seen. Increased body mass index (BMI) was protective of grade ≥ 2 acute toxicity (OR = 0.84, 95%CI = 0.70-1.00).

CONCLUSION

In the largest series to date of PBT reRT for breast cancer recurrence or new primary after prior definitive breast or chest wall RT, excellent locoregional control and few high-grade toxicities were encountered. PBT reRT may provide a relatively safe and highly effective salvage option. Additional patients and follow-up are needed to correlate composite normal tissue doses with toxicities and assess long-term outcomes.

Surgical Management of Locoregional Recurrence in Breast Cancer

Locoregional recurrences from breast cancer represent a heterogeneous group of disease that poses a therapeutic challenge and needs a multidisciplinary team management. The incidence of local recurrence after breast conservation surgery ranges from 10 to 22% and 5-15% after mastectomy at 10-year follow-up. Management of locoregional recurrence depends on tumor biology, stage at presentation, and prior local and systemic therapy. With improvements in diagnostic, pathological, and surgical techniques, radiation and systemic therapy approach, outcomes in these patients have improved. In this review, we discuss the risk factors, prognostic factors, surgical and reconstruction options, re-irradiation, and role of systemic therapy to define a reasonable treatment approach without compromising oncologic safety and achieve good cosmetic and survival outcomes.

Impact of preoperative breast MRI on 10-year survival of patients included in the Swedish randomized multicentre POMB trial

Background

The value of preoperative breast MRI as an adjunct technique regarding its effect on re-excision rates has been a subject of discussion. No survival data regarding preoperative breast MRI are available from randomized studies.

Methods

Ten-year follow-up of the POMB randomized multicentre study was analysed, evaluating MRI and its effect on disease-free survival (DFS) and overall survival (OS). Patients with newly diagnosed breast cancer were randomized to either preoperative MRI or conventional imaging. Kaplan–Meier plots were used to analyse DFS and OS, and Cox regression to estimate hazard ratios (HRs).

Results

A total of 440 patients, aged 56 years or less, with newly diagnosed breast cancer were randomized to either preoperative MRI (220) or conventional imaging (220; control). Median follow-up for each group was 10 years. DFS rates were 85.5 and 80.0 per cent for the MRI and control groups respectively (P = 0.099). The risk of relapse or death was 46 per cent higher in the control group (HR 1.46, 95 per cent c.i. 0.93 to 2.29). OS rates after 10 years were 90.9 and 88.6 per cent in the MRI and control groups respectively (P = 0.427). The risk of death was 27 per cent higher in the control group (HR 1.27, 0.71 to 2.29). Locoregional, distant, and contralateral recurrence outcomes combined were increased in the control group (P = 0.048). A subgroup analysis of patients with breast cancer stages I–III showed that preoperative MRI improved DFS compared with conventional imaging, but this did not reach statistical significance (P = 0.057).

Conclusion

After 10 years of follow-up, preoperative breast MRI as an adjunct to conventional imaging resulted in slightly, but non-significantly, improved DFS and OS. Registration number: NCT01859936 (http://www.clinicaltrials.gov).

Breast conserving surgery versus salvage mastectomy for ipsilateral breast cancer recurrence: a propensity score matching analysis

Salvage mastectomy is regarded as the treatment of first choice for ipsilateral breast cancer recurrence (IBCR), even if a second breast conserving surgery (BCS) is feasible. The purpose of this study was to compare the long-term oncological outcomes of IBCR patients who had undergone either mastectomy or second BCS, performing a propensity score matching (PSM) analysis to reduce the selection bias. All the consecutive patients with IBCR were retrospectively reviewed and divided into two different groups of treatment: repeat BCS versus salvage mastectomy. The propensity score predicting the probability of surgical treatment was determined for each patient and a 1:1 matching was performed. Disease-free survival (DFS), distant disease-free survival (DDFS), overall survival (OS), and breast cancer-specific survival (BCSS) were analyzed and compared between the two groups. A total of 309 patients underwent surgical treatment for IBCR. After PSM, 108 patients treated with repeat BCS and 108 patients treated with salvage mastectomy were included in the analysis. There was no significant difference in terms of DFS between patients with IBCR receiving repeat BCS or salvage mastectomy (p = 0.167). However, patients with IBCR undergoing second BCS had significantly better DDFS, OS, and BCSS compared to salvage mastectomy (p < 0.001). Salvage mastectomy should not be considered the optimal treatment for IBCR and it does not seem to improve prognosis compared to repeat conserving surgery. Second BCS for IBCR is a safe option with encouraging long-term oncological outcomes and should be proposed to all patients, when technically feasible.

Cellular dormancy in minimal residual disease following targeted therapy

BACKGROUND

Breast cancer mortality is principally due to tumor recurrence, which can occur following extended periods of clinical remission that may last decades. While clinical latency has been postulated to reflect the ability of residual tumor cells to persist in a dormant state, this hypothesis remains unproven since little is known about the biology of these cells. Consequently, defining the properties of residual tumor cells is an essential goal with important clinical implications for preventing recurrence and improving cancer outcomes.

METHODS

To identify conserved features of residual tumor cells, we modeled minimal residual disease using inducible transgenic mouse models for HER2/neu and Wnt1-driven tumorigenesis that recapitulate cardinal features of human breast cancer progression, as well as human breast cancer cell xenografts subjected to targeted therapy. Fluorescence-activated cell sorting was used to isolate tumor cells from primary tumors, residual lesions following oncogene blockade, and recurrent tumors to analyze gene expression signatures and evaluate tumor-initiating cell properties.

RESULTS

We demonstrate that residual tumor cells surviving oncogenic pathway inhibition at both local and distant sites exist in a state of cellular dormancy, despite adequate vascularization and the absence of adaptive immunity, and retain the ability to re-enter the cell cycle and give rise to recurrent tumors after extended latency periods. Compared to primary or recurrent tumor cells, dormant residual tumor cells possess unique features that are conserved across mouse models for human breast cancer driven by different oncogenes, and express a gene signature that is strongly associated with recurrence-free survival in breast cancer patients and similar to that of tumor cells in which dormancy is induced by the microenvironment. Although residual tumor cells in both the HER2/neu and Wnt1 models are enriched for phenotypic features associated with tumor-initiating cells, limiting dilution experiments revealed that residual tumor cells are not enriched for cells capable of giving rise to primary tumors, but are enriched for cells capable of giving rise to recurrent tumors, suggesting that tumor-initiating populations underlying primary tumorigenesis may be distinct from those that give rise to recurrence following therapy.

