Isolated Chest Wall Recurrence Research Articles

Axillary management of breast cancer patients with isolated chest wall recurrence after mastectomy.

National Comprehensive Cancer Network (NCCN) guidelines on the axillary management of breast cancer patients with isolated chest wall recurrence after mastectomy are unclear. Though sentinel lymph node biopsy (SLNB) is possible and may be considered, there is limited data on its usefulness. We aimed to determine if axillary restaging surgery was required in this cohort of patients who developed operable isolated chest wall recurrences after mastectomy. Breast cancer patients treated at a tertiary institution from 1st September 2005 to 31st October 2017 and developed isolated chest wall invasive recurrences after mastectomy were retrospectively reviewed. We excluded patients with bilateral cancers, concurrent regional or distant metastases, patients without surgery for their chest wall recurrences and patients who were lost to follow-up. The demographics, pathological data and second recurrences were collected from a prospectively maintained database and compared between patients with axillary lymph node dissection (ALND), SLNB and no axillary operation. Of the 1,841 patients who underwent mastectomy, 26 (1.4%) patients developed isolated chest wall recurrences. Twenty two eligible patients were analysed. The mean age at diagnosis of the recurrence was 54.7 years (range, 37-84 years). 1, 2 and 19 patients had ALND, SLNB and no axillary operation respectively. On mean follow-up of 38.3 months, no axillary recurrences were noted. In breast cancer patients with isolated chest wall recurrences after mastectomy, axillary restaging surgery can be safely omitted with no increased axillary recurrences on medium term follow-up. This finding could refine existing guidelines in the management of the axilla for patients with chest wall recurrences after mastectomy.

Patterns of breast cancer second recurrences in patients after mastectomy.

Little is known about second recurrences in breast cancer patients, especially in patients with mastectomy. We aimed to determine the risk factors, prevalence and patterns of second recurrence in mastectomy patients after first recurrence. Stage I-III breast cancer patients treated at a tertiary institution from 1st September 2005 to 31st October 2017 and developed first and second recurrences after mastectomy were retrospectively reviewed. We excluded patients with bilateral cancers and patients who were lost to follow-up. The demographics, pathological and recurrence data were collected from a prospectively maintained database and analysed. Of the 1619 mastectomy patients, 214 (13.2%) patients developed recurrences at a mean 39.9months from primary cancer diagnosis. 23, 8 and 183 had isolated chest wall recurrences (CWR), regional and systemic metastases, respectively. Excluding 2 CWR patients without surgery, second recurrences occurred in 3/21 (14.3%) and 3/8 (37.5%) in patients with CWR and regional metastasis at 27.7months (range: 5-42) and 32months (range: 18-40), respectively. In both groups, systemic metastasis as second recurrence occurred within 2years after first recurrence, whilst locoregional second recurrences occurred later. No risk factors for second recurrence were identified. In patients with mastectomy, second recurrences occurred in 20.7% of patients with treated locoregional first recurrence, with no risk factors identified. Systemic metastases manifesting as second recurrence occurred in the first 2years after first recurrence. Continued clinical surveillance and restaging patients in the first 2years after first locoregional recurrence may enable early prognostication and treatment with the newer metastatic drugs.

Treatment and prognostic analysis of isolated chest wall recurrence of breast cancer after mastectomy

