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Surgical Treatment of Local Recurrence in Breast Cancer Patients, Study notes of Health sciences

Ultimate Medical AcademyHealth sciences

The definition and classification of local recurrence in breast cancer patients, as well as risk factors and surgical treatment options. It emphasizes the importance of accurate classification of local recurrence and identifies several risk factors for recurrence after breast-conserving surgery or mastectomy. The document also discusses the use of adjuvant therapies and close follow-up for patients at higher risk of recurrence. Surgical treatment options for chest wall recurrence are also explored.

Typology: Study notes

2017/2018

Available from 10/14/2023

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349
© Springer International Publishing AG 2017
U. Veronesi et al. (eds.), Breast Cancer, DOI 10.1007/978-3-319-48848-6_25
Surgical Treatment of Local Recurrence
in Breast Cancer Patients
Jose Vila, Francisco Ripoll, and Oreste D. Gentilini
25.1 Introduction
25.1.1 Definition of Local Recurrence
Local recurrence is defined as the reappearance of an inva-
sive tumor in the ipsilateral preserved breast after Breast-
conserving surgery (BCS), or a breast cancer recurrence in
the skin, subcutaneous tissue, muscle, or underlying bone
after mastectomy. When a local recurrence occurs after a
conservative approach, it is called ipsilateral breast tumor
recurrence (IBTR) and chest wall recurrence (CWR) when it
occurs after mastectomy [1]. Local recurrence tends to occur
later after a conservative procedure than after mastectomy,
especially in those patients treated by endocrine or chemo-
therapy [2–4]. Chest wall recurrences are generally diag-
nosed during physical examination. In contrast, IBTRs are
more frequently detected during posttreatment mammo-
graphic surveillance [5].
A local failure is considered a marker of aggressiveness
as it has been demonstrated to be associated with a three to
five times greater risk of distant metastasis and represents the
main cause of breast cancer-related death [6]. In the US
National Surgical Adjuvant Breast and Bowel Project B-06
(NSABP B-06) study, Fisher et al. demonstrated that patients
with IBTR have 3.41 greater risk of developing distant
metastasis than patients who do not develop such recurrences
[7]. Several factors have been associated with the reappear-
ance of breast cancer such as initial surgery and use of adju-
vant therapies (chemotherapy, hormonal therapy, and
radiation therapy), residual tumor burden, clinical and
pathologic characteristics, and biologic markers of the
primary breast tumor [8, 9]. Recently, Shangani et al. updated
and validated a web-based predictive model, called IBTR!
Version 2.0, to estimate individualized risk of IBTR after
breast-conserving therapy. This online tool incorporates
seven variables that are routinely assessed and has been asso-
ciated with increased risk of local failure after conservative
surgery, such as age, margin status, lymphovascular invasion
(LVI), size tumor, grade, and use of chemo- and/or hormone
therapy [10]. This nomogram can be easily implemented in
many centers worldwide and may help guide decisions about
adjuvant therapies in patients according to their risk of IBTR.
A recent analysis of 86.598 patients from 53 randomized
clinical trials showed that isolated local-regional recurrences
are now an uncommon event. Advances in the management
of early stage breast cancer have significantly reduced the
rate of local-regional recurrence from approximately 30% in
past studies to 5–15% in recent trials [11]. Even though a
rare event, local recurrences are associated with an increased
risk of distant metastasis, especially early recurrences
occurred within the first 2 years after primary treatment. So,
a careful restaging evaluation including a complete blood
test, radionuclide bone scan, breast magnetic resonance
imaging (MRI), a total body positron emission tomography
(PET), and/or chest, abdomen, and pelvis computed tomog-
raphy (CT) scan may be appropriate in all patients with local
recurrence after BCS or mastectomy to rule out the presence
of distant disease.
25.1.2 Classification of IBTR
IBTR after BCS comprises a heterogeneous group of
tumors with distinct biological behavior and different rates
of survival. Although a recognized standard classification
for local recurrence after BCS does not exist to date, IBTR
has traditionally been categorized as true local recurrence
(TR) and new primary tumor (NPT). These two entities
were first described by Veronesi et al. in 1995 and were
classified basically by its location relative to the primary
tumor. TR was defined as the regrowth of invasive disease
25
J. Vila • F. Ripoll
Hospital Universitario y Politécnico La Fe, Valencia, Spain
O.D. Gentilini (*)
Breast Surgery, San Raffaele Scientific and Research Hospital,
Milan, Italy
e-mail: gentilini.oreste@hsr.it
pf3
pf4
pf5
pf8

Partial preview of the text

Download Surgical Treatment of Local Recurrence in Breast Cancer Patients and more Study notes Health sciences in PDF only on Docsity!