CONCLUSIONS

Residual cancer cells surviving targeted therapy reside in a well-vascularized, desmoplastic microenvironment at both local and distant sites. These cells exist in a state of cellular dormancy that bears little resemblance to primary or recurrent tumor cells, but shares similarities with cells in which dormancy is induced by microenvironmental cues. Our observations suggest that dormancy may be a conserved response to targeted therapy independent of the oncogenic pathway inhibited or properties of the primary tumor, that the mechanisms underlying dormancy at local and distant sites may be related, and that the dormant state represents a potential therapeutic target for preventing cancer recurrence.

Long-term survival outcomes of repeat lumpectomy for ipsilateral breast tumor recurrence: a propensity score-matched analysis

PURPOSE

This study aimed to compare long-term survival outcomes of repeat lumpectomy with total mastectomy after ipsilateral breast tumor recurrence (IBTR) using propensity score matching (PSM).

METHODS

We retrospectively analyzed patients with IBTR who had undergone initial breast-conserving surgery for breast cancer at our institution between January 1990 and December 2013. The Kaplan-Meier method and Cox proportional hazards model were used to compare survival rates between the two groups. PSM was performed using the following covariates: age at initial operation, initial T stage, N stage, hormone receptor status, human epidermal growth factor receptor 2 status, chemotherapy, radiotherapy, and IBTR tumor size.

RESULTS

We enrolled 335 IBTR patients with a median follow-up of 126.6 months. No significant differences were observed in the 5-year overall survival (OS), breast cancer-specific survival (BCSS), OS after IBTR, and BCSS after IBTR and 10-year survival probability between the two groups in a multivariate analysis. After PSM, patients who had undergone repeat lumpectomy and total mastectomy (n = 90 in both groups) were included. No significant differences were observed in the 10-year OS (hazard ratio [HR] 1.08, 95% confidence interval [CI] 0.49-2.39), BCSS (HR 0.83, 95% CI 0.35-1.95), OS after IBTR (HR 0.83, 95% CI 0.38-1.83), and BCSS after IBTR (HR 0.64, 95% CI 0.28-1.47) between the two groups.

CONCLUSIONS

No significant differences were observed in survival outcomes between patients with IBTR who underwent repeat lumpectomy or total mastectomy. Our results can be helpful in selecting the appropriate surgical method for IBTR.

Prognostic study for isolated local recurrence operated with salvage excision in hormone-receptor-positive patients with invasive breast cancer after primary breast surgery

BACKGROUND

This study aimed to identify the factors that predict distant recurrence and survival outcome after patients with primary positive hormone receptor-positive (HR+) invasive breast cancer undergo complete excision for isolated local recurrence (ILR).

METHODS

From January 2000 to December 2009, we performed a retrospective review of our database and identified 51 patients with HR + invasive breast cancer who underwent complete excision for ILR as a component of salvage therapy. The distant metastasis-free survival (DMFS) and overall survival (OS) from the time of ILR were calculated using the Kaplan-Meier method, and a Cox regression model was used for multivariate analysis.

RESULTS

Of the 51 cases of ILR, 28 were of ipsilateral breast tumor recurrence and 23 were of chest wall recurrence. By receiver operating characteristic curve analyses, the cut-off time point for time to ILR was determined to be 29 months. According to time to ILR (≤29 vs. >29 months) and primary tumor size (≤2 vs. >2 cm), patients were divided into four risk groups as variables for analysis. On multivariate analysis, two independent prognostic factors for DMFS and OS after ILR were identified: risk groups (ILR≤29 months with primary tumor size >2 cm vs. ILR>29 months with primary tumor size ≤ 2 cm, HR = 8.53 for DMFS and HR = 11.18 for OS) and primary tumor grade (2/3 vs. 1, HR = 6.10 for DMFS and 4.27 for OS).

CONCLUSION

We demonstrated that poor DMFS and OS are associated with high risk group defined as short time to ILR (≤29 months) with primary tumor size (>2 cm) and higher primary tumor grade (2/3) among patients with HR + invasive breast cancer treated with complete excision for ILR. Therapeutic strategies for ILR based on hormone therapy with new agents should be explored in future prospective studies, especially for patients with poor outcome.

Effectiveness of Breast-Conserving Surgery and 3-Dimensional Conformal Partial Breast Reirradiation for Recurrence of Breast Cancer in the Ipsilateral Breast: The NRG Oncology/RTOG 1014 Phase 2 Clinical Trial

Importance

Mastectomy is standard for recurrence of breast cancer after breast conservation therapy with whole breast irradiation. The emergence of partial breast irradiation led to consideration of its application for reirradiation after a second lumpectomy for treatment of recurrence of breast cancer in the ipsilateral breast.

Objectives

To assess the effectiveness and adverse effects of partial breast reirradiation after a second lumpectomy and whether the treatment is an acceptable alternative to mastectomy.

Design, Setting, and Participants

The NRG Oncology/Radiation Therapy Oncology Group 1014 trial is a phase 2, single-arm, prospective clinical trial of 3-dimensional, conformal, external beam partial breast reirradiation after a second lumpectomy for recurrence of breast cancer in the ipsilateral breast after previous whole breast irradiation. The study opened on June 4, 2010, and closed June 18, 2013. Median follow-up was 5.5 years. This analysis used all data received at NRG Oncology through November 18, 2018. Eligible patients experienced a recurrence of breast tumor that was less than 3 cm and unifocal in the ipsilateral breast more than 1 year after breast-conserving therapy with whole breast irradiation and who had undergone excision with negative margins.

Interventions

Adjuvant partial breast reirradiation, 1.5 Gy twice daily for 30 treatments during 15 days (45 Gy), using a 3-dimensional conformal technique.

Main Outcomes and Measures

The main outcomes of the present study were the predefined secondary study objectives of recurrence of breast cancer in the ipsilateral breast, late adverse events (>1 year after treatment), mastectomy incidence, distant metastasis-free survival, overall survival, and circulating tumor cell incidence.