Objective: To analyze the prognostic factors of breast cancer patients with isolated chest wall recurrence (ICWR) after mastectomy, and investigate the optimal treatment. Methods: A total of 201 breast cancer patients with ICWR after mastectomy who were treated in Cancer Hospital, Chinese Academy of Medical Sciences and the Fifth Medical Center Chinese PLA General Hospital from October 1998 to April 2018 were retrospectively analyzed. The median follow-up was 92.8 months and survival data were obtained. Results: Among 201 patients with ICWR, 103 patients developed subsequent locoregional recurrence (sLRR) and 5-year cumulative sLRR rate was 49.1%; 134 patients developed distant metastasis (DM) and 5-year DM rate was 64.4%; 103 patients died, the median progression-free survival (PFS) was 17.4 months and the 5-year PFS rate was 23.2%; the median overall survival (OS) was 62.5 months and the 5-year OS rate was 52.1%. Multivariate analysis showed that the recurrence interval (HR=2.17, 95% CI: 1.26-3.73) and the locoregional treatment (HR=1.59, 95% CI: 1.05-2.40) were the independent prognostic factors for sLRR. The initial HER2 status (HR=1.60, 95% CI: 1.03-2.48) was the independent prognostic factor for DM. The recurrence interval (HR=1.99, 95% CI: 1.30-3.04), the locoregional treatment (HR=1.99, 95% CI: 1.43-2.76) and the treatment modalities after recurrence (HR=1.70, 95% CI: 1.18-2.46) were the independent prognostic factors for PFS. The initial HER2 status (HR=1.69, 95% CI: 1.02-2.81), the recurrence interval (HR=1.85, 95% CI: 1.15-2.98) and the treatment modalities after recurrence (HR=2.48, 95% CI: 1.56-3.96) were the independent prognostic factors for OS. Conclusions: Breast cancer patients after ICWR have an optimistic OS until now, but the risk of sLRR and DM is high. Comprehensive treatment modalities including surgery, radiotherapy and systemic therapy improve the outcome of breast cancer patients with ICWR after mastectomy.

Prognosis and Prophylactic Regional Nodal Irradiation in Breast Cancer Patients With the First Isolated Chest Wall Recurrence After Mastectomy.

Background and PurposeOptimal radiation target volumes for breast cancer patients with their first isolated chest wall recurrence (ICWR) after mastectomy are controversial. We aimed to analyze the regional failure patterns and to investigate the role of prophylactic regional nodal irradiation (RNI) for ICWR.Materials and MethodsAltogether 205 patients with ICWR after mastectomy were retrospectively analyzed. Post-recurrence progression-free survival (PFS) and overall survival (OS) rates were calculated by Kaplan-Meier method and the differences were compared with Log-rank test. Competing risk model was used to estimate the subsequent regional recurrence (sRR) and locoregional recurrence (sLRR) rates, and the differences were compared with Gray test.ResultsThe 5-year sRR rate was 25.2% with median follow-up of 88.6 months. Of the 52 patients with sRR, 30 (57.7%) recurred in the axilla, 29 (55.8%) in supraclavicular fossa (SC), and five (9.6%) in internal mammary nodes. Surgery plus radiotherapy was independently associated with better sLRR and PFS rates (p<0.001). The ICWR interval of ≤ 4 years was associated with unfavorable sRR (p=0.062), sLRR (p=0.014), PFS (p=0.001), and OS (p=0.005). Among the 157 patients who received radiotherapy after ICWR, chest wall plus RNI significantly improved PFS (p=0.004) and OS (p=0.021) compared with chest wall irradiation alone. In the 166 patients whose ICWR interval was ≤ 4 years, chest wall plus RNI provided the best PFS (p<0.001) and OS (p=0.022) compared with chest wall irradiation alone or no radiotherapy.ConclusionPatients with ICWR have a high-risk of sRR in SC and axilla. Chest wall plus RNI is recommended.

Radiotherapy for First Isolated Chest Wall Recurrence of Breast Cancer after Mastectomy in the Contemporary Era: A Joint Analysis of 201 Cases from Two Institutions

Radiotherapy for First Isolated Chest Wall Recurrence of Breast Cancer after Mastectomy in the Contemporary Era: A Joint Analysis of 201 Cases from Two Institutions