© Springer I nternational P u b lishing A G 2017 349 U. Veronesi et al. ( eds.), Breast Cancer , DOI 10.1007/978-3-319-48848-6_

Surgical Treatment of Local Recurrence

in Breast Cancer Patients

Jose Vila, Francisco Ripoll, and Oreste D. Gentilini

25.1 Introduction

25.1.1 Definition of Local Recurrence

Local recurrence is defined as the reappearance of an inva-

sive tumor in the ipsilateral preserved breast after Breast-

conserving surgery (BCS), or a breast cancer recurrence in

the skin, subcutaneous tissue, muscle, or underlying bone

after mastectomy. When a local recurrence occurs after a

conservative approach, it is called ipsilateral breast tumor

recurrence (IBTR) and chest wall recurrence (CWR) when it

occurs after mastectomy [1]. Local recurrence tends to occur

later after a conservative procedure than after mastectomy,

especially in those patients treated by endocrine or chemo-

therapy [2–4]. Chest wall recurrences are generally diag-

nosed during physical examination. In contrast, IBTRs are

more frequently detected during posttreatment mammo-

graphic surveillance [5].

A local failure is considered a marker of aggressiveness

as it has been demonstrated to be associated with a three to

five times greater risk of distant metastasis and represents the

main cause of breast cancer-related death [6]. In the US

National Surgical Adjuvant Breast and Bowel Project B-

(NSABP B-06) study, Fisher et al. demonstrated that patients

with IBTR have 3.41 greater risk of developing distant

metastasis than patients who do not develop such recurrences

[7]. Several factors have been associated with the reappear-

ance of breast cancer such as initial surgery and use of adju-

vant therapies (chemotherapy, hormonal therapy, and

radiation therapy), residual tumor burden, clinical and

pathologic characteristics, and biologic markers of the

primary breast tumor [8, 9]. Recently, Shangani et al. updated

and validated a web-based predictive model, called IBTR!

Version 2.0, to estimate individualized risk of IBTR after

breast-conserving therapy. This online tool incorporates

seven variables that are routinely assessed and has been asso-

ciated with increased risk of local failure after conservative

surgery, such as age, margin status, lymphovascular invasion

(LVI), size tumor, grade, and use of chemo- and/or hormone

therapy [10]. This nomogram can be easily implemented in

many centers worldwide and may help guide decisions about

adjuvant therapies in patients according to their risk of IBTR.

A recent analysis of 86.598 patients from 53 randomized

clinical trials showed that isolated local-regional recurrences

are now an uncommon event. Advances in the management

of early stage breast cancer have significantly reduced the

rate of local-regional recurrence from approximately 30% in

past studies to 5–15% in recent trials [11]. Even though a

rare event, local recurrences are associated with an increased

risk of distant metastasis, especially early recurrences

occurred within the first 2 years after primary treatment. So,

a careful restaging evaluation including a complete blood

test, radionuclide bone scan, breast magnetic resonance

imaging (MRI), a total body positron emission tomography

(PET), and/or chest, abdomen, and pelvis computed tomog-

raphy (CT) scan may be appropriate in all patients with local

recurrence after BCS or mastectomy to rule out the presence

of distant disease.

25.1.2 Classification of IBTR

IBTR after BCS comprises a heterogeneous group of

tumors with distinct biological behavior and different rates

of survival. Although a recognized standard classification

for local recurrence after BCS does not exist to date, IBTR

has traditionally been categorized as true local recurrence

(TR) and new primary tumor (NPT). These two entities

were first described by Veronesi et al. in 1995 and were

classified basically by its location relative to the primary

tumor. TR was defined as the regrowth of invasive disease

J. Vila • F. Ripoll Hospital Universitario y Politécnico La Fe, Valencia, Spain

O.D. Gentilini (*) Breast Surgery, San Raffaele Scientific and Research Hospital, Milan, Italy e-mail: gentilini.oreste@hsr.it

at the tumor bed or the boost volume of the treated breast

and NPT as a new lesion located at a different site from the

primary tumor [12].

Others methods of classifying IBTRs have been proposed

by different groups that have attempted to evaluate indicators

of prognosis in patients with IBTR. In this sense, Huang

et al. classified local recurrences after BCS as either NP or

TR based on location and histology [13]. More recently,

Sakai et al. have proposed a novel classification of IBTR into

four different subtypes based on strict pathologic rules [14].

Initially IBTRs should be classified according to their origin

as new primary or true recurrence, similar to others, but sub-

sequently classified again according to the relationship

between the IBTR and the primary lumpectomy scar, surgi-

cal margin of the primary tumor, and the presence of carci-

noma in situ into the IBTR.

The importance of establishing an accurate classifica-

tion of IBTR is due to the prognostic significance related

to both entities [15]. A new primary tumor has been asso-

ciated with a more favorable prognosis than true local

recurrences. Smith et al., in a retrospective study on 130

patients with IBTR, 60 of which were classified as a true

recurrence and 70 as a new primary according to the site

of failure, histologic subtype, and results from the flow

cytometry, assessed the prognostic value of this classifica-

tion. After a median follow-up of 10.4 years, patients with

NPT had significantly better 10-year overall survival, dis-

tant-free survival, and cause-specific survival than patients

diagnosed with TR [16].

25.1.3 Risk Factors of Local Recurrence

As local recurrence after BCS or mastectomy has been asso-

ciated with a poor prognosis, it is important to identify

patients who are at higher risk of recurrence and might ben-

efit from additional adjuvant therapies and close follow-up

[17]. In this sense, several risk factors of local recurrence

have been identified either in patients treated with primary

conservative surgery or mastectomy [18, 19].

