Long-term prognosis of patients with local recurrence after breast conservation therapy for early breast cancer. A report of the Dutch Study Group on Local Recurrence after Breast Conservation (BORST)

BACKGROUND:The objective of this study was to examine clinical outcomes and patterns of failure in patients with early stage breast cancer who developed an ipsilateral breast tumor recurrence (IBTR) after breast-conserving therapy (BCT) using accelerated partial breast irradiation (APBI). METHODS: In total, 1440 patients (1449 tumors) with early stage breast cancer who underwent BCT were treated with the MammoSite device to deliver APBI (34 Gray [Gy] in 3.4-Gy fractions). One thousand two hundred fifty-five patients (87%) had invasive breast cancer (IBC) (median tumor size, 10 mm), and 194 patients (13%) had ductal carcinoma in situ (DCIS) (median tumor size, 8 mm). The median follow-up was 60 months. RESULTS: Fifty patients (3.5%) developed an IBTR for a 5-year actuarial rate of 3.61% (3.65% for IBC and 3.36% for DCIS). It was determined that 36 recurrences (72%) represented new primary cancers, and 14 recurrences (28%) represented recurrences of the index lesion. Of the 32 recurrences with known histology, 78% were IBC, and 22% were DCIS. After IBTR, 28 of 38 patients (74%) underwent salvage mastectomy, and 9 of 38 patients (26%) had a second attempt at BCT. Adjuvant therapies included tamoxifen in 8 patients (16%) and systemic chemotherapy in 6 patients (12%).The 3-year rates of disease-free survival, cause-specific survival, and overall survival after IBTR were 58.7%, 92.1%, and 80.5%, respectively. CONCLUSIONS: With 5 years of follow-up, APBI produced clinical outcomes and patterns of failure comparable to those achieved with whole breast irradiation. Patients who developed an IBTR after APBI had excellent 3-year survival outcomes after salvage treatments. Cancer 2012;118:4126-31. V C 2012 American Cancer Society.KEYWORDS: Breast conserving therapy, brachytherapy, radiation, partial breast irradiation, MammoSite. INTRODUCTIONWith more than 25 years of follow-up, it has been demonstrated that breast-conserving therapy (BCT) provides longterm outcomes equivalent to the outcomes achieved with mastectomy in the management of early stage breast cancer. Although whole-breast irradiation (WBI) has been considered the standard adjuvant radiation therapy (RT) technique in these patients, 1 concern that remains is the 6 to 7 weeks required to deliver RT. Some studies indicate that up to 20% of patients do not receive adjuvant RT, and protracted treatment times and distance from an RT facility have been identified as contributing factors. 1 Accelerated partial breast irradiation (APBI) is a relatively new technique that allows for the delivery of adjuvant RT while shortening the treatment course to 1 week or less. Currently, APBI can be delivered using multiple techniques, including interstitial catheters, a balloon-based catheter, or external-beam RT. With 5 to 10 years of follow-up, it has been demonstrated that APBI is associated with excellent clinical outcomes. 2,3 One concern with BCT is how to address recurrent local disease within the previously irradiated breast. One strategy to help stratify these recurrence...

Section: Historic Perspectivesupporting

confidence: 79%

Section: Historic Perspectivementioning

confidence: 99%

Section: Historic Perspectivementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Outcome after ipsilateral breast tumor recurrence in patients who receive accelerated partial breast irradiation

Shah

Vicini

Keisch

et al. 2012

“…3,4,[6][7][8][9][10][11][12][13][14][15][16][17] These studies demonstrated that a second local recurrence in the form of a chest wall recurrence occurs in approximately 2-32% of patients. Thus, mastectomy after in-breast local recurrence does not necessarily eliminate the risk of subsequent secondary local recurrences at the chest wall.…”