Abstract ES7-1: Challenges in the management of locoregional recurrence

Abstract The increasing trend toward tailoring treatment of the primary breast cancer with limited surgery of both the breast and axilla has increased the challenge of managing locoregional recurrence (LRR). In the era when patients uniformly had axillary dissection, the appropriateness of repeat sentinel node biopsy was not a question. Similarly, the dogma that all ipsilateral breast tumor recurrences must be treated with mastectomy if the breast has been previously irradiated is also being challenged. LRR events are infrequent with modern multi-modality therapy, and there are no randomized trials to address these questions. Re-operative sentinel node (SN) biopsy after breast conserving surgery therapy (BCT) has been shown to be feasible, with the likelihood of identifying additional SNs related to the number of nodes excised at the time of initial SN biopsy. The accuracy of SN biopsy after mastectomy is less clear. However, the impact of identification of nodal disease on management of LRR is controversial. In a study of 12 patients with isolated chest wall recurrence post mastectomy, 10/12 had successful mapping and 7/10 had an axillary SN. The absence of nodal metastases was an indication to avoid supraclavicular RT (Johnson J. Ann Surg Oncol 2016;23:715). In a study of 83 patients with in breast (n=79) or chest wall recurrence who were clinically node negative, 47 had axillary surgery and 36 did not. At a median of 4.2 years after LR, rates of axillary and non-axillary local recurrence, distant metastases, and death did not differ significantly between groups (Ugras S. Ann Surg Oncol 2016). With the findings of the CALOR trial that systemic chemotherapy is beneficial in the management of LRR, the finding of axillary metastases is less likely to influence systemic therapy than in the past and repeat axillary staging could potentially be avoided. In the untreated breast, drainage to the contralateral axilla is very rare and contralateral axillary metastases classify a patient as Stage IV. After initial axillary dissection, between 4% and 33% of patients with local recurrence will have contralateral axillary drainage. In a systemic review of 48 cases of contralateral nodal recurrence without other distant metastatic disease, at a mean follow-up of 50.3 months disease free survival was 65% and overall survival 83% after treatment that included both local and systemic therapy (Moossdorff M. Eur J Surg Oncol 2015;41:1128). These findings raise the possibility that in the setting of LR, contralateral axillary metastases should be treated aggressively for cure after excluding distant metastases. Citation Format: Morrow M. Challenges in the management of locoregional recurrence [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr ES7-1.

P0096 Thoracoepigastric flap: A novel technique in chest wall reconstruction for locally recurrent breast cancer

Background Chest wall recurrence can occur after breast cancer. Isolated chest wall recurrences usually occur after treatment that uses all three methods: surgery, chemotherapy, and radiation to the chest wall. Chest wall recurrences usually require one or two rib resections for oncological clearance. Our aim was to assess the usefulness of thoracoepigastric flap in the reconstruction of chest wall for isolated chest wall local recurrence of breast carcinoma. Methods We studied 36 patients aged 31–65 years with isolated chest wall involvement, with or without rib infiltration, for 24 months. Patients underwent immediate chest wall reconstruction with mesh and a thoracoepigastric flap. Outcomes were oncological safety and cosmetic outcomes after chest wall reconstruction. To assess oncological safety we used margin status. We used a questionnaire to evaluate personal experience after the reconstruction. Findings After modified radical mastectomy, 16 patients had positive or close margins and 20 patients were margin-negative. Operating time ranged from 130 to 210 min (mean time 154 min). Blood loss ranged from 75 to 300 mL (mean volume 134 mL). The skin island used for volume replacement ranged from 4 cm by 3 cm to 10 cm by 6 cm. No patient had margin positivity or close margins. Major wound complications occurred in three patients. Minor wound complications occurred in five patients. Five patients developed seroma. We followed up patients for 12–23 months. Interpretation Isolated chest wall recurrences are completely resectable if we have oncoplastic options such as the thoracoepigastric flap. This technique has increased the oncological safety with less margin-positive resections after immediate reconstruction of chest wall with good cosmetic outcome and less donor site morbidity.

67P Analysis of Local-Regional Recurrence in Young Women (≤ 35Y) Receiving Mastectomy for Operable Breast Cancer

PurposeYoung women with breast cancer have a higher risk of local-regional recurrence (LRR) than older women. The study aimed to determine risk factors for LRR and the impact of post-mastectomy radiotherapy (PMRT) in women ≤ 35 years old. Materials and methodsThis is a retrospective analysis of 459 women, all ≤35 years old, who were treated with mastectomy for breast cancer between 1989 and 2004. Chemotherapy was given to 423 patients, and 160 patients received endocrine therapy. PMRT was administered in 220 patients (47.9%). Statistical analysis was carried out with SPSS, version 16.0 (SPSS Inc, Chicago, IL). ResultsThe median age of this cohort was 32 years, and median follow-up was 50.1 months. The median disease-free interval before the first isolated local-regional recurrence (ILRR) was 18.8±2.7 months. The 5-year and 10-year isolated local-regional control rates were 74.9% and 70.0%, respectively. Compared to the patients without ILRR, patients with ILRR had a shorter 5-year metastasis-free survival (MFS; 66.6% vs. 53.8%, P = 0.003). In univariate analysis, surgical modality, tumor size, lymphnode status, chemotherapy and ILRR were significant predictors for overall surviva l(OS). In multivariate analysis, higher T stage (P = 0.047, HR = 1.58, 95% CI = [1.02-2.42]) and higher N stage (P = 0.005, HR = 1.57, 95% CI = [1.15-2.78]) were independent predictors for ILRR. Higher T stage (P = 0.014, HR = 1.52, 95% CI = [1.09-2.12]), higher N stage (P < 0.001, HR = 2.25, 95% CI = [1.67-3.03]), endocrine therapy (P = 0.014, HR = 0.59, 95% CI = [0.39-0.90]) and ICWR (isolated chest-wall recurrence)(P = 0.006, HR = 1.87, 95% CI = [1.20-2.91]) were independent predictors for MFS. In terms of OS, all factors above were independent prognostic factors, except for the use of endocrine therapy. ConclusionYoung women with operable breast cancer receiving mastectomy are at high risk for ILRR and appear to have a shorter disease-free interval than older women. It is critical to re-evaluate the impact of PMRT in young patients. The chest wall is at high risk of recurrence and should not be neglected as a PMRT target. DisclosureAll authors have declared no conflicts of interest.