  • Patients treated with primary BCS. Reasonably, the most

important predictor of increased risk for IBTR in patients

treated with BCS is the failure to achieve optimal local

control. Optimal local control includes a margin-negative

surgery (no evidence of invasive cells at the inked border

on microscopic evaluation) and use of radiation therapy

with or without regional nodal irradiation. Other risk fac-

tors for recurrence after BCS include (1) tumors with

aggressive biology such as triple-negative tumors, high

proliferation rate of Ki-67, multicentric disease, tumors

with high nuclear grade, etc., (2) young age at diagnosis

of primary tumor, and (3) lymphatic invasion and exten-

sive intraductal component at the first tumor.

  • Patients treated initially with mastectomy. The clinical

risk factors associated with increased risk of local failure

after mastectomy include (1) young age at diagnosis, (2)

tumor greater than 5 cm, and (3) multicentric disease.

Histopathologic risk factors for CWR include (1) patients

with four or more positive lymph nodes, (2) positive mar-

gins, (3) high-grade triple-negative tumors, and (4) pres-

ence of lymphovascular invasion.

25.2 Surgical Treatment of Chest Wall

Recurrence

The incidence of CWR after mastectomy ranges from 8 to

40% and depends on several factors such as primary tumor

characteristics and the use of adjuvant therapies after mas-

tectomy, mainly the use of postmastectomy radiation therapy

(PMRT). Several studies have demonstrated that the use of

PMRT resulted in better local control of primary tumors by

reducing the rate of CWR by up to 70%, especially in patients

with node-positive disease in whom the absolute reduction in

the recurrence risk is bigger [20]. Similar CWR rates and

survival outcome have been found between patients treated

with conventional mastectomy versus skin-sparing mastec-

tomy as well as comparing different types of reconstruction

[21, 22]. CWR is diagnosed with concomitant distant disease

in up to 30% of patients. Absolute contraindications for cura-

tive intent resection include extensive local disease with

multiple skin nodules and concomitant distant metastasis.

Those patients are candidates to receive systemic therapy

prior to evaluate the role of salvage surgery [23]. Although

CWR may manifest itself as a macroscopically extensive

disease or fungating masses, often it is presented as an

asymptomatic nodule in the skin or a slight erythematous

rash. Hence, diagnosis requires an experienced physician

with high index of suspicion, particularly in high-risk

patients. Any suspicious lesion mandates a careful evalua-

tion including biopsy and pathologic confirmation.

The surgical management of these patients is complex

and requires a preoperative planning between breast sur-

geons and plastic surgeons to help decide on the best recon-

structive option. An estimation of the extent of the disease

and the need for skin grafts or rotational flaps are discussed

at these meetings. In all cases, achieving clear margins is

essential to provide excellent long-term local control.

For no-reconstructed breast patients with isolated CWR

confined to the bed tumor or proximal to the scar, a surgical

tumor resection followed by primary closure is generally

feasible and oncologically safe. However, for extensive

recurrence, chest wall reconstruction using coverage with

J. Vila et al.

Patient selection criteria are crucial and represent a guide

to selecting the best candidates for consideration of second

conservative surgery. Vila et al. in a recent review proposed

six clinical conditions that should be taken into account to

help select the subset of patients who might benefit of less

radical surgery with acceptable long-term survival outcome

and local-regional control [43]. The selection criteria are

listed in Table 25.2. Careful restaging workup of patients

with local recurrence after BCS is mandatory to exclude dis-

tant disease and to identify patients who can be managed

with curative intent.

25.3.1 Mastectomy

Although breast cancer treatment is becoming more conser-

vative, mastectomy still remains the standard treatment for

ipsilateral breast tumor recurrence after breast-conserving

surgery [44]. Mastectomy for IBTR provides excellent local

control that ranges from 69 to 98% [45]. The benefit of chest

wall or regional nodal irradiation in patients treated with

post-recurrence mastectomy has not been addressed but gen-

erally is not recommended in previously irradiated patients.

However, regional nodal irradiation should be considered in

high-risk patients who initially did not receive irradiation of

the regional nodes. Ideally, mastectomy should be followed

by immediate breast reconstruction using either a breast

implant or autologous tissue.

25.3.2 Second Breast-Conserving

Surgery ± Radiation Therapy

Retrospective studies addressing the role of a second conser-

vative procedure have shown similar survival outcome when

compared with mastectomy. Clinical outcome of patients

treated with a second lumpectomy with or without re-

irradiation is listed in Table 25.3. The largest series evaluat-

ing second BCS alone for in-breast local relapse was reported

by Gentilini et al. This retrospective study evaluated 161

patients who underwent a second conservative alone

approach after BCS and whole breast irradiation [55]. With a

median follow-up of 81 months after IBTR, the 5-year

overall survival was 84% (95% confidence interval [CI]

78–89) and a 5-year cumulative incidence of a further local

reappearance of the tumor of 29%. This rate was lower than

previous series and may be related to the small tumor size in

the second BCS cohort (60% of the tumors were <1 cm).

