Recurrent Breast Cancer

Breast cancer can recur locally, regionally or systemically. The management of each is separate.

Local Recurrence

Local recurrence can occur in several scenarios:

  • After wide local excision alone (about 30% risk; most likely but also rarely done)
  • After wide local excision with adjuvant radiotherapy (about 10% risk, most common scenario)
  • After mastectomy without radiotherapy (about 10% risk)
  • After mastectomy with adjuvant radiotherapy (about 10% risk as RT only offered for high risk disease)

Management options vary according to the scenario. It is important to restage the patient:

  • Whole body bone scan
  • CT Chest/Abdomen/Pelvis
  • PET scan is controversial and unfunded

Recurrence after wide local excision alone

Mastectomy is typically recommended. This is because:

  • Cosmetic outcome after two wide local excisions may be suboptimal
  • If a single recurrence has occured then a second recurrence may be likely after repeat WLE

Nevertheless, patients may refuse mastectomy and have repeat wide local excision. In this case they should definitely receive adjuvant whole breast radiotherapy but this may also be refused.

Recurrence after wide local excision with adjuvant radiotherapy

This is a more common scenario. Mastectomy is standard of care due to potential toxicities from repeat breast radiotherapy. Investigational approaches using repeat wide local excision and partial breast radiotherapy have been reported. Repeat wide local excision is best suited to small tumours < 2 cm that recur after 2 years; larger tumours or early recurrences have high rates (30-50%) of second recurrence and mastectomy is preferred. Patients should be considered for partial breast irradiation as this has been shown in prospective series to provide good local control.

Recurrence after mastectomy without radiotherapy

Repeat surgical excision is standard practice with an attempt to achieve negative margins. Chest wall radiotherapy should follow (50 Gy in 25 fractions) with a boost (10 Gy in 5 fractions) to areas with microscopically positive margins or 16 Gy to macroscopic residual disease.

Recurrence after mastectomy treated with adjuvant chest wall radiotherapy

This is perhaps the most controversial and complicated group. Surgical excision is mandantory if possible. Repeat radiotherapy to the entire chest wall is not done. Local radiotherapy treatment to the tumour site is frequently recommended and often well tolerated. The appropraite technique depends on the location but often a direct electron beam with bolus is suitable. The dose should not by hypofractionated and some would recommend hyperfractionation (eg. 45 Gy in 30 fractions, 1.5 Gy BD, followed by a further 15 Gy boost); there is no evidence that this is superior to conventional fractionation.

Regional recurrence

Regional recurrence can occur in the axilla (~10% of recurrences), the supraclavicular fossa (~ 40%), or both.

Axillary Recurrence

Axillary recurrence has better outcomes with 50% 5 year survival.
If not performed previously, and axillary dissection is undertaken. If this has previously been done, then wide local excision of the recurrent mass is mandantory.
Adjuvant treatment is variable. If radiotherapy has not been previously used, then some would consider this appropriate whereas others avoid it unless the disease meets typical axillary radiotherapy requirements (eg. > 50% nodes involved, < 10 nodes removed, extracapsular extension, positive margins). The dose is 45-50 Gy in 25 fractions.

Supraclavicular Recurrence

Whether this represents local or distant failure is controversial. Outcomes are poor with local treatment (20% 5 year survival) but some patients to have long term survival and therefore local treatment is warranted.
Systemic therapy is typically recommended as first line. If distant disease does not develop, then local therapy with surgical excision, radiotherapy or both is warranted.

  • Surgical excision is favoured when radiotherapy has been previously used
  • Radiotherapy is often safer if it has not been previously used
  • Repeat radiotherapy is risky due to risk of brachial plexopathy and should be avoided.

Distant Recurrence

This represents incurable disease in the majority of patients. A small number of patients may present with oligometastatic disease in the sternum, lung or liver. Several studies have demonstrated the potential for long term survival in these patients.

Oligometastatic sternal involvement

The sternum does not communicate as freely with the other bones as do the vertebrae and oligometastatic disease in this site may respond well to local surgery and systemic therapy.

Oligometastatic lung involvement

Patients with a single lung metastasis may benefit from surgical excision. The typical approach would be to trial systemic therapy and if there is no further metastatic disease attempt a wedge resection or lobectomy.

Oligometastatic liver involvement

This is uncommon; liver metastases usually develop in the late phase of the disease but about 5% of patients may develop a liver oligometastasis. Some of these patients may have long term survival with intensive local therapy (eg. partial hepatectomy, radiofrequency ablation, stereotactic body irradiation).

Isolated bony metastatic disease

Patients with bone-only metastatic disease have an improved prognosis compared to those with visceral involvement. The disease may behave more indolently. There is