Updated: November 2004

Locoregional recurrence may follow modified radical mastectomy or partial mastectomy, node dissection and irradiation therapy.

Locoregional recurrence following modified radical mastectomy carries a poor prognosis but some 15% of patients will be long term survivors after further locoregional therapy.

Recurrence in the breast following partial mastectomy is curable with much greater probability. The survival of patients under these circumstances is parallel to that of patients with new tumours of similar stage.

Tumours should be carefully assessed as some of these in breast 'recurrences' are not recurrences but new primary breast cancers which may require different treatment and may give a different prognosis. (i.e. the new tumour may be ER+ and the initial tumour ER-).

1) Locoregional Recurrence Following Modified Radical Mastectomy

These patients should have a biopsy to confirm recurrent disease and to assess estrogen receptor status.

A significant proportion of these patients will already have demonstrable metastatic disease and a full metastatic work-up should be performed. This should include a mammogram of the contralateral breast as well as a CBC, enzymes, bone scan and chest X-ray.

Surgery

If the recurrence is on a previously irradiated chest wall and is solitary, wide local excision may be advised. If the recurrence is in the axilla and the patient has not previously had an axillary node dissection then an axillary node dissection should be undertaken.

The patient may be referred to the BCCA for an opinion from the multi-disciplinary group at the Breast Conference.

Radiation Therapy

If the patient has not had previous radiation therapy then radiation should be given to the chest wall and the lymph node bearing areas with appropriate dose build-up at the site of the recurrence after it has been excised.

Chemotherapy

At present there is no defined role for chemotherapy under these circumstances, but it should be discussed in patients who have never received adjuvant systemic therapy and are otherwise well.

Hormone Therapy

Tamoxifen has been demonstrated to delay recurrence, but a statistically significant improvement in survival has not been demonstrated in randomized trials. If the initial tumour or the recurrent lesion is hormone receptor positive or unknown then an appropriate hormonal maneuver should be considered. This will usually be tamoxifen 20 mg po daily for five years or longer. An aromatase inhibitor is indicated if tamoxifen has been used.  For premenopausal women, as well as tamoxifen, there should be consideration of ovarian ablation by surgery or radiation therapy. Aromatase inhibitors have yet to be assessed in these specific circumstances. However, extrapolating from the metastatic setting, first line aromatase inhibitors are superior to tamoxifen in terms of time to disease progression and are therefore an appropriate first line option for post menopausal patients in this setting.

2) Local Recurrence After Previous Partial Mastectomy, Axillary Dissection and Radiation Therapy

Investigations

Surgery

Mastectomy is recommended for patients without demonstrable metastases. The cure rate will approach that of primary surgery on a similar lesion. The axilla will usually have been previously dissected so that a total mastectomy is the recommended procedure.

Radiation Therapy

If the recurrence is in the axilla or supraclavicular fossa and these lymph node areas have not previously been irradiated then radical radiation therapy should be offered to the axilla and supraclavicular node areas, with an appropriate blocking technique for the previously irradiated breast.

There will be some patients who initially refused or were not given radiation, but are prepared to accept it on recurrence. In these patients breast conservation is still possible and a repeat local excision can be carried out with radiation therapy given as in 6.4.2.

Chemotherapy

The role of chemotherapy or hormonal therapy is not clearly defined. However, if the recurrence is in the axilla or if lymphatic, vascular or perineural invasion is identified, or if the invasive tumour is > 2 cms, any grade or >1 cm grade III, then adjuvant chemotherapy or hormone therapy may be considered, depending upon the patient's age, history of prior adjuvant treatment and estrogen receptor status. As yet, there are no data available to evaluate the benefit of systemic therapy in this setting. Referral to a medical oncologist is encouraged.