However, for patients with the diagnosis of a small relapse

(<2 cm) occurring late after primary treatment (>48 months),

the cumulative incidence of a further in-breast event was

15%. This finding suggests that motivated patients with the

early diagnosis of a second primary tumor might be consid-

ered for a repeat BCS as an alternative to mastectomy. The

local control after repeat BCS in the published series is simi-

lar to the outcome achieved by conservative surgery alone

without radiotherapy. Therefore, due to improved radiother-

apy treatments, a second course of radiation treatment should

be carefully considered in those patients undergoing a sec-

ond conservative procedure for the treatment of IBTR [56].

The largest experience evaluating the combination of a

second conservative procedure followed by radiation therapy

in patients with previously irradiated breast exists for multi-

catheter brachytherapy. As shown in Table 25.3, the addition

of a second course of irradiation resulted in better local con-

trol. For patients treated with second lumpectomy alone, the

Table 25.2 Suggested selection criteria for second Breast-conserving surgery

Suggested selection criteria for a second breast-conservative approach Age ≥50 years Small cancer ≤ 2 cm Late recurrence (>48 months) Absence of multifocality and/or multicentricity on clinical and conventional imaging examination including breast MR Desire of the patient for conservative approach Acceptable cosmetic results

From Vila J, Garcia-Etienne CA, Gentilini O. Conservative surgery for ipsilateral breast tumor recurrence. J Surg Oncol 2014; 110:62–67 [43]

Table 25.3 Outcome of BCS ± re-irradiation for ipsilateral breast tumor recurrence

Author (ref.)

Total patients

Re-irradiation (type)

Follow-up (months)

2nd LR

5-year OS Maulard et al. [46]

38 Yes (BT) 48 21 55

Voogd et al. [5] 16 No 53 38 NA Deutsch [47] 39 Yes (EBRT) 51 20.5 77. Resch et al. [48] 17 Yes (BT) 59 24 88 Kraus- Tiefenbacher et al. [49]

17 Yes (IORT) 26 NA 94

Chadha et al. [50]

15 Yes (BT) 36 7 100 a

Trombetta et al. [51]

26 Yes (BT) 38 4 88.5 b

Guix et al. [52] 36 Yes (BT) 89 3 96.7c Ishitobi et al. [53]

78 No 40 21 NA

Kauer-Dorner et al. [54]

39 Yes (BT) 57 NA 87

Gentilini et al. [55]

161 No 81 29 84

Hannoun-Levi et al. [56]

217 Yes (BT) 47 7 88.

Abbreviations: ref reference, LR local recurrence, OS overall survival, BT brachytherapy, EBRT external beam radiation therapy, NA not available a3-year OS b3.2-year OS c10-year OS

J. Vila et al.

second LR rate ranged from 19% to as high as 39%, while in

patients treated with a second course of irradiation, the sec-

ond LR rate ranged from 3 to 21%. However, OS was less

influenced by the effect of the re-irradiation as similar 5-year

OS rates were observed.

Several limitations have been associated with these retro-

spective studies such as patient selection for second conserv-

ing surgery and the fact that no prospective studies or

randomized trials have been performed comparing both pro-

cedures. So, the most important question still remains unan-

swered: Are all patients with operable tumor recurrence

forced to undergo mastectomy instead of a second conserva-

tive procedure? The answer is no.

25.4 Surgical Axillary Management

in Local Recurrence of Patients

with Prior BCS

Although sentinel lymph node biopsy (SLNB) has replaced

axillary lymph node dissection (ALND) in primary early

stage breast tumors for women with clinically negative axilla

[57], the axillary surgical management of women diagnosed

with IBTR is highly controversial. Widely consulted guide-

lines still suggest that prior axillary surgery due to oncologi-

cal reasons is a contraindication to the use of SLNB as the

draining lymphatic channels are thought to be disrupted

caused by the fibrosis directly related to the surgery resulting

in unacceptable false-negative rates [44]. However, data

from several retrospective series showed that SLNB is a

technically feasible and an oncologically safe procedure to

restage the axilla in patients with IBTR (Table 25.4). The

success rate of second SLNB ranges from 53.7 to 92.5%.

The numbers of the lymph nodes removed during the first

surgery is one of the most important factors for successful

identification when a second SLNB is performed [58]. In

case of previous axillary lymph node dissection, no further

treatment of the axilla should be necessary although several

studies have reported that SLNB is feasible even in these

patients. However, previous ALND is associated with the

lowest detection rate of sentinel nodes.

The prognostic value of axillary restaging and the role for

treatment decision making process has not been fully eluci-

dated yet. A recent study by Ugras et al. from Memorial

Sloan Kettering Cancer Center evaluated the value of axillary

restaging in 83 patients with local recurrence (79 IBTR and 4

CWR) and clinically negative nodes at diagnosis. Axillary

surgery was performed in 47 patients and 36 patients did not

undergo axillary staging. Both groups of patients were simi-

lar according to primary tumor characteristics and adjuvant

therapies received; however, time to local recurrence in the

non-axillary surgery group was significantly shorter (median

3.5 vs. 6.5 years; p < 0.05). After a median follow-up of 4.

years, both groups of treatment had similar rates of axillary

failure, non-axillary recurrence, distant metastasis, and death.

