End Results of Salvage Therapy After Failure of Breast-Conservation Surgery

Lannin and Haffty provide aninteresting and informative reviewon the management andclinical course of an ipsilateral breasttumor recurrence (IBTR) followinglumpectomy and breast irradiation forprimary breast cancer. They presentan engaging discussion concerningthe distinction of a true recurrencefrom a new primary tumor within theipsilateral breast. Although bothevents are included in the term IBTR,the authors point out that the morefavorable outcome follows treatmentof a new primary as opposed to a truerecurrence. Presumably, the true recurrencewould indicate tumor thathas not been eradicated by surgeryand radiotherapy (with or without systemictherapy), which would be amore aggressive malignancy. Thebetter prognosis for a new primarynotwithstanding, there is still a lackof data to indicate whether treatmentshould be different for these twoentities.Risk Factors
The authors reiterate the knownrisk factors for IBTR after lumpectomyand breast irradiation, includingyoung age, positive or close microscopicmargins, multifocality, extensiveintraductal component, and nohistory of tamoxifen use. However, itis important to realize that whereasthese various patient, tumor, and treatmentfactors increase the risk of anIBTR, the majority of patients withsome or all of these factors will stillbe free of an in-breast tumor recurrence10 years later. Using the recursivepartitioning model described byFreedman et al, who identified subgroupsof patients with different risksfor IBTR, the highest-risk group (witha 34% 10-year risk of IBTR) comprisedonly 10 of 912 patients.[1]Patients with an IBTR are at greaterrisk for distant metastases, and Lanninand Haffty discuss the controversyconcerning whether or not the IBTRis a marker or an instigator of distantmetastases. Regardless, it has beendifficult to show a significant differencein overall or disease-free survivalfor patients treated by breastconservationtherapy vs mastectomy.Therefore, a woman with one or morerisk factors for an IBTR should notnecessarily be denied breast-conservationtherapy.Optimal Treatment
As the authors point out, mastectomyis considered to be the standardtherapy for IBTR. However, therehave been a few reports with smallnumbers of patients in which reexcisionalone, reexcision with high-doseexternal-beam radiotherapy, or reexcisionand brachytherapy have beenused. The local recurrence rate followingmastectomy is likely to belower than that following a repeatlumpectomy, but there is little evidenceto suggest that mastectomy forIBTR vs repeat excision with or withoutradiotherapy provides a statisticallysignificant improvement inoverall survival. That said, there havebeen no randomized clinical trials addressingthis issue.Following mastectomy for anIBTR, radiotherapy should be consideredfor cases in which tumor isfound at the margin of resection, thereis underlying pectoral muscle involvement,or there is skin involvement. I have occasionally administered radiotherapyto the chest wall followingmastectomy for IBTR that developedafter previous lumpectomy and breastirradiation, and have not observed anyserious sequelae. Similarly, radiotherapyshould also be considered for subsequentrecurrence on the chest wallfollowing mastectomy for an IBTR.Cosmetic Results
The cosmetic result following asalvage lumpectomy for IBTR is likelyto be less favorable than after theinitial lumpectomy for the original tumor.Factors influencing the cosmeticresult after a second lumpectomyinclude the appearance of the breastbefore the IBTR, the quadrant inwhich the IBTR is located, size of therecurrent tumor, and amount of breasttissue excised.In my experience, the salvagelumpectomy (as opposed to repeat irradiation)was the main determinantof the cosmetic result.[2] Of 36 evaluablepatients treated with salvagelumpectomy and a repeat course ofradiotherapy (5,000 cGy/25 fractions),the cosmetic result was excellent orvery good in 12 patients. In this sameseries, 15 patients had a good cosmeticresult but with a noticeable asymmetrybetween the two breasts and/ornoticeable pigmentation. Nine patientshad a fair or poor cosmetic result withmarked deformity or marked differencein size between the two breasts,usually with obvious pigmentationchanges.Final Recommendations
In the above series of repeat highdoseexternal-beam irradiation forIBTR after previous lumpectomy andwhole breast irradiation, the initialnodal status appeared to be a strongpredictor for post-IBTR distant metastases.[2] Thus, I strongly advocatesystemic therapy for all such patients with an IBTR, whether they are treatedby mastectomy or repeat lumpectomy.In addition, given that a sizeableproportion of in-breast tumor recurrencesmay actually be "new primaries,"one should consider systemictherapy in most, if not all, cases ofIBTR, perhaps with the same criteriathat are used for patients presentingwith a first cancer in the breast.It is important to emphasize thatsalvage therapy of an IBTR "resultsin a reasonably good chance forcur..... ." This suggests that the presenceof one or two risk factors for anIBTR following breast-conservationtherapy should not necessarily be considereda reason for performing amastectomy. As the authors note, theincreased use of adjuvant systemictherapy has resulted in lower rates ofIBTR than seen in the initial trialswhere just radiotherapy was administeredpostlumpectomy. I agree withthe authors that there must be closeand thorough follow-up of all patientsfollowing lumpectomy and breast irradiation,so that an IBTR, if it occurs,can be detected and treatedpromptly to maximize the chance ofsubsequent long-term disease-freesurvival.

Disclosures:

The author has nosignificant financial interest or other relationshipwith the manufacturers of any productsor providers of any service mentioned in thisarticle.

References:

1.

Freedman GM, Hanlon AL, Fowble BL,et al: Recursive partitioning identifies patientsat high and low risk for ipsilateral tumor recurrenceafter breast-conserving surgery and radiation.J Clin Oncol 20:4015-4021, 2002.

2.

Deutsch M: Repeat high-dose externalbeam irradiation for in-breast tumor recurrenceafter previous lumpectomy and whole breastirradiation. Int J Radiat Oncol Biol Phys53:687-691, 2002.