Introduction
After primary therapy, patients with breast cancer should be followed up for life for at least two reasons: to detect recurrences and to observe the opposite breast for a second primary carcinoma. Local and distant recurrences occur most frequently within the first 2 years. During this period, the patient should be examined every 6 months. Thereafter, examination is done annually. Special attention is paid to the contralateral breast, because 10-20% of patients will develop a new primary breast malignancy. The patient should examine her own breast monthly, and a mammogram should be obtained annually. In some cases, metastases are dormant for long periods and may appear 10-15 years or longer after removal of the primary tumor. Estrogen and progestational agents are rarely used for a patient free of disease after treatment of primary breast cancer, particularly if the tumor was hormone receptor positive. Studies nevertheless have failed to show an adverse effect of hormonal agents in patients who are free of disease. Even pregnancy has not been clearly associated with shortened survival of patients rendered disease free - yet most oncologists are reluctant to advise a young patient with breast cancer that she may become pregnant, and most are less than enthusiastic about prescribing hormone replacement therapy for the postmenopausal breast cancer patient. The use of estrogen replacement therapy may be considered for a woman with a history of breast cancer after discussion of the benefits and risks of such therapy for conditions such as osteoporosis and hot flushes, but is not recommended.

Local Recurrence
The incidence of local recurrence correlates with tumor size, the presence and number of involved axillary nodes, the histologic type of tumor, the presence of skin edema or skin and fascia fixation with the primary tumor, and the type of initial local (breast) therapy. As many as 8% of patients develop local recurrence on the chest wall after total mastectomy and axillary dissection. When the axillary nodes are not involved, the local recurrence rate is less than 5%, but the rate is as high as 25% when they are heavily involved. A similar difference in local recurrence rate was noted between small and large tumors. Factors such as multifocal cancer, in situ tumors, positive resection margins, chemotherapy, and radiotherapy have an effect on local recurrence in patients treated with breast-conserving surgery.

Chest wall recurrences usually appear within the first 2 years but may occur as late as 15 or more years after mastectomy. All suspicious nodules and skin lesions should be biopsied. Local excision or localized radiotherapy may be feasible if an isolated nodule is present. If lesions are multiple or accompanied by evidence of regional involvement in the internal mammary or supraclavicular nodes, the disease is best managed by radiation treatment of the entire chest wall including the parasternal, supraclavicular, and axillary areas and usually by systemic therapy.

Local recurrence after mastectomy usually signals the presence of widespread disease and is an indication for studies to search for evidence of metastases. Most patients with locally recurrent tumor will develop distant metastases within 2 years. When there is no evidence of metastases beyond the chest wall and regional nodes, irradiation for cure or complete local excision should be attempted. Patients with local recurrence may be cured with local resection and radiation. After partial mastectomy, local recurrence may not have as serious a prognostic significance as after mastectomy. However, those patients who do develop a breast recurrence have a worse prognosis than those who do not. It is speculated that the ability of a cancer to recur locally after radiotherapy is a sign of aggressiveness and resistance to therapy. Completion of the mastectomy should be done for local recurrence after partial mastectomy; some of these patients will survive for prolonged periods, especially if the breast recurrence is DCIS or more than 5 years after initial treatment. Systemic chemotherapy or hormonal treatment should be used for women who develop disseminated disease or those in whom local recurrence occurs.

Edema of the Arm
Significant edema of the arm occurs in about 10-30% of patients after axillary dissection with or without mastectomy. It occurs more commonly if radiotherapy has been given or if there was postoperative infection. Partial mastectomy with radiation to the axillary lymph nodes is followed by chronic edema of the arm in 10-20% of patients. Because axillary dissection is more accurate for staging operation than axillary sampling, it is recommended that at least level I and II lymph nodes be removed, in combination with partial mastectomy. Sentinel lymph node dissection offers accurate staging without the removal of level I and II nodes and has a much lower risk of lymphedema for node-negative patients. Judicious use of radiotherapy, with treatment fields carefully planned to spare the axilla as much as possible, can greatly diminish the incidence of edema, which will occur in only 5% of patients if no radiotherapy is given to the axilla after a partial mastectomy and lymph node dissection.

Late or secondary edema of the arm may develop years after treatment, as a result of axillary recurrence or of infection in the hand or arm, with obliteration of lymphatic channels. Infection in the arm or hand on the dissected side should be treated with antibiotics, rest, and elevation. When edema develops, careful examination of the axilla for recurrence should be done. If there is no sign of recurrence, the swollen extremity should be treated with rest and elevation. A mild diuretic may be helpful. If there is no improvement, a compressor pump or manual decompression decreases the swelling, and the patient is then fitted with an elastic glove or sleeve. Most patients are not bothered enough by mild edema to wear an uncomfortable glove or sleeve and will treat themselves with elevation or manual decompression alone. Benzopyrones have been reported to decrease lymphedema but are not approved for this use in the United States. Rarely, edema may be severe enough to interfere with use of the limb.

Breast Reconstruction
Breast reconstruction is usually feasible after standard or modified radical mastectomy. Reconstruction should be discussed with patients prior to mastectomy, because it offers an important psychological focal point for recovery. Reconstruction is not an obstacle to the diagnosis of recurrent cancer. The most common breast reconstruction has been implantation of a silicone gel prosthesis in the subpectoral plane between the pectoralis minor and pectoralis major muscles. Although the FDA has placed a moratorium on the purely cosmetic use of silicone gel implants because of possible leakage of silicone and possible associated autoimmune phenomena, they can be used in the reconstructed patient with appropriate prior consent. Most plastic surgeons currently would place a saline-filled prosthesis rather than a silicone gel implant. Alternatively, autologous tissue can be used for reconstruction.

Autologous tissue flaps are aesthetically superior to implant reconstruction in most patients. They also have the advantage of not feeling like a foreign body to the patient. The most popular autologous technique currently is the trans-rectus abdominis muscle flap (TRAM flap), which is done by rotating the rectus abdominis muscle with attached fat and skin cephalad to make a breast mound. The free TRAM flap is done by completely removing the rectus with overlying fat and skin and using microvascular surgical techniques to reconstruct the vascular supply on the chest wall. A latissimus dorsi flap can be swung from the back but offers less fullness than the TRAM flap and is therefore less acceptable cosmetically. Reconstruction may be performed immediately (at the time of initial mastectomy) or may be delayed until later, usually when the patient has completed adjuvant therapy. When considering reconstructive options, concomitant illnesses should be considered, since the ability of an autologous flap to survive depends on medical comorbidities. In addition, the need for radiotherapy may affect the choice of reconstruction.