The authors concluded that preoperative SLNB, although

technically feasible, may not be necessary in some cases and

should be confirmed in larger cohort of patients [66].

Conclusions

The surgical management of local recurrences after BCS

or mastectomy requires integration of health profession-

als providing multidisciplinary care that comprises breast

and plastic surgeons, oncologists, and radiotherapists.

Factors such as time to recurrence, site of relapse, initial

nodal status, and clinical characteristics of the primary

tumor have been shown to predict for differences in over-

all survival, disease-free survival, and local-regional con-

trol. A summary of the surgical options for breast tumor

recurrence is represented in Fig. 25.1.

The management of isolated CWR depends on accurate

assessment of many variables, such as age, comorbidities

and desire of the patients, initial treatment, and size and

location of the recurrence. For patients with previously

non-irradiated mastectomy, wide resection with clear

margins followed by radiation therapy should be indi-

cated. In patients who previously received PMRT, a sec-

ond course of irradiation may be considered when patients

have a high risk of second recurrence. In case of IBTR,

motivated patients with the early diagnosis of a second

primary tumor might be considered for a repeat BCS as an

alternative to mastectomy. Careful preoperative workup

including breast MRI should be performed for the best

patient selection. A second course of radiation treatment

should be carefully considered in those patients undergo-

ing a second conservative procedure for the treatment of

IBTR. Although a second sentinel lymph node biopsy has

demonstrated to be technically feasible and oncologically

safe, little is known about the value of axillary restaging

in these patients. Further prospective studies involving

patients with local recurrences after BCS and mastectomy

are needed to provide solid data that help guide physi-

cians’ treatment decisions.

Table 25.4 Experience with the use of second sentinel lymph node biopsy in locally recurrent breast cancer

Author (ref) N

Success rate of sSLNB

Percentage of extra-axillary drainages Port et al. [58] 54 74.1% (40/54) 5.5% (3) Cox et al. [59] 56 80.4% (45/56) 2.2% (1) Schrenk et al. [60] 15 80.0% (12/15) 14.3% (2) van der Ploeg et al. [61] 36 72.2% (26/36) 47% (17) Maaskant-Braat et al. [62] 41 53.7% (22/41) 25% (10) Intra et al. [63] 212 92.5% (196/212) 8% (17) Uth et al. [64] 73 65.7% (48/73) 8.2% (6) Matsumoto et al. [65] 22 81.8% (18/22) 4.5% (1)

Abbreviations: ref reference, sSLNB second sentinel lymph node biopsy

25 Surgical Treatment of Local Breast Cancer Recurrence

  1. Sakai T, Nishimura S, Ogiya A, Tanabe M, Kimura K, Morizono H, Iijima K, Miyagi Y, Makita M, Ito Y, Oguchi M, Horii R, Akiyama F, Iwase T (2015) Four types of ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery: classification of IBTR based on precise pathological examination. Pathol Int 65:113–118. doi:10.1111/pin.
  2. Yi M, Buchholz TA, Meric-Bernstam F, Bedrosian I, Hwang RF, Ross MI, Kuerer HM, Luo S, Gonzalez-Angulo AM, Buzdar AU, Symmans WF, Feig BW, Lucci A, Huang EH, Hunt KK (2011) Classification of ipsilateral breast tumor recurrences after breast conservation therapy can predict patient prognosis and facilitate treatment planning. Ann Surg 253:572–579. doi:10.1097/ SLA.0b013e318208fc2a
  3. Smith TE, Lee D, Turner BC, Carter D, Haffty BG (2000) True recurrence vs. new primary ipsilateral breast tumor relapse: an anal- ysis of clinical and pathologic differences and their implications in natural history, prognoses, and therapeutic management. Int J Radiat Oncol Biol Phys 48:1281–
  4. Fortin A, Larochelle M, Laverdière J, Lavertu S, Tremblay D (1999) Local failure is responsible for the decrease in survival for patients with breast cancer treated with conservative surgery and postoperative radiotherapy. J Clin Oncol 17:101–
  5. Bosma SCJ, van der Leij F, van Werkhoven E, Bartelink H, Wesseling J, Linn S, Rutgers EJ, van de Vijver MJ, Elkhuizen PHM (2016) Very low local recurrence rates after breast-conserv- ing therapy: analysis of 8485 patients treated over a 28-year period. Breast Cancer Res Treat 156:391–400. doi:10.1007/ s10549-016-3732-
  6. Freedman GM, Fowble BL (2000) Local recurrence after mastec- tomy or breast-conserving surgery and radiation. Oncology (Williston Park, NY) 14:1561–1581. discussion 1581–2–1582–
  7. Clarke M, Collins R, Darby S, Davies C, Elphinstone P, Evans V, Godwin J, Gray R, Hicks C, James S, MacKinnon E, McGale P, McHugh T, Peto R, Taylor C, Wang Y, Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) (2005) Effects of radio- therapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 366:2087–2106. doi:10.1016/ S0140-6736(05)67887-
  8. Langstein HN, Cheng M-H, Singletary SE, Robb GL, Hoy E, Smith TL, Kroll SS (2003) Breast cancer recurrence after immediate reconstruction: patterns and significance. Plast Reconstr Surg 111:712–720. doi:10.1097/01.PRS.0000041441.42563.95discuss ion 721–
  9. Petit JY, Gentilini O, Rotmensz N, Rey P, Rietjens M, Garusi C, Botteri E, De Lorenzi F, Martella S, Bosco R, Khuthaila DK, Luini A (2008) Oncological results of immediate breast recon- struction: long term follow-up of a large series at a single institu- tion. Breast Cancer Res Treat 112:545–549. doi:10.1007/ s10549-008-9891-x
  10. Skinner HD, Strom EA, Motwani SB, Woodward WA, Green MC, Babiera G, Booser DJ, Meric-Bernstam F, Buchholz TA (2013) Radiation dose escalation for loco-regional recurrence of breast cancer after mastectomy. Radiat Oncol 8:13. doi:10.1186/ 1748-717X-8-
  11. Pfannschmidt J, Geisbüsch P, Muley T, Hoffmann H, Dienemann H (2005) Surgical resection of secondary chest wall tumors. Thorac Cardiovasc Surg 53:234–239. doi:10.1055/s-2005-
  12. Howard MA, Polo K, Pusic AL, Cordeiro PG, Hidalgo DA, Mehrara B, Disa JJ (2006) Breast cancer local recurrence after mas- tectomy and TRAM flap reconstruction: incidence and treatment options. Plast Reconstr Surg 117:1381–1386. doi:10.1097/01. prs.0000208116.86765.4a
  13. Chagpar A, Meric-Bernstam F, Hunt KK, Ross MI, Cristofanilli M, Singletary SE, Buchholz TA, Ames FC, Marcy S, Babiera GV, Feig BW, Hortobagyi GN, Kuerer HM (2003) Chest wall recurrence

