What is the optimal local and systemic therapy of local recurrence in the breast?

OVERVIEW: Approximately 80-90% of breast cancer local recurrences appear within five years after mastectomy. One-fourth to one-third of patients with local or regional recurrence have had preceding distant metastases. Another one-fourth of patients are diagnosed as having simultaneous local and distant failure or develop distant metastases within a few months of the local recurrence. The management of these patients continues to evolve and a gold standard for treatment is controversial. Should patients who initially had breast conserving surgery now have a mastectomy, or is re-excision appropriate? What is the role of radiotherapy and chemotherapy? Should tamoxifen be discontinued and should the patient be started on an aromatase inhibitor and/or ovarian ablation? The answer to these questions are determined according to thoughtful consideration of the clinical and pathological characteristics of the patient at the time of recurrence.

A woman is diagnosed by mammogram with an upper, outer quadrant lesion that is excised and proven to be a 0.8 cm noncomedo DCIS. The margins are clear to 1 cm. She is treated with radiation therapy and tamoxifen. Years later, she presents with a nodule in the suture line, which is excised and found to be recurrent DCIS.

SURGERY FOR LOCAL RECURRENCE

Although salvage mastectomy is currently the standard surgical treatment for IBTR [ipsalateral breast tumor recurrence], a small series has shown that breast conservation plus salvage radiotherapy to the operative area is well tolerated and results in reasonable long-term local control of the disease. This strategy needs to be further explored and eventually compared directly with salvage mastectomy.

—Mamounas E P. Clin Oncol 2001;19(18):3798-3800.
Abstract

CHEMOTHERAPY FOR LOCAL RECURRENCE

Although there are few retrospective studies to address the care of patients with local-regional recurrent nonmetastatic breast cancer, treatment consisting of complete surgical excision, comprehensive irradiation, and systemic therapy is now considered the standard of care by many. The role of chemotherapy is perhaps the most controversial aspect of treating local-regional recurrence after mastectomy.

—Ballo M et al. Int J Radiat Oncol Biol Phys 1999;44(1):105-112.
Abstract

Local recurrences occur most frequently in the skin, and the optimal treatment consists of complete excision of gross disease followed by irradiation. This approach has improved local control and survival in most series. For systemic management, antihormonal therapy should be administered concurrently with irradiation to all receptor-positive patients. Chemotherapy, using a combined or sequential application of Adriamycin and Taxol, has become a standard treatment in advanced breast cancer, but it may be ineffective in resolving local recurrence.

—Harms W et al. Int J Radiat Oncol Biol Phys 2001;
49(1):205-10. Abstract

INNOVATIVE RADIOTHERAPIES FOR LOCALLY RECURRENT BREAST CANCERS

PDR (Pulsed-Dose-Rate)Brachytherapy

Even applying the most appropriate treatment, local failure rates up to 52% have been reported after treatment of local recurrences. Treatment options in this situation are limited, and, due to an increased normal tissue complication probability, reirradiation is used with caution. On the other hand, 62% of the patients with uncontrolled locoregional recurrences experience severe clinical problems and an extremely impaired quality of life. As an alternative to reirradiation with electrons...PDR (pulsed-dose-rate) brachytherapy molds for breast cancer local recurrences is effective and provides a high local control rate with acceptable toxicity.

—Harms W et al. Int J Radiat Oncol Biol Phys 2001;
49(1):205-10. Abstract

HYPERFRACTIONATED, ACCELERATED RADIOTHERAPY (HART)

The need for radiation therapy after surgical excision is well supported by the literature, but optimal dose, treatment volume and schedule are often debated... Hyperfractionated, accelerated radiotherapy (HART) has been advocated for patients with local-regionally recurrent breast cancer because it is believed to enhance treatment effects in rapidly proliferating or chemoresistant tumors. It allows delivery of intense radiotherapy in a shortened time period, reducing the patient’s hospital visits and hastening the delivery of additional chemotherapy. In our study, we found that no obvious advantage was shown for HART and the reduction of overall treatment time seemed unable to improve the local-regional control achieved when the equivalent dose of conventionally fractionated radiotherapy was used. Our current strategies to improve on these outcomes include dose escalation and concurrent chemoradiotherapy for this patient population.

—Ballo M et al. Int. J. Radiat Oncol Biol Phys 1999;
44(1):105-112. Abstract

SERIES OF 43 DCIS PATIENTS WITH LOCAL RECURRENCE

Salvage Treatment for Local Recurrence after Breast-Conserving Surgery and Radiation as Initial Treatment for Mammographically Detected DCIS of the Breast (n=43)

“In summary, the current study has demonstrated that local recurrences after the initial treatment of mammographically detected DCIS using breast-conserving surgery and definitive breast irradiation can be salvaged with high rates of overall survival, cause specific survival, and freedom from distant metastases. Favorable prognostic factors after salvage treatment were intraductal carcinoma as the histology of the local recurrence and mammography only as the method of detection of the local recurrence. As local recurrences are generally salvageable with further treatment, prolonged and careful follow-up after the initial management of DCIS with breast-conserving surgery and definitive breast irradiation is warranted.”

—Solin LJ et al. Cancer 2001;91(6):1090-97.
Abstract

MILAN SERIES OF 191 LOCAL RECURRENCE CASES AFTER BREAST CONSERVING SURGERY FOR EARLY BREAST CANCER

—Derived from Salvadori B et al. Brit J of Surg 1999;86(1):84-7.

“Since the two surgical options were not randomized, no statistically reliable comparison could be obtained. Furthermore, the favourable results after re-excision could simply reflect patient selection. However, total mastectomy does not seem to prevent patients from developing distant metastases. In conclusion, half the patients were disease-free five years after reoperation. Re-excision was not disadvantageous in selected patients. Selection should include small solitary recurrences in a breast large enough to permit a satisfactory cosmetic result. The patient should be consented appropriately about the risk of a further IBTR.”

—Salvadori B et al. Brit J of Surg 1999;86(1):84-7.

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