Long-Term Outcomes in Patients With Isolated Supraclavicular Nodal Recurrence After Mastectomy and Doxorubicin-Based Chemotherapy for Breast Cancer

To examine the outcome of patients who developed an isolated locoregional recurrence (LRR) involving the supraclavicular fossa (SCV) after initial treatment with modified radical mastectomy and chemotherapy. Records from 140 breast cancer patients treated on five prospective trials with mastectomy and doxorubicin-based chemotherapy, with or without radiation, who developed a LRR were reviewed. Kaplan-Meier survival times were calculated using date of LRR as time zero. The median follow-up after LRR was 2.9 years (N = 140; interquartile range, 1.3-6.6 years). In all, 47 of 140 patients (34%) had an SCV component to their LRR. These patients had lower 3-y distant metastasis-free survival (40% vs. 54%, p = 0.003) and overall survival (49% vs. 69%, p = 0.04) than patients without an SCV component. Multivariate analysis revealed that LRR involving an SCV component (hazard ratio, 1.96, p = 0.004) and patients with lymphovascular space invasion in their primary tumors (hazard ratio, 1.65, p = 0.029) were independently associated with a poor distant metastasis-free survival. However, among 23 patients with isolated SCV recurrence, Overall survival was not statistically significantly different between isolated chest wall recurrence and isolated SCV recurrence. Patients with isolated SCV recurrence displayed a median follow-up of 3.3 years (IR, 1.2-5.2). Only 6 LRR of 23 patients were treated with aggressive local therapy, including surgery, chemotherapy, and radiation (alone or in combination). Although breast cancer recurrence with SCV involvement carries a high risk of distant metastasis and death, among women with recurrence limited to the SCV alone, overall survival after isolated SCV recurrence can be long (25% >5 years).

Management of locoregional recurrence of breast cancer

The locoregional recurrence of breast cancer is not a sign of distant metastases, and a substantial proportion of cases are cured by salvage therapy. Patients with locoregional recurrence should not be treated with palliative intent as if they have visceral metastases. The recommended treatment for ipsilateral breast recurrence after breast conservative therapy is a mastectomy. For patients who suffer from isolated chest wall recurrence after mastectomy, a surgical approach is recommended. Neoadjuvant chemotherapy is considered for patients with unresectable disease in order to render the disease resectable. For patients with isolated chest wall recurrence who have received no prior radiotherapy, postoperative radiotherapy involving the chest wall and regional lymph nodes is recommended. Patients with isolated axillary lymph node recurrence should be treated with axillary dissection or resection. Although the effectiveness of systemic therapy for patients with locoregional recurrence is unclear, there is a trend toward treating patients with supraclavicular lymph node recurrence with radiotherapy plus systemic therapy. Pain relief and the eradication of other distressing symptoms resulting from inoperable disease are achieved in two-thirds to three-quarters of patients by radiotherapy with or without systemic therapy. New anti-cancer agents and molecular target therapies should be evaluated with the objective of improving the treatment outcome of patients with locoregional recurrence. A combination of approaches is required for treatment of patients with locoregional recurrence, and a multidisciplinary tumor board should be organized at each institute.