after mastectomy does not always portend a dismal outcome. Ann Surg Oncol 10:628–

  1. Schuck A, Könemann S, Matthees B, Rübe CE, Reinartz G, Hesselmann S, Micke O, Schäfer U, Willich N (2002) Radiotherapy in the treatment of locoregional relapses of breast cancer. Br J Radiol 75:663–669. doi:10.1259/bjr.75.896.
  2. Stadler B, Kogelnik HD (1987) Local control and outcome of patients irradiated for isolated chest wall recurrences of breast can- cer. Radiother Oncol 8:105–
  3. Harms W, Geretschläger A, Cescato C, Buess M, Köberle D, Asadpour B (2015) Current treatment of isolated locoregional breast cancer recurrences. Breast Care (Basel) 10:265–271. doi:10.1159/
  4. Wahl AO, Rademaker A, Kiel KD, Jones EL, Marks LB, Croog V, McCormick BM, Hirsch A, Karkar A, Motwani SB, Tereffe W, Yu T-K, Sher D, Silverstein J, Kachnic LA, Kesslering C, Freedman GM, Small W (2008) Multi-institutional review of repeat irradia- tion of chest wall and breast for recurrent breast cancer. Int J Radiat Oncol Biol Phys 70:477–484. doi:10.1016/j.ijrobp.2007.06.
  5. Hannoun-Levi J-M, Raoust I (2008) In regard to Wahl et al. (Int J Radiat Oncol Biol Phys 2008;70:477–484). Int J Radiat Oncol Biol Phys 71:1603–1604. doi:10.1016/j.ijrobp.2008.03.060author reply 1604
  6. Fowble B, Solin LJ, Schultz DJ, Rubenstein J, Goodman RL (1990) Breast recurrence following conservative surgery and radiation: patterns of failure, prognosis, and pathologic findings from mastec- tomy specimens with implications for treatment. Int J Radiat Oncol Biol Phys 19:833–
  7. Huston TL, Simmons RM (2005) Inflammatory local recurrence after breast-conservation therapy for noninflammatory breast can- cer. Am J Clin Oncol 28:431–
  8. Kurtz JM, Amalric R, Brandone H, Ayme Y, Spitalier JM (1988) Results of salvage surgery for mammary recurrence following breast-conserving therapy. Ann Surg 207:347–
  9. Dalberg K, Mattsson A, Sandelin K, Rutqvist LE (1998) Outcome of treatment for ipsilateral breast tumor recurrence in early-stage breast cancer. Breast Cancer Res Treat 49:69–
  10. Salvadori B, Marubini E, Miceli R, Conti AR, Cusumano F, Andreola S, Zucali R, Veronesi U (1999) Reoperation for locally recurrent breast cancer in patients previously treated with conservative surgery. Br J Surg 86:84–87. doi:10.1046/j. 1365-2168.1999.00961.x
  11. Alpert TE, Kuerer HM, Arthur DW, Lannin DR, Haffty BG (2005) Ipsilateral breast tumor recurrence after breast conservation ther- apy: outcomes of salvage mastectomy vs. salvage breast-conserving surgery and prognostic factors for salvage breast preservation. Int J Radiat Oncol Biol Phys 63:845–851. doi:10.1016/j. ijrobp.2005.02.
  12. Fodor J, Major T, Polgár C, Orosz Z, Sulyok Z, Kásler M (2008) Prognosis of patients with local recurrence after mastectomy or conservative surgery for early-stage invasive breast cancer. Breast 17:302–308. doi:10.1016/j.breast.2007.11.
  13. Chen SL, Martinez SR (2008) The survival impact of the choice of surgical procedure after ipsilateral breast cancer recurrence. Am J Surg 196:495–499. doi:10.1016/j.amjsurg.2008.06.
  14. Lee JH, Lee SK, Park SM, Ryu JM, Paik HJ, Yi HW, Bae SY, Lee JE, Kim SW, Nam SJ (2015) Independent prognostic factors for overall survival after salvage operation for ipsilateral breast tumor recurrence following breast-conserving surgery. J Breast Cancer 18:386–393. doi:10.4048/jbc.2015.18.4.
  15. Kolben T, Schwarz TM, Goess C, Blume C, Degenhardt T, Engel J, Wuerstlein R, Ditsch N, Harbeck N, Kahlert S (2015) Surgical management of ipsilateral breast tumor recurrence. Int J Surg 23:141–146. doi:10.1016/j.ijsu.2015.08.
  16. Yoshida A, Takahashi O, Okumura Y, Arima N, Nakatsukasa K, Tanabe M, Shien T, Masuda N, Tanaka S, Komoike Y, Taguchi T,

