Among patients who experience failure within the treated breast after breast-conservation therapy, mastectomy is the standard of care. When there has been a considerable disease-free interval between the treatment of the primary tumor and the recurrent breast tumor and, assuming systemic disease has been ruled out, chest-wall radiation may be considered. When there are high-risk features (pectoralis/skin invasion/positive margin), postmastectomy chest-wall radiation can be utilized following previous irradiation of the intact breast.

This is a very unusual circumstance in our experience. The cumulative dose to the bone and soft tissue of the chest wall will be approximately 100 Gy. Again, cosmesis in this situation would be anticipated to be very poor, with dense fibrosis, atrophic skin changes and osteonecrosis being common.

Patients who have undergone mastectomy and who never received chest-wall radiation are candidates for comprehensive chest-wall radiation if they experience a local-regional failure. In this situation, a full extent-of-disease workup is performed and other prognostic factors, such as the interval between the initial mastectomy and chest-wall recurrence and the number and size of recurrent lesions, are considered.

Commonly, such patients will receive systemic chemotherapy and, thereafter, local-regional radiation is indicated.

For such patients, local-regional failure may be a repetitive problem if not dealt with thoroughly at the outset. Simple excision of a chest-wall recurrence in a patient who has never had chest-wall radiation is not adequate treatment. The likelihood that subclinical disease remains within the chest wall or peripheral lymphatic system is extremely high and can usually be effectively controlled with moderate doses of radiation.

Among patients who manifest local-regional failure solely at the supraclavicular fossa, we offer neoadjuvant chemotherapy to effect tumor shrinkage in this area, and if a suitable response has been obtained, comprehensive chest-wall radiation is utilized. Although these patients are believed to have systemic disease, a small percentage are candidates for curative management and, particularly in cases involving a long disease-free interval, a radical approach to therapy should not be excluded.

Karen D. Schupak
American College of Physicians

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