Results

A total of 65 women were enrolled, with 58 evaluable for analysis (mean [SD] age, 65.12 [9.95] years; 48 [83%] white). Of the recurrences of breast cancer in the ipsilateral breast, 23 (40%) were noninvasive and 35 (60%) were invasive. In all 58 patients, 53 (91%) had tumors 2 cm or smaller. All tumors were clinically node negative. A total of 44 patients (76%) tested positive for estrogen receptor, 33 (57%) for progesterone receptor, and 10 (17%) for ERBB2 (formerly HER2 or HER2/neu) overexpression. Four patients had breast cancer recurrence, with a 5-year cumulative incidence of 5% (95% CI, 1%-13%). Seven patients underwent ipsilateral mastectomies for a 5-year cumulative incidence of 10% (95% CI, 4%-20%). Both distant metastasis-free survival and overall survival rates were 95% (95% CI, 85%-98%). Four patients (7%) had grade 3 and none had grade 4 or higher late treatment adverse events.

Conclusions and Relevance

For patients experiencing recurrence of breast cancer in the ipsilateral breast after lumpectomy and whole breast irradiation, a second breast conservation was achievable in 90%, with a low risk of re-recurrence of cancer in the ipsilateral breast using adjuvant partial breast reirradiation. This finding suggests that this treatment approach is an effective alternative to mastectomy.

Proton beam therapy reirradiation for breast cancer: Multi-institutional prospective PCG registry analysis

To investigate adverse events (AEs, CTCAE v4.0) and clinical outcomes for proton beam therapy (PBT) reirradiation (reRT) for breast cancer. From 2011 to 2016, 50 patients received PBT reRT for breast cancer in the prospective Proton Collaborative Group (PCG) registry. Acute AEs occurred within 180 days from start of reRT. Late AEs began or persisted beyond 180 days. Fisher's exact and Mann-Whitney rank-sum tests were utilized. Kaplan-Meier methods were used to estimate overall survival (OS) and local recurrence-free survival (LFRS). Median follow-up was 12.7 months (0-41.8). Median prior RT dose was 60 Gy (10-96.7). Median reRT dose was 55.1 Gy (45.1-76.3). Median cumulative dose was 110.6 Gy (70.6-156.8). Median interval between RT courses was 103.8 months (5.5-430.8). ReRT included regional nodes in 84% (66% internal mammary node [IMN]). Surgery included the following: 44% mastectomy, 22% wide local excision, 6% lumpectomy, 2% reduction mammoplasty, and 26% no surgery. Grade 3 AEs were experienced by 16% of patients (10% acute, 8% late) and were associated with body mass index (BMI) > 30 kg/m² (P = 0.04), bilateral recurrence (P = 0.02), and bilateral reRT (P = 0.004). All grade 3 AEs occurred in patients receiving IMN reRT (P = 0.08). At 1 year, LRFS was 93%, and OS was 97%. Patients with gross disease at time of PBT trended toward worse 1-year LRFS (100% without vs. 84% with, P = 0.06). PBT reRT is well tolerated with favorable local control. BMI > 30, bilateral disease, and IMN reRT were associated with grade 3 AEs. Toxicity was acceptable despite median cumulative dose > 110 Gy.

Second breast-conserving therapy with interstitial brachytherapy (APBI) as a salvage treatment in ipsilateral breast tumor recurrence: a retrospective study of 40 patients

Purpose

Breast-conserving treatment (BCT) have emerged as an alternative to mastectomy in patients with ipsilateral breast tumor recurrence (IBTR). We evaluated survival outcomes and treatment-related toxicity in a series of 40 patients with IBTR, who underwent tumorectomy plus interstitial brachytherapy (APBI) as a salvage treatment.

Material and methods

Retrospective analysis included 40 patients diagnosed with IBTR and treated with intraoperative (26 patients) or post-operative (14 patients) multicatheter brachytherapy for APBI at our institution between June 2002 and October 2017. We assessed cosmesis, toxicity, overall survival (OS), and cancer-specific survival (CSS).

Results

Tumorectomy was performed in all cases, including intraoperative tumor margin assessment and sentinel node biopsy. Median age was 65 years (range, 41-92). The total prescribed dose was 32 Gy (8 fractions) in 19 patients and 34 Gy (10 fractions) in 20 patients. One elderly patient (age 92) received a single fraction of 16 Gy. Median follow-up was 61.5 months (range, 6-153). A median of 14 tubes were inserted. Mean treated V₁₀₀ was 115 cc. Two patients developed a second relapse at 3 and 5 years after salvage treatment: one patient underwent salvage mastectomy and remains alive 10 years after brachytherapy, and the second one developed both local relapse and bone metastasis. The disease is stable at present. Five-year OS and CSS rates were 85.3% and 97.5%, respectively. Two patients died from cancer-related causes. Acute and late toxicity rates were low; seven patients developed acute infectious mastitis. Late fibrosis > grade 3 and late mastitis were observed in 14 and 6 cases, respectively.

Conclusions

Second BCT with APBI as a salvage treatment in ipsilateral breast recurrence achieves good local disease control, with a satisfactory toxicity profile compared to mastectomy. This approach seems to be safe and effective, although more data from randomized trials are needed.

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.

Évaluation d’un second traitement chirurgical conservateur pour récidive locale d’un cancer du sein

Objectif : Évaluation d’un deuxième traitement conservateur (T) [n = 41] par rapport à une mastectomie totale (M) [n = 93]. Étude rétrospective unicentrique de 134 patientes ayant présenté une récidive mammaire homolatérale isolée et opérable.

Résultats : La survie globale à cinq ans est de 82,5 % dans les deux groupes. Pas de différence significative pour la survie spécifique et la survie sans métastase dans les deux groupes. Le contrôle local à cinq ans est de 92,9 % dans le groupe Met de 66,2 % dans le groupe T (RR de nouvelle récidive de 4,48). La présence d’emboles, le caractère multifocal et la révélation clinique de la récidive sont des facteurs pronostiques péjoratifs de survie. Sur l’ensemble de la série (n = 134), 25 (18,6 %) ont conservé leur sein.

Conclusion : Pour minimiser le risque de récidive après un second traitement conservateur, on peut envisager cette chirurgie si la récidive est isolée, de petite taille, de bas grade, sans embole, et strictement unifocale. L’acte chirurgical doit assurer des marges saines et un résultat esthétique satisfaisant. La patiente participe au choix du traitement.