25 Surgical Treatment of Local Breast Cancer Recurrence

Iwase T, Nishimura R, Inaji H, Yamauchi H, Ishitobi M, Collaborative Study Group of Scientific Research of the Japanese Breast Cancer Society (2016) Prognosis after mastectomy versus repeat lumpectomy in patients with ipsilateral breast cancer recur- rence: a propensity score analysis. Eur J Surg Oncol 42:474–480. doi:10.1016/j.ejso.2016.01.

  1. Vila J, Garcia-Etienne CA, Vavassori A, Gentilini O (2014) Conservative surgery for ipsilateral breast tumor recurrence. J Surg Oncol 110:62–67. doi:10.1002/jso.
  2. Gradishar WJ, Anderson BO, Balassanian R, Blair SL, Burstein HJ, Cyr A, Elias AD, Farrar WB, Forero A, Giordano SH, Goetz M, Goldstein LJ, Hudis CA, Isakoff SJ, Marcom PK, Mayer IA, McCormick B, Moran M, Patel SA, Pierce LJ, Reed EC, Salerno KE, Schwartzberg LS, Smith KL, Smith ML, Soliman H, Somlo G, Telli M, Ward JH, Shead DA, Kumar R (2016) Invasive Breast Cancer Version 1.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 14:324–
  3. Kuerer HM, Arthur DW, Haffty BG (2004) Repeat breast- conserving surgery for in-breast local breast carcinoma recurrence: the potential role of partial breast irradiation. Cancer 100:2269–
    1. doi:10.1002/cncr.
  4. Maulard C, Housset M, Brunel P, Delanian S, Taurelle R, Baillet F (1995) Use of perioperative or split-course interstitial brachyther- apy techniques for salvage irradiation of isolated local recurrences after conservative management of breast cancer. Am J Clin Oncol 18:348–
  5. Deutsch M (2002) Repeat high-dose external beam irradiation for in-breast tumor recurrence after previous lumpectomy and whole breast irradiation. Int J Radiat Oncol Biol Phys 53:687–
  6. Resch A, Fellner C, Mock U, Handl-Zeller L, Biber E, Seitz W, Pötter R (2002) Locally recurrent breast cancer: pulse dose rate brachytherapy for repeat irradiation following lumpectomy—a sec- ond chance to preserve the breast. Radiology 225:713–718. doi:10.1148/radiol.
  7. Kraus-Tiefenbacher U, Bauer L, Scheda A, Schoeber C, Schaefer J, Steil V, Wenz F (2007) Intraoperative radiotherapy (IORT) is an option for patients with localized breast recurrences after previous external-beam radiotherapy. BMC Cancer 7:178. doi:10.1186/ 1471-2407-7-
  8. Chadha M, Feldman S, Boolbol S, Wang L, Harrison LB (2008) The feasibility of a second lumpectomy and breast brachytherapy for localized cancer in a breast previously treated with lumpectomy and radiation therapy for breast cancer. Brachytherapy 7:22–28. doi:10.1016/j.brachy.2007.10.
  9. Trombetta M, Julian TB, Werts DE, McWilliams W, Kim Y, Miften M, Parda D (2009) Long-term cosmesis after lumpectomy and brachytherapy in the management of carcinoma of the previously irradiated breast. Am J Clin Oncol 32:314–318. doi:10.1097/ COC.0b013e31818af0b
  10. Guix B, Lejárcegui JA, Tello JI, Zanón G, Henríquez I, Finestres F, Martínez A, Fernandez-Ibiza J, Quinzaños L, Palombo P, Encinas X, Guix I (2010) Exeresis and brachytherapy as salvage treatment for local recurrence after conservative treatment for breast cancer: results of a ten-year pilot study. Int J Radiat Oncol Biol Phys 78:804–810. doi:10.1016/j.ijrobp.2009.08.
  11. Ishitobi M, Okumura Y, Nishimura R, Nakatsukasa K, Tanabe M, Yoshida A, Masuda N, Shien T, Tanaka S, Komoike Y, Arima N, Taguchi T, Inaji H, Collaborative Study Group of Scientific Research of the Japanese Breast Cancer Society (2014) Repeat lumpectomy for ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery: the impact of radiotherapy on second IBTR. Breast Cancer 21:754–760. doi:10.1007/s12282-013-0454-
  12. Kauer-Dorner D, Pötter R, Resch A, Handl-Zeller L, Kirchheiner K, Meyer-Schell K, Dörr W (2012) Partial breast irradiation for