Clinical characteristics of women presenting with skin-only recurrence of breast cancer

Background Locoregional failure after breast cancer treatment is usually heralded as a significant risk factor for systemic recurrence. However, locoregional recurrence may have different presentations, some of which may represent a more benign course. An example of this is the phenomenon of isolated chest wall recurrence (CWR). Given the paucity of data describing the clinical outcomes of women who recur this way, we sought to review the natural history and prognosis of patients presenting with this specific presentation. Methods Women who previously underwent primary treatment for breast cancer and subsequently developed an isolated CWR were identified. Histologic and treatment data as it related to their primary diagnosis and demographic data were obtained by chart review. Modalities of treatment for isolated CWR were also collected. Results We identified 17 patients who experienced an isolated CWR from January 1987 to May 2005. The median age at original diagnosis was 61 years (range 33–94 years). Median time to isolated CWR was 20 months (range 6–134). Eleven patients were treated with primary resection, 12 with radiotherapy, and 3 with a combination of hyperthermia and electron beam radiation. Ten patients went on to receive endocrine therapy, 6 received chemotherapy, and 2 were observed. Ten of these patients (58%) experienced a second event and for this group the median time to second event was 24 months (range 8–109). Median overall survival was 80 months (range 3–134) for the entire cohort. Conclusions Patients experiencing a chest wall recurrence may have a benign course suggesting this may be an indolent presentation of local regional recurrence. The proper therapy of these patients may require further study.

Full-Thickness Chest Wall Resection for Recurrent Breast Carcinoma: An Institutional Review and Meta-analysis

Locoregional recurrence of breast cancer can occur in up to 30 per cent of patients and has often been considered to indicate a poor prognosis. We reviewed our experience with full-thickness chest wall resection for recurrent breast cancer and conducted a meta-analysis of the English literature to determine patient characteristics and outcomes. Twenty-two women with isolated chest wall recurrence of breast cancer were treated between 1970 and 2000 at our institution. We reviewed their preoperative demographics, operative management and outcome, and combined our results with seven other English language studies. A majority of women (90%) underwent a mastectomy as initial management of their breast cancer. Only 18 per cent of patients had metastatic disease at the time of chest wall resection, and 71 per cent of patients had an R0 resection. The 5-year disease-free survival at City of Hope National Medical Center (COH) was 67 per cent and was 45 per cent for the entire group of 400 patients. The 5-year overall survival was 71 per cent for the COH group and 45 per cent for the entire group. Several studies reported prognostic factors, the most common being a better prognosis in patients with a disease-free interval greater than 24 months. Full-thickness chest wall resection for patients with isolated local recurrence of breast cancer can provide long-term palliation and even cure in some patients.

Locoregional treatment outcomes for patients with ipsilateral supraclavicular metastases at diagnosis of breast cancer

Locoregional treatment outcomes for patients with ipsilateral supraclavicular metastases at diagnosis of breast cancer

Radiation therapy for chest wall recurrence of breast cancer after mastectomy in a favorable subgroup of patients

Purpose: Long-term outcome after radiation therapy for local–regional recurrence of breast cancer after mastectomy is generally poor. This study was performed to evaluate the long-term outcome for a potentially favorable subgroup of patients with chest wall recurrence. Methods and Materials: Of 71 patients with an isolated local–regional recurrence of breast cancer after mastectomy, 18 were identified who met the following favorable selection criteria: 1) a disease-free interval after mastectomy of 2 years or more, 2) an isolated chest wall recurrence, and 3) tumor size < 3 cm or complete excision of the recurrent disease. All 18 patients were treated with local–regional irradiation between 1967 and 1988. Radiotherapy (RT) was delivered to the chest wall to a median total dose of 60 Gy (range 30–66 Gy). Four patients received adjuvant chemotherapy and six patients received adjuvant hormonal therapy. Results: With a median follow-up of 8.4 years, nine of 18 patients were alive and free of disease. The 10-year actuarial overall and cause-specific survivals were 72% and 77%, respectively. The 10-year actuarial relapse-free survival and local control were 42% and 86%, respectively. Conclusion: Treatment for a local–regional recurrence of breast cancer after mastectomy in a favorable subgroup of patients results in a high rate of long-term survival as well as excellent local control. Aggressive treatment is warranted in this favorable subgroup of patients. 1998 Elsevier Science Inc.

Outcome of surgical resection for chest wall recurrence in breast cancer patients.