Management of In-Breast Tumor Recurrence

The management of isolated in-breast tumor recurrence is complex, requiring careful consideration of prior local therapies to plan future multimodality treatment. Options for surgical management have evolved from standard salvage mastectomy with axillary clearance and now include repeat breast conservation with axillary staging in select patients. Reattempting sentinel lymph node biopsy may avoid the morbidity of extensive axillary surgery and has been shown to be feasible in clinically node-negative patients with oncologically safe outcomes. In the adjuvant setting, partial breast irradiation has emerged as a valuable means to improve local control rates with limited associated toxicity and acceptable overall cosmesis. Furthermore, results from prospective trials are now available to support the use of chemotherapy in hormone-receptor negative subgroups, which is associated with improvements in long-term, disease-free, and overall survival.

Screening women with a personal history of breast cancer: overview of the evidence on breast imaging surveillance

This work reviews the evidence on breast imaging for screening (surveillance) in women with a history of breast cancer (BC). Early detection of second BCs in these women improves their prognosis based on studies using mammography (usually with clinical examinations) for surveillance. Cohort studies have estimated that mammography surveillance has moderate sensitivity (65.4%) and good specificity (98.3%), and have shown that these women are at a higher risk of interval BC than age- and breast density-matched women without a history of BC. Studies of adjunct imaging (ultrasound, magnetic resonance imaging) for surveillance that have reported detection and accuracy measures have generally shown that adjunct imaging detected more second BCs than mammography and added substantially to the amount of false-positive results; however, little evidence exists regarding screening efficacy of adjunct imaging as part of routine surveillance.

Preoperative breast MRI and mortality in older women with breast cancer

PURPOSE

The survival benefit from detecting additional breast cancers by preoperative magnetic resonance imaging (MRI) continues to be controversial.

METHODS

We followed a cohort of 4454 women diagnosed with non-metastatic breast cancer (stage I-III) from 2/2005-6/2010 in five registries of the breast cancer surveillance consortium (BCSC). BCSC clinical and registry data were linked to Medicare claims and enrollment data. We estimated the cumulative probability of breast cancer-specific and all-cause mortality. We tested the association of preoperative MRI with all-cause mortality using a Cox proportional hazards model.

RESULTS

917 (20.6%) women underwent preoperative MRI. No significant difference in the cumulative probability of breast cancer-specific mortality was found. We observed no significant difference in the hazard of all-cause mortality during the follow-up period after adjusting for sociodemographic and clinical factors among women with MRI (HR 0.90; 95% CI 0.72-1.12) compared to those without MRI.

CONCLUSION

Our findings of no breast cancer-specific or all-cause mortality benefit supplement prior results that indicate a lack of improvement in surgical outcomes associated with use of preoperative MRI. In combination with other reports, the results of this analysis highlight the importance of exploring the benefit of preoperative MRI in patient-reported outcomes such as women's decision quality and confidence levels with decisions involving treatment choices.

Shifting breast cancer surveillance from current hospital setting to a community based setting: a cost-effectiveness study

BACKGROUND

This study explores the effectiveness and cost-effectiveness of surveillance after breast cancer treatment provided in a hospital-setting versus surveillance embedded in the community-based National Breast Cancer Screening Program (NBCSP).

METHODS

Using a decision tree, strategies were compared on effectiveness and costs from a healthcare perspective over a 5-year time horizon. Women aged 50-75 without distant metastases that underwent breast conserving surgery in 2003-2006 were selected from the Netherlands Cancer Registry (n = 14,093). Key input parameters were mammography sensitivity and specificity, risk of loco regional recurrence (LRR), and direct healthcare costs. Primary outcome measure was the proportion true test results (TTR), expressed as the positive and negative predictive value (PPV, NPV). The incremental cost-effectiveness ratio (ICER) is defined as incremental costs per TTR forgone.

RESULTS

For the NBCSP-strategy, 13,534 TTR (8 positive; 13,526 negative), and 12,923 TTR (387 positive; 12,536 negative) were found for low and high risks respectively. For the hospital-based strategy, 26,663 TTR (13 positive; 26,650 negative) and 24,883 TTR (440 positive; 24,443 negative) were found for low and high risks respectively. For low risks, the PPV and NPV for the NBCSP-based strategy were 3.31% and 99.88%, and 2.74% and 99.95% for the hospital strategy respectively. For high risks, the PPV and NPV for the NBCSP-based strategy were 64.10% and 98.87%, and 50.98% and 99.71% for the hospital-based strategy respectively. Total expected costs of the NBCSP-based strategy were lower than for the hospital-based strategy (low risk: €1,271,666 NBCSP vs €2,698,302 hospital; high risk: €6,939,813 NBCSP vs €7,450,150 hospital), rendering ICERs that indicate cost savings of €109 (95%CI €95-€127) (low risk) and €43 (95%CI €39-€56) (high risk) per TTR forgone.

CONCLUSION

Despite expected cost-savings of over 50% in the NBCSP-based strategy, it is nearly 50% lower accurate than the hospital-based strategy, compromising the goal of early detection of LRR to an extent that is unlikely to be acceptable.

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.

NRG Oncology-Radiation Therapy Oncology Group Study 1014: 1-Year Toxicity Report From a Phase 2 Study of Repeat Breast-Preserving Surgery and 3-Dimensional Conformal Partial-Breast Reirradiation for In-Breast Recurrence

PURPOSE

To determine the associated toxicity, tolerance, and safety of partial-breast reirradiation.

METHODS AND MATERIALS

Eligibility criteria included in-breast recurrence occurring >1 year after whole-breast irradiation, <3 cm, unifocal, and resected with negative margins. Partial-breast reirradiation was targeted to the surgical cavity plus 1.5 cm; a prescription dose of 45 Gy in 1.5 Gy twice daily for 30 treatments was used. The primary objective was to evaluate the rate of grade ≥3 treatment-related skin, fibrosis, and/or breast pain adverse events (AEs), occurring ≤1 year from re-treatment completion. A rate of ≥13% for these AEs in a cohort of 55 patients was determined to be unacceptable (86% power, 1-sided α = 0.07).

RESULTS

Between 2010 and 2013, 65 patients were accrued, and the first 55 eligible and with 1 year follow-up were analyzed. Median age was 68 years. Twenty-two patients had ductal carcinoma in situ, and 33 had invasive disease: 19 ≤1 cm, 13 >1 to ≤2 cm, and 1 >2 cm. All patients were clinically node negative. Systemic therapy was delivered in 51%. All treatment plans underwent quality review for contouring accuracy and dosimetric compliance. All treatment plans scored acceptable for tumor volume contouring and tumor volume dose-volume analysis. Only 4 (7%) scored unacceptable for organs at risk contouring and organs at risk dose-volume analysis. Treatment-related skin, fibrosis, and/or breast pain AEs were recorded as grade 1 in 64% and grade 2 in 7%, with only 1 (<2%) grade ≥3 and identified as grade 3 fibrosis of deep connective tissue.