Section: Local Recurrence Risk After Mastectomy For In-breast Local Rmentioning

confidence: 99%

Repeat breast‐conserving surgery for in‐breast local breast carcinoma recurrence

Kuerer

Arthur

Haffty

2004

Mastectomy is the current standard of care for in-breast local recurrence of breast carcinoma. The objective of the current study was to critically review the rationale for and the theoretic and actual risks and benefits of repeat breast-conserving surgery followed by partial breast irradiation (PBI) for in-breast local recurrence of breast carcinoma. The main outcomes of interest were local control and survival after in-breast local recurrence and side effects, complications, and cosmesis after reirradiation of the breast. The risk of local recurrence was not found to be eliminated with mastectomy; approximately 2-32% of patients treated with mastectomy develop a chest wall recurrence. The interpretation of local control rates in evaluating repeat breast-conserving surgery studies is difficult because of the lack of information regarding preoperative diagnostic mammography to rule out concurrent multicentric disease and microscopic margin status after surgery. Rates of subsequent local recurrence in these studies appeared to be between 19 -50%, similar to reported rates of in-breast local recurrence in patients with a first diagnosis of breast carcinoma who were treated with conservative surgery without irradiation. Early follow-up studies of breast reirradiation suggest that catheterbased interstitial brachytherapy and standard external beam radiation therapy can be delivered to the breast more than once without significant side effects in most patients and with acceptable cosmesis in some patients. Mastectomy may not be necessary in all patients with an in-breast local recurrence of breast carcinoma. KEYWORDS: recurrent breast carcinoma, breast surgery, radiation therapy, accelerated partial breast irradiation, three-dimensional conformal radiation therapy, brachytherapy.A t present, the standard surgical approach for the treatment of in-breast local recurrence of breast carcinoma is mastectomy. The rationale for the general consensus for this recommendation is threefold. First, a third local recurrence after repeat conservative surgery is reported in approximately 35% of patients. Second, a second lumpectomy would yield a cosmetically unacceptable outcome. Third, reirradiation of the whole breast after breast-conserving surgery is considered inappropriate because of the likelihood of serious tissue damage. Recently, novel brachytherapy devices and three-dimensional conformal radiation therapy techniques have brought accelerated partial breast irradiation (APBI) to the forefront as a potential treatment approach in women with in-breast local recurrence of 2269

Predictors of systemic recurrence and disease‐specific survival after ipsilateral breast tumor recurrence

Shen

Hunt

Mirza

et al. 2005

BACKGROUNDIn patients with breast carcinoma, ipsilateral breast tumor recurrence (IBTR) after breast‐conserving therapy (BCT) is an independent predictor of systemic recurrence and disease‐specific survival (DSS). However, only a subgroup of patients with IBTR develop systemic recurrences. Therefore, the management of isolated IBTR remains controversial. The objective of the current study was to identify determinants of systemic recurrence and DSS after IBTR.METHODSThe medical records of 120 women who underwent BCT for Stage 0–III breast carcinoma between 1971 and 1996 and who subsequently developed isolated IBTR were reviewed. Clinicopathologic factors were studied using univariate and multivariate analyses for their association with DSS and the development of systemic recurrence after IBTR.RESULTSThe median time to IBTR was 59 months. At a median follow‐up of 80 months after IBTR, 45 patients (37.5%) had a systemic recurrence. Initial lymph node status was the strongest predictor of systemic recurrence according to the a univariate analysis (P = 0.001). Other significant factors included lymphovascular invasion (LVI) in the primary tumor, time to IBTR ≤ 48 months, clinical and pathologic IBTR tumor size > 1 cm, LVI in the recurrent tumor, and skin involvement at IBTR. In a multivariate logistic regression analysis, initially positive lymph node status (relative risk [RR], 5.3; 95% confidence interval [95% CI], 1.4–20.1; P = 0.015) and skin involvement at IBTR (RR, 15.1; 95% CI, 1.5–153.8; P = 0.022) remained independent predictors of systemic recurrence. The 5‐year and 10‐year DSS rates after IBTR were 78% and 68%, respectively. In a multivariate Cox proportional hazards model analysis, only LVI in the recurrent tumor was found to be an independent predictor of DSS (RR, 4.6; 95% CI, 1.5–14.1; P = 0.008).CONCLUSIONSPatients who initially had lymph node‐positive disease or skin involvement or LVI at IBTR represented especially high‐risk groups that warranted consideration for aggressive, systemic treatment and novel, targeted therapies after IBTR. Determinants of prognosis after IBTR should be taken into account when evaluating the need for further systemic therapy and designing risk‐stratified clinical trials. Cancer 2005. © 2005 American Cancer Society.