Although recurrent breast cancer is a systemic disease, there might be several exceptions where local treatment has a favorable outcome. From 1989 to 1996, 15 patients underwent full thickness chest wall resection, supported by peri- and postoperative systemic treatments for patients with isolated chest wall recurrences, including soft tissue local recurrence and parasternal lymph node metastasis. The 5-year survival rate after surgical removal was 47%. Patients with > 5-year disease-free intervals (DFI) after mastectomy showed a long survival after chest wall resection. Local failures appeared in four cases whose surgical margins were positive. No serious complication except one pyothorax occurred after surgery. It is suggested that surgical treatment with a full thickness chest wall resection might have a favorable prognosis for selected patients with solitary lesion and long DFI.

Surgical treatment for chest wall recurrence of breast cancer

From 1977 to 1987, 23 patients with isolated chest wall recurrence, excluding sternal metastasis, from breast cancer underwent full thickness chest wall resection. The 5-year survival rate after chest wall resection was 48%, but the 5-year relapse-free survival rate was 26%. Mediastinal metastasis was proved histologically at the time of chest wall resection in 7 patients, and survival period with mediastinal involvement was significantly ( P < 0.01) shorter than that with no mediastinal involvement ( n = 16). In 17 patients with a long disease-free interval (DFI ≥ 24 months), survival was longer than in 6 patients with a short DFI (< 24 months). For the selected patients without mediastinal involvement and long DFI, surgical treatment for chest wall recurrence of breast cancer should play a significant role in improving the quality of life, and even in prolonging the survival rate.

The results of radiation therapy for isolated local regional recurrence after mastectomy

Between 1967 and 1988 128 patients with isolated local-regional recurrence of breast cancer after mastectomy were treated with definitive radiation therapy. Recurrence was confined to a single site in 108 patients and multiple sites in 20. The chest wall was the most common location (86) and the supraclavicular region was the second most common (20). Surgical treatment for recurrence prior to irradiation consisted of excision of all gross disease in 78 patients and incisional biopsy in 49 patients. Irradiation was directed to the entire chest wall in 19% of patients with isolated chest wall recurrences and to the chest wall and regional nodes in 81%. In patients with isolated nodal failures, treatment was directed to the nodal site and chest wall in 87% and to the regional site alone in 13%. Patients with multiple sites received treatment to the chest wall and regional nodes in all cases. Electively treated sites usually received 4500–5000 cGy. Following excision of chest wall disease, the median dose was 6000 cGy. Gross disease on the chest wall received a median dose of 6100 cGy. Gross disease in nodal sites received a median dose of 5600 cGy; 66 patients received systemic therapy at recurrence. The 5-year actuarial local-regional control was 43%. In a multivariate analysis only the estrogen receptor status of the recurrence remained significant (p = .002). The 5-year actuarial survival was 49% with a relapse-free survival of 24%. In a multivariate analysis for survival, the disease-free interval (p = .007 local regional control (p = .006), and excisional biopsy for recurrence (p = .03) remained significant. In a multivariate analyis for relapse-free survival, the disease-free interval (p = .03), excisional biopsy (p = .0001 and the extent of axillary nodal involvement (p = .007) remained significant. In the subgroup of patients with a disease-free interval ≥ 24 months, excisional biopsy, and local regional control, the 5-year survival was 61% with a relapse-free survival of 59%. This subgroup represents 18% of the entire group and has a relatively good prognosis after recurrence.

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

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.

Analysis of prognostic factors in patients with isolated chest wall recurrence of breast cancer.

A retrospective analysis of a series of 162 patients treated for isolated chest wall recurrence of breast cancer after mastectomy was undertaken. Cumulative survival, distant relapse-free survival, and freedom from local progression after 5 years from the diagnosis of recurrence were 34%, 28%, and 45% respectively. Five prognostic factors influenced survival: axillary node status, primary T stage, length of disease-free interval, and number and size of recurrences. Four prognostic factors influenced the local control: axillary node status, primary T stage, disease-free interval, and number of recurrences. Patients with three or more, out of five, favorable prognostic factors fared much better than those with two or less: 75% versus 15% survival at 5 years. Our findings suggest that it is possible to identify a group of patients with a distinctly good medium-term survival and local control of disease.

Local control and outcome of patients irradiated for isolated chest wall recurrences of