locally recurrent breast cancer within a second breast conserving treatment: alternative to mastectomy? Results from a prospec- tive trial. Radiother Oncol 102:96–101. doi:10.1016/j.radonc. 2011.07.

  1. Gentilini O, Botteri E, Veronesi P, Sangalli C, Del Castillo A, Ballardini B, Galimberti V, Rietjens M, Colleoni M, Luini A, Veronesi U (2012) Repeating conservative surgery after ipsilateral breast tumor reappearance: criteria for selecting the best candidates. Ann Surg Oncol 19:3771–3776. doi:10.1245/ s10434-012-2404-
  2. Hannoun-Levi J-M, Resch A, Gal J, Kauer-Dorner D, Strnad V, Niehoff P, Loessl K, Kovács G, Van Limbergen E, Polgár C, GEC-ESTRO Breast Cancer Working Group (2013) Accelerated partial breast irradiation with interstitial brachytherapy as second conservative treatment for ipsilateral breast tumour recurrence: multicentric study of the GEC-ESTRO Breast Cancer Working Group. Radiother Oncol 108:226–231. doi:10.1016/j.radonc. 2013.03.
  3. Veronesi U, Paganelli G, Viale G, Luini A, Zurrida S, Galimberti V, Intra M, Veronesi P, Robertson C, Maisonneuve P, Renne G, De Cicco C, De Lucia F, Gennari R (2003) A randomized comparison of sentinel-node biopsy with routine axillary dissec- tion in breast cancer. N Engl J Med 349:546–553. doi:10.1056/ NEJMoa
  4. Port ER, Garcia-Etienne CA, Park J, Fey J, Borgen PI, Cody HS (2007) Reoperative sentinel lymph node biopsy: a new frontier in the management of ipsilateral breast tumor recurrence. Ann Surg Oncol 14:2209–2214. doi:10.1245/s10434-006-9237-z
  5. Cox CE, Furman BT, Kiluk JV, Jara J, Koeppel W, Meade T, White L, Dupont E, Allred N, Meyers M (2008) Use of reoperative senti- nel lymph node biopsy in breast cancer patients. J Am Coll Surg 207:57–61. doi:10.1016/j.jamcollsurg.2008.01.
  6. Schrenk P, Tausch C, Wayand W (2008) Lymphatic mapping in patients with primary or recurrent breast cancer following previous axillary surgery. Eur J Surg Oncol 34:851–856. doi:10.1016/j. ejso.2007.11.
  7. van der Ploeg IMC, Oldenburg HSA, Rutgers EJT, Baas-Vrancken Peeters M-JTFD, Kroon BBR, Valdés Olmos RA, Nieweg OE (2010) Lymphatic drainage patterns from the treated breast. Ann Surg Oncol 17:1069–1075. doi:10.1245/s10434-009-0841-
  8. Maaskant-Braat AJG, Roumen RMH, Voogd AC, Pijpers R, Luiten EJT, Rutgers EJT, Nieuwenhuijzen GAP (2013) Sentinel node and recurrent breast cancer (SNARB): results of a nationwide registra- tion study. Ann Surg Oncol 20:620–626. doi:10.1245/ s10434-012-2625-
  9. Intra M, Viale G, Vila J, Grana CM, Toesca A, Gentilini O, Galimberti V, Veronesi P, Luini A, Rotmensz N, Bagnardi V, Mattar D, Colleoni M (2015) Second axillary sentinel lymph node biopsy for breast tumor recurrence: experience of the European Institute of Oncology. Ann Surg Oncol 22:2372–2377. doi:10.1245/ s10434-014-4282-
  10. Uth CC, Christensen MH, Oldenbourg MH, Kjær C, Garne JP, Teilum D, Kroman N, Tvedskov TF (2015) Sentinel lymph node dissection in locally recurrent breast cancer. Ann Surg Oncol 22:2526–2531. doi:10.1245/s10434-014-4338-
  11. Matsumoto A, Jinno H, Nakamura T, Saito J, Takahashi M, Hayashida T, Kameyama K, Kitagawa Y (2015) Technical feasibil- ity of sentinel lymph node biopsy in patients with ipsilateral breast tumor recurrence and previous axillary surgery. Int J Surg 22:28–31. doi:10.1016/j.ijsu.2015.07.
  12. Ugras S, Matsen C, Eaton A, Stempel M, Morrow M, Cody HS (2016) Reoperative sentinel lymph node biopsy is feasible for locally recurrent breast cancer, but is it worthwhile? Ann Surg Oncol 23:744–748. doi:10.1245/s10434-015-5003-

J. Vila et al.