CONCLUSION

Partial-breast reirradiation with 3-dimensional conformal radiation therapy after second lumpectomy for patients experiencing in-breast failures after whole-breast irradiation is safe and feasible, with acceptable treatment quality achieved. Skin, fibrosis, and breast pain toxicity was acceptable, and grade 3 toxicity was rare.

Can Locoregionally Recurrent Breast Cancer Be Cured?

Locoregional recurrence (LRR) of breast cancer can occur after multidisciplinary treatment of a primary breast cancer. With modern multidisciplinary breast cancer treatment, the incidence of isolated LRR is decreasing. Improvements in systemic therapy are driving the decrease in LRR. LRR does still occur, however. LRR reflects biology of the cancer, as does systemic recurrence. LRR of breast cancer is frequently associated with systemic disease recurrence and poor prognosis. Given this associated poor prognosis, historically, it has been unclear whether patients with LRR would benefit from aggressive therapy with curative intent. Findings in retrospective studies suggest that prognosis for patients with LRR is not universally poor, and some patients may benefit from aggressive locoregional and systemic therapy. The challenge remains to assess prognosis and appropriately treat patients with locoregional breast cancer recurrence.

Local recurrence risk after previous salvage mastectomy

INTRODUCTION

Breast-conserving surgery is a standard treatment for early breast cancer. For ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery, salvage mastectomy is the current standard surgical procedure. However, it is not rare for patients with IBTR who have received salvage mastectomy to develop local recurrence. In this study, we examined the risk factors of local recurrence after salvage mastectomy for IBTR.

PATIENTS AND METHODS

A total of 118 consecutive patients who had histologically confirmed IBTR without distant metastases and underwent salvage mastectomy without irradiation for IBTR between 1989 and 2008 were included from eight institutions in Japan. The risk factors of local recurrence were assessed.

RESULTS

The median follow-up period from salvage mastectomy for IBTR was 4.6 years. Patients with pN2 or higher on diagnosis of the primary tumor showed significantly poorer local recurrence-free survival than those with pN0 or pN1 at primary tumor (p < 0.001). Multivariate analysis showed that the lymph node status of the primary tumor was a significantly independent predictive factor of local recurrence-free survival (p = 0.02).

CONCLUSION

The lymph node status of the primary tumor might be a predictive factor of local recurrence-free survival after salvage mastectomy for IBTR. Further research and validation studies are needed. (UMIN-CTR number UMIN000008136).

Survival after locoregional recurrence or second primary breast cancer: impact of the disease-free interval

The association between the disease-free interval (DFI) and survival after a locoregional recurrence (LRR) or second primary (SP) breast cancer remains uncertain. The objective of this study is to clarify this association to obtain more information on expected prognosis. Women first diagnosed with early breast cancer between 2003–2006 were selected from the Netherlands Cancer Registry. LRRs and SP tumours within five years of first diagnosis were examined. The five-year period was subsequently divided into three equal intervals. Prognostic significance of the DFI on survival after a LRR or SP tumour was determined using Kaplan-Meier estimates and multivariable Cox regression analysis. Follow-up was complete until January 1, 2014. A total of 37,278 women was included in the analysis. LRRs or SP tumours were diagnosed in 890 (2,4%) and 897 (2,4%) respectively. Longer DFI was strongly and independently related to an improved survival after a LRR (long versus short: HR 0.65, 95% CI 0.48–0.88; medium versus short HR 0.81, 95% CI 0.65–1.01). Other factors related to improved survival after LRR were younger age (<70 years) and surgical removal of the recurrence. No significant association was found between DFI and survival after SP tumours. This is the first study to explore the association between the DFI and survival after recurrence in a nationwide population-based cancer registry. The DFI before a LRR is an independent prognostic factor for survival, with a longer DFI predicting better prognosis.

Partial breast re-irradiation for local recurrence of breast carcinoma: Benefit and long term side effects

INTRODUCTION AND AIMS

To evaluate the outcome after partial breast re-irradiation for in-breast tumor recurrence (IBTR) following second breast conserving surgery (BCS) as alternative to salvage mastectomy.

METHODS AND RESULTS

A survey of the literature was performed including publications between 2002 and 2012 (PubMed). Strategies comprised partial breast radiotherapy by external beam radiotherapy (EBRT), interstitial brachytherapy (BT) in low-, high- and pulse-dose rate technique, combined EBRT/BT, and intraoperative radiotherapy (IORT). Published evidence is scarce, with altogether ten articles identified, in sum reporting about 310 patients. The vast majority (82%) was treated by brachytherapy. Selection criteria for a second breast conservation attempt were comparable within all reports: all women presented with T0-2 recurrent lesions, late onset after primary treatment (70 months, mean of means) and no evidence of metastatic disease before undergoing gross tumor resection with free surgical margins. Treatment doses were in a similar range for brachytherapy (LDR 30-55 Gy, HDR 30-34 Gy; PDR 40-50 Gy), biologically comparable to the only series exclusively using EBRT (50 Gy). Follow-up times amounted 49 months (mean of the means, range 21-89). Oncologic results were similar among the different methods with local control rates ranging between 76% and 100%, and disease free and overall survival rates comparable to mastectomy series. Acute toxicity was low in all cohorts. All authors reported cosmetic outcome, scoring results from excellent to good in 60-80% of patients, mostly without using standardized evaluation schemes. Major late effects were fibrosis in re-irradiated parenchyma as a function of dose and volume, asymmetry (primarily due to double surgery), and breast pain. There were hardly any G3 and no G4 late reactions noted.

DISCUSSION AND CONCLUSION

In a highly selected group of patients with IBTR, partial breast irradiation after second BCS is a viable alternative to mastectomy, yielding high breast preservation rates without compromising oncologic safety. Whereas the evidence for brachytherapy is more solid, there is still little information about the effectiveness of PBI via EBRT or novel strategies like IORT, which therefore should preferably be investigated within trials.

Regional lymphatic recurrence after salvage surgery for ipsilateral breast tumor recurrence of breast cancer without local treatment for regional lymphatic basin

BACKGROUND

There is limited information regarding rates of and risk factors for regional lymphatic recurrence (RLR) after salvage surgery for ipsilateral breast tumor recurrence (IBTR) without local treatment for the regional lymphatic basin.

