Local-regional recurrence after breast-conservation treatment or mastectomy

Abstract

Local recurrence after breast-conservation treatment is most often detected by breast imaging followed by a biopsy for histopathological confirmation. Patients with invasive local recurrence should also undergo a staging workup, mostly by a positron emission tomography-computed tomography (PET-CT), to eliminate the possibility of systemic disease. Although mastectomy is the standard treatment, data are also available regarding a repeat breast-conservation approach with or without reirradiation with accelerated brachytherapy or intraoperative radiotherapy with a potential subsequent increased risk for local recurrence. Local recurrence after mastectomy as a chest wall recurrence (CWR) is most commonly detected by physical examination and diagnosed by a tissue biopsy for confirmation and for hormone receptor and HER2-neu analysis. A staging workup is necessary to plan the appropriate therapy and is primarily performed by PET-CT. In the absence of distant metastases, CWR should be considered for surgical local excision if the lesion is not fixed to the underlying intercostal bony structures or sternum and if the recurrent lesions are not multiple and diffuse on the chest wall or associated with diffuse skin thickening and erythema requiring neoadjuvant chemotherapy or hormonal therapy. In a patient with an ER/PR-positive HER2-neu (-) local recurrence without distant metastases, adjuvant hormonal therapy followed by surgery for local excision should be primarily considered. Adjuvant radiotherapy is indicated in patients without prior postmastectomy radiation therapy. CWR in patients with autologous reconstruction should be locally excised without reconstruction or prosthesis removal. Therefore, no standard treatment for patients with CWR is available. Reirradiation for bulky disease may be considered in patients in whom surgery and chemotherapy are not considered. Hyperthermia or photodynamic treatment may also provide alternative therapeutic options for the management of these patients. A tissue biopsy for diagnosis and hormone receptor and HER2-neu evaluation should be established along with a full metastatic workup. If no distant metastases are noted and the regional recurrence is operable, surgical excision should be considered as the first-line treatment. In hormone receptor (HR)-positive patients, endocrine therapy should be changed or started followed by surgery, whereas chemotherapy should be administered in triple-negative patients followed by surgery. Similarly, anti-HER2-neu therapy with or without chemotherapy and/ or endocrine therapy should be considered (e.g., trastuzumab, pertuzumab, lapatinib, TDM-1) in patients with HER2-neu positivity. Therefore, systemic therapies should be personalized to each individual patient. © Springer International Publishing Switzerland 2016.