Surgery for Recurrent Disease
Local Recurrence
Local recurrence after BCT may be detected on mammography, physical examination or both. Signs of recurrence are often subtle and difficult to distinguish from effects of surgery and radiation. Any changes that occur, especially changes occurring more than 2 years after the end of radiation therapy, must be considered suspicious.
The overwhelming majority of patients who present clinically with an isolated breast recurrence after BCT have no evidence of systemic disease and are therefore candidates for salvage treatment. Breast recurrence after BCT carries a 5 year systemic disease-free survival of about 50%. Factors influencing the prognosis are the initial node status at BCT and the interval between BCT and recurrence.
Patients who were initially node positive have a significantly worse prognosis after failed BCT than those patients who were node negative. Patients who recur in the breast in less than 24 months also have a significantly worse prognosis than do those with a disease-free interval of greater than 4 years. The standard treatment for isolated operable local recurrence after BCT is salvage mastectomy. If radiation therapy has not been used previously, it may be possible to repeat a wide-local excision with adjuvant radiation therapy. For recurrence after wide excision and radiation therapy, repeat local excision is generally not advisable.
Chest-Wall Recurrence
Chest-wall recurrence after total mastectomy usually presents as a painless lump in the scar or on the chest wall. Diffuse chest-wall recurrence sometimes occurs early after mastectomy for locally advanced disease. Most chest-wall recurrences occur within 5 years of the mastectomy. Up to one-half of patients with chest-wall recurrence have had prior or have simultaneous distant metastatic disease.
Chest-wall recurrence is an ominous finding. Nevertheless, at least 50% of patients will live 5 years disease free; therefore, isolated recurrence should be treated for cure. Node-negative patients with a disease-free interval of more than 2 years have an approximately 60% 5 year survival after curative resection of localized chest-wall recurrence, whereas node-positive patients with a short disease-free interval do very poorly.
Distant Metastatic Disease
Surgery has a negligible role in the management of distant recurrences.
There have been few series looking at the rate of cure with lung or liver resection. In general, such procedures would only be considered in otherwise well patients who have no evidence of other metastatic disease and a long disease-free interval. With solitary lung lesions, the alternative diagnosis of primary lung cancer must be considered.
Surgery is occasionally required for the palliation of recurrences. The most common situation is in the management of bony metastases, where internal fixation of long bones can prevent pathologic fractures, or may be needed in their treatment.
Patrick I. Borgen and Bruce Mann
Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.
References
- Veronesi U, Saccozzi R, Del Vecchio M et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiation therapy in patients with small cancers of the breast. N Engl J Med 1981; 305:6-11.
This is the landmark report of the first randomized prospective trial of breast-conservation therapy. - Fisher B, Bauer M, Margolese R et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985; 312:665-73.
This is the first report of the major North American trial of breast-conservation therapy from the NSABP. - Borgen PI, Heerdt AS, Moore MP et al. Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.
This is a review of all aspects of breast-conservation therapy. - Fisher B, Costantino J, Redmond C et al. Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Engl J Med 1993: 1581-6.
This is the major trial of conservative therapy for DCIS - Adair F, Berg J, Joubert L et al. Long-term follow-up of breast cancer: the 30-year report. Cancer 1974; 33:1145-50.
This is an older report from the days before adjuvant therapy that demonstrates the effectiveness of surgery in node-positive disease. - Fisher B, Redmond C, Fisher E et al. Ten year result of a randomized clinical trial comparing radical mastectomy and total mastectomy with of without irradiation. N Engl J Med 1985; 312:674-81.
This is a very influential trial that showed that less-extensive surgery had similar results to radical mastectomy. - Warmuth MA, Bowen G, Prosnitz LR et al. Complications of axillary lymph node dissection for carcinoma of the breast: a report based on a patient survey. Cancer 1998; 83:1362-8.
This report gives a good idea of the range of complications after axillary dissection.