METHODS

One hundred two patients, who underwent salvage breast surgery without local treatment for the regional lymphatic basin (surgery or radiotherapy) for IBTR that relapsed after breast-conserving surgery for primary breast cancer, were reviewed retrospectively to examine the rate of and risk factors for RLR.

RESULTS

Of the 102 patients, 9 patients (8.8%) had RLR with a median follow-up period of 3.7 years after salvage breast surgery for IBTR. The estrogen receptor (ER) status and lymphovascular invasion of the recurrent breast tumor were both independent predictive factors of RLR (P = 0.04 and 0.02, respectively).

CONCLUSIONS

The rate of RLR was not low in patients with IBTR who received salvage breast surgery only without any treatment for the regional lymphatic basin. The ER status and lymphovascular invasion of the recurrent breast tumor were predictive factors of RLR.

Clinical outcome of isolated locoregional recurrence in patients with breast cancer according to their primary local treatment

INTRODUCTION

This study assessed the clinical outcome and prognostic factors in patients with breast cancer who presented with isolated locoregional recurrence (ILRR) as a first event.

MATERIALS AND METHODS

Between 1970 and 2008, 2960 patients with pT1-2, N0-3, M0 primary invasive breast cancer had either breast-conserving therapy (BCT) using lumpectomy and radiation therapy (RT) (group A = 1849 patients) or mastectomy without RT (group B = 1111 patients). Out of groups A and B, 117 and 103 patients, respectively, developed ILRR as a first event. Those 220 patients served as the basis for this study. A multivariate analysis was performed to estimate the clinical outcome of both groups, taking into account clinically relevant variables for the primary tumor and ILRR.

RESULTS

The median follow-up after ILRR was 83 months. The median disease-free interval (DFI) was 79 and 38 months for groups A and B, respectively. The overall survival (OS) for group A was 81% and 69% at 5 and 8 years, respectively. For group B, it was 61% and 46%, respectively. The distant metastasis-free survival (DMFS) for group A was 84% at 5 years and remained 84% at 8 years. The DMFS for group B was 60% at 5 years and 52% at 8 years. In multivariate analysis, initial local treatment (BCT vs. mastectomy without RT), pathologic T stage, locoregional recurrence site (local vs. regional), and DFI (≤ 4 years vs. > 4 years) were significant prognostic variables for both OS and DMFS.

CONCLUSION

Patients with breast cancer who developed ILRR after BCT as their initial local treatment have better clinical outcome compared with those who had mastectomy without RT.

Outcomes and predictive factors for salvage therapy after local--regional recurrence following neoadjuvant chemotherapy and breast conserving therapy

BACKGROUND

There are few data addressing local-regional recurrence (LRR) and salvage therapies in patients treated with neoadjuvant chemotherapy (NCT) compared to those treated with surgery first. We characterize the clinical course and predictive features of salvage treatment for LRR after breast conserving therapy (BCT) analyzed by initial treatment.

METHODS

We identified 1,589 patients who underwent BCT; 1,141 (72 %) patients underwent initial surgery, and 448 (28 %) received NCT. Kaplan-Meier and Cox regression analyses were performed to analyze factors associated with overall survival (OS), local control (LC) of recurrence, and distant metastasis-free survival (DMFS) following LRR.

RESULTS

56 patients had a LRR, for a crude recurrence rate of 3 %. For patients with potentially curable recurrence (excluding distant metastases within 3 months of LRR), the 5-year OS, LC, and DMFS rates were 52, 77, and 69 %. On multivariate analysis, initial pathologically negative node status and use of surgery for salvage were significant factors associated with higher OS. Additionally, older age was associated with higher LC rates after salvage. Estrogen receptor-positive disease and surgery for LRR were associated with reduced risk of distant metastases; regional recurrence and use of initial adjuvant chemotherapy were associated with increased risk of distant metastases. For each of these endpoints, the addition of NCT to the multivariate model did not approach significance.

CONCLUSIONS

LRR is an uncommon event after BCT and many patients with LRR remain curable (5-year OS >50 %). Our data indicate that NCT does not compromise salvage after LRR, providing further assurance that this strategy is safe for appropriately selected breast cancer patients.

Local treatment options for ipsilateral breast tumour recurrence

PURPOSE

In case of ipsilateral breast tumour recurrence (IBTR), radical mastectomy represents the treatment option frequently proposed. A second conservative treatment (2ndCT) has been proposed using either lumpectomy alone or associated with a re-irradiation of the tumor bed. However, in both clinical situations, the proof level of such therapeutic approaches remains low, based on cased-series or retrospective studies (level C).

MATERIAL AND METHODS

In order to assess the different strategies of local treatment proposed in case of IBTR, a PubMed literature review was performed using the following keywords: breast cancer, ipsilateral recurrence, mastectomy, radiation therapy, brachytherapy. Four different salvage options were analyzed: (a) salvage mastectomy alone; (b) salvage mastectomy with postoperative re-irradiation; (c) 2ndCT with surgery alone; (d) 2ndCT with re-irradiation.

RESULTS

The rate of second local recurrence is about 10% [3-32%], about 25% [7-36%] and about 10% [2-26%], after salvage mastectomy, salvage lumpectomy alone or combined with a re-irradiation of the tumor bed respectively. However, the 5-year overall survival rates after salvage mastectomy and 2ndCT seem to be equivalent (≈75%) mainly influenced by distant metastatic progression.

CONCLUSION

In terms of Evidence Based Medicine, different options can be discussed such as Phase III or II randomized trials comparing salvage mastectomy versus 2ndCT, retrospective studies based on a matched-pair analysis or observatory studies. Those study designs need to be carefully analyzed to be able to propose new treatment options for women who experience an IBCR.

[Does molecular biology play any role in ductal carcinoma in situ?]

The natural history of ductal carcinoma in situ (DCIS) is not fully elucidated, but it is recognized that DCIS is the true precursor of invasive carcinoma. Studies could show that DCIS is as heterogeneous as invasive ductal carcinoma, yet, they were unable to predict which DCIS will progress to invasion. Several biomarkers were also demonstrated to have a certain prognostic value. However, except for estrogen receptors and HER2, biomarkers are not yet widely used in clinical practice since their predictive value has not proven to be better than the grade and the classical classifying systems of DCIS. Identifying biomarkers for risk of invasiveness in DCIS could be of great value to help high risk patients through the management of their disease and to avoid overtreatment in low risk patients.

