Isolated local-regional recurrence of breast cancer following mastectomy: Radiotherapeutic management

Abstract

Two hundred twenty-four patients with their first, isolated local-regional recurrence of breast cancer were irradiated with curative intent. Patients who had previous chest wall or regional lymphatic irradiation were not included in the study. With a median follow-up of 46 months (range 24 to 241 months), the 5- and 10-year survival for the entire group were 43% and 26%, respectively. Overall, 57% of the patients were projected to be loco-regionally controlled at 5 years. The 5-year local-regional tumor control was best for patients with isolated chest wall recurrences (63%), intermediate for nodal recurrences (45%), and poor for concomitant chest wall and nodal recurrences (27%). In patients with solitary chest wall recurrences, large field radiotherapy encompassing the entire chest wall resulted in a 5- and 10-year freedom from chest wall re-recurrence of 75% and 63% in contrast to 36% and 18% with small field irradiation ( p = 0.0001). For the group with recurrences completely excised, tumor control was adequate at all doses ranging from 4500 to 7000 cGy. For the recurrences < 3 cm, 100% were controlled at doses ≥ 6000 cGy versus 76% at lower doses. No dose response could be demonstrated for the larger lesions. The supraclavicular failure rate was 16% without elective radiotherapy versus 6% with elective radiotherapy ( p = 0.0489). Prophylactic irradiation of the uninvolved chest wall decreased the subsequent re-recurrence rate (17% versus 27%), but the difference is not statistically significant ( p = .32). The incidence of chest wall re-recurrence was 12% with doses ≥ 5000 cGy compared to 27% with no elective radiotherapy, but again was not statistically significant ( p = .20). Axillary and internal mammary failures were infrequent, regardless of prophylactic treatment. Although the majority of patients with local and/or regional recurrence of breast cancer will eventually develop distant metastases and succumb to their disease, a significant percentage will live 5 years. Therefore, aggressive radiotherapy should be used to provide optimal local-regional control. We recommend (a) radiation therapy to the entire site of involvement, as more localized therapy is associated with an excessive incidence of re-recurrence; (b) elective irradiation of the uninvolved supraclavicular fossa to 4600–5000 cGy; (c) serious consideration for elective chest wall irradiation to at least 5000 cGy, particularly in patients with supraclavicular or axillary involvement since chest wall failure developed in 29% and 21% of these patients respectively; (d) at least 5000 cGy for completely excised recurrences, and at least 6000 cGy for incompletely excised, small (<3 cm) recurrences. The tumor control in larger lesions was only 50% even with doses of 7000 cGy.