Benefit of semiannual ipsilateral mammographic surveillance following breast conservation therapy

PURPOSE

To compare cancer recurrence outcomes on the basis of compliant semiannual versus noncompliant annual ipsilateral mammographic surveillance following breast conservation therapy (BCT).

MATERIALS AND METHODS

A HIPAA-compliant retrospective review was performed of post-BCT examinations from 1997 through 2008 by using a deidentified database. The Committee on Human Research did not require institutional review board approval for this study, which was considered quality assurance. Groups were classified according to compliance with institutional post-BCT protocol, which recommends semiannual mammographic examinations of the ipsilateral breast for 5 years. A compliant semiannual examination was defined as an examination with an interval of 0-9 months, although no examination had intervals less than 3 months. A noncompliant annual examination was defined as an examination with an interval of 9-18 months. Cancer recurrence outcomes were compared on the basis of the last examination interval leading to diagnosis.

RESULTS

Initially, a total of 10 750 post-BCT examinations among 2329 asymptomatic patients were identified. Excluding initial mammographic follow-up, there were 8234 examinations. Of these, 7169 examinations were semiannual with 94 recurrences detected and 1065 examinations were annual with 15 recurrences detected. There were no differences in demographic risk factors or biopsy rates. Recurrences identified at semiannual intervals were significantly less advanced than those identified at annual intervals (stage I vs stage II, P = .04; stage 0 + stage I vs stage II, P = .03). Nonsignificant findings associated with semiannual versus annual intervals included smaller tumor size (mean, 11.7 vs 15.3 mm; P = .15) and node negativity (98% vs 91%, P = .28).

CONCLUSION

Results suggest that a semiannual interval is preferable for ipsilateral mammographic surveillance, allowing detection of a significantly higher proportion of cancer recurrences at an earlier stage than noncompliant annual surveillance.

Prospective study of factors predicting adherence to surveillance mammography in women treated for breast cancer

PURPOSE

This prospective study examined the factors that predicted sustained adherence to surveillance mammography in women treated for breast cancer.

METHODS

Breast cancer survivors (N = 204) who were undergoing surveillance mammography completed questionnaires assessing mammography-related anticipatory anxiety, persistent breast pain, mammography pain, and catastrophic thoughts about mammography pain. Adherence to mammography in the following year was assessed.

RESULTS

In the year after study entry, 84.8% of women (n = 173) returned for a subsequent mammogram. Unadjusted associations showed that younger age, shorter period of time since surgery, and having upper extremity lymphedema were associated with lower mammography adherence. Forty percent of women reported moderate to high levels of mammography pain (score of ≥ 5 on a 0 to 10 scale). Although mammography pain was not associated with adherence, higher levels of mammography-related anxiety and pain catastrophizing were associated with not returning for a mammogram (P < .05). The impact of anxiety on mammography use was mediated by pain catastrophizing (indirect effect, P < .05).

CONCLUSION

Findings suggest that women who are younger, closer to the time of surgery, or have upper extremity lymphedema may be less likely to undergo repeated mammograms. It may be important for health professionals to remind selected patients directly that some women avoid repeat mammography and to re-emphasize the value of mammography for women with a history of breast cancer. Teaching women behavioral techniques (eg, redirecting attention) or providing medication for reducing anxiety could be considered for women with high levels of anxiety or catastrophic thoughts related to mammography.

Identifying Patients Who May Be Candidates for a Clinical Trial of Salvage Accelerated Partial Breast Irradiation after Previous Whole Breast Irradiation

Background and Objectives. Accelerated partial breast irradiation (APBI) has been proposed as an alternative to salvage mastectomy for patients with ipsilateral breast tumor recurrence (IBTR) after prior breast conservation. We studied factors that are associated with a more favorable local recurrence profile that could make certain patients eligible for APBI. Methods. Between 1980 and 2005, 157 Stage 0–II breast cancer patients had an IBTR treated by mastectomy. Clinical and pathological features were analyzed to identify factors associated with favorable IBTR defined as unifocal DCIS or T1 ≤ 2 cm, without skin involvement, and >2 year interval from initial treatment. Results. Median followup was 140 months and time to recurrence was 73 months. Clinical stage distribution at recurrence was DCIS in 32 pts (20%), T1 in 90 pts (57%), T2 in 14 pts (9%), T3 in 4 pts (3%), and T4 in 9 pts (6%). IBTR was classified as favorable in 71%. Clinical stage of IBTR predicted for pathologic stage –95% of patients with clinical T1 IBTR had pathologic T1 disease at salvage mastectomy (P < 0.0001). Conclusions. Clinical stage at presentation strongly correlated with pathologic stage at mastectomy. More than 70% of recurrences were favorable and may be appropriate candidates for salvage APBI trials.

Expression of thioredoxin system and related peroxiredoxin proteins is associated with clinical outcome in radiotherapy treated early stage breast cancer

BACKGROUND AND PURPOSE

Deregulated redox systems provide cancer cells protection from increased oxidative stress, such as that induced by ionizing radiation. Expression of the thioredoxin system proteins (thioredoxin, thioredoxin reductase and thioredoxin interacting protein) and downstream peroxiredoxins (I-VI), was examined in tumor specimens from early stage breast cancer patients, subsequently treated by breast conserving surgery and locoregional radiotherapy, to determine if redox protein expression is associated with clinical outcome.

MATERIAL AND METHODS

Nuclear and cytoplasmic expression was assessed using conventional immunohistochemistry on a tissue microarray of 224 tumors.

RESULTS

High expression of cytoplasmic peroxiredoxin-I correlated with a greater risk of local recurrence (p=0.009). When nuclear and cytoplasmic expression patterns were combined, patients with low nuclear but high cytoplasmic expression of peroxiredoxin-I increased significance (p=0.005). Both were independent factors (p=0.006 and 0.003) from multivariate analysis. Associations were obtained between tumor grade and nuclear thioredoxin interacting protein (p=0.01) and with cytoplasmic expression of peroxiredoxin-V (p=0.007) but not with peroxiredoxin-I suggesting that the latter may exert influence via regulation of oxidative stress rather than via altering the tumor phenotype.

CONCLUSIONS

Results highlight the potential of using redox protein expression, namely peroxiredoxin-I, to predict clinical outcome and support further studies to validate its usefulness as an independent prognostic, and potentially predictive, marker.

The impact of local and regional recurrence on distant metastasis and survival in patients treated with breast conservation therapy

Purpose

We evaluated the effect of local recurrence (LR) and regional recurrence (RR) on distant metastasis and survival in patients treated with breast conservation therapy (BCT).

Methods

We analyzed 907 patients who were treated for invasive breast cancer between 1993 and 2006. With 53 months of follow-up, 28 patients (3.1%) developed LR in the breast and 12 patients (1.3%) developed RR before distant metastasis. LR and RR were separated into four patterns to determine the prognostic relevance of recurrence site and time to recurrence: LR within 3 years (early LR), LR after 3 years (late LR), RR within 3 years (early RR), and RR after 3 years (late RR).

Results

Early LR (hazard ratio [HR], 4.76; p=0.003) and early RR (HR, 18.16; p<0.001) were independent predictors of distant metastasis. In terms of overall survival, early LR (HR, 5.24; p=0.002), and early RR (HR, 18.80; p<0.001) were significantly related with poor survival. Patients with late LR/RR had a similar favorable prognosis compared with patients who never experienced LR/RR.

Conclusion

The result suggests that time to LR/RR following BCT is a significant predictor developing a distant metastasis and surviving.

Outcome after Mastectomy for Ipsilateral Breast Tumor Recurrence after Breast Conserving Surgery

Ipsilateral breast tumor recurrence (IBTR) is a risk after breast conserving surgery, and is traditionally treated with mastectomy. Given the limited literature on outcome after mastectomy for IBTR, we evaluated our long-term data for this group. A retrospective review was conducted using a database of 2101 breast cancer patients at a single institution. Fifty-nine patients underwent breast conserving surgery and experienced an IBTR. Exclusion criteria included repeat lumpectomy or metastatic disease before mastectomy. Patients presented with invasive ductal (58%), invasive lobular (7%), other invasive (11%), or ductal carcinoma in situ (24%). Initial tumors were Tis (24%), T1 (42%), T2 (20%), T3 (2%), or not recorded (12%). IBTR lesions were Tis (20%), T1 (46%), T2 (25%), or T3 (9%). Median follow-up after mastectomy was 4.6 years. Thirteen patients (22%) had post-mastectomy recurrence (PMR), which decreased overall survival ( P = 0.002). PMR was more common with larger IBTR tumors ( P = 0.03), specifically IBTR ≥ T2 ( P = 0.003). Eighty-five per cent of PMR occurred within 2 years of mastectomy. Mastectomy for IBTR remains effective treatment for most patients, but the risk of PMR remains. Patients with IBTR tumors >2 cm have an increased risk of PMR. Strict follow-up should be routine, especially during the first 24 months.

Mammographic surveillance in women with a personal history of breast cancer: how accurate? How effective?

We review the accuracy and potential effect of mammography in surveillance of women with a personal history of breast cancer (PHBC). A literature review was performed to identify studies on screening mammography or breast surveillance reporting data on the accuracy or detection capability of mammography, or the effect of early detection of second breast cancers, in women with a PHBC. Evidence on mammography screening in women with PHBC comes from non-randomised studies, and is generally limited by several factors including design limitations. The proportion of ipsilateral breast recurrences detected with mammography ranges between 50% and 80% (including cancers detected also on clinical examination) but is lower at 8%-51% for mammography-only detection. Mammography detects approximately 45%-90% of contralateral cancers. There is evidence of a potential benefit for asymptomatic/early-detected second breast cancers (range of estimated hazard ratios: 0.10-0.86) relative to symptomatic or clinical-detection, in various surveillance strategies that include mammography, however these estimates are likely to have overestimated screening benefit. New evaluations of screening women with a PHBC are needed from screening programs or population datasets, to provide comprehensive measures of screening accuracy and outcomes in this population of women.

Management of locoregional recurrence of breast cancer

The locoregional recurrence of breast cancer is not a sign of distant metastases, and a substantial proportion of cases are cured by salvage therapy. Patients with locoregional recurrence should not be treated with palliative intent as if they have visceral metastases. The recommended treatment for ipsilateral breast recurrence after breast conservative therapy is a mastectomy. For patients who suffer from isolated chest wall recurrence after mastectomy, a surgical approach is recommended. Neoadjuvant chemotherapy is considered for patients with unresectable disease in order to render the disease resectable. For patients with isolated chest wall recurrence who have received no prior radiotherapy, postoperative radiotherapy involving the chest wall and regional lymph nodes is recommended. Patients with isolated axillary lymph node recurrence should be treated with axillary dissection or resection. Although the effectiveness of systemic therapy for patients with locoregional recurrence is unclear, there is a trend toward treating patients with supraclavicular lymph node recurrence with radiotherapy plus systemic therapy. Pain relief and the eradication of other distressing symptoms resulting from inoperable disease are achieved in two-thirds to three-quarters of patients by radiotherapy with or without systemic therapy. New anti-cancer agents and molecular target therapies should be evaluated with the objective of improving the treatment outcome of patients with locoregional recurrence. A combination of approaches is required for treatment of patients with locoregional recurrence, and a multidisciplinary tumor board should be organized at each institute.

Ipsilateral breast tumor recurrence: is there any evidence for benefit of further systemic therapy?

To date, there are no standard guidelines for treating patients with ipsilateral breast tumor recurrence (IBTR). Current practice is to resect the recurrence with a radical intent followed possibly by radiotherapy if the patient has not received this before, but the role of further adjuvant medical (hormone or chemotherapy) therapy remains undefined. Currently Phase III trials are underway to answer this question. In this review, we will focus on published data relating to IBTR and discuss recent trials. The results from the Phase III trials will not be available for sometime. At the time of IBTR, it is reasonable to change the endocrine therapy with indirect evidence from sequencing of impact on outcome. There is currently no conclusive evidence to suggest that further adjuvant chemotherapy post loco-regional recurrence impacts on survival, though the use of noncross-resistant chemotherapy drugs may make sense in those at highest risk. Biopsy at IBTR is helpful to distinguish whether it is a true recurrence or a new primary tumor and receptor phenotyping may be helpful for HER2. Future trials in IBTR need to address the following issues: to be able to distinguish between true recurrence and new primary (consensus required on definitions); pathologic processing relating to margins needs to be standardized (1 or 5 mm wide specimens); documentation of the pattern of IBTR in relation to each histopathologic subtype and methods used for pathologic examination by centers. Regional nodal recurrence including supraclavicular node recurrence is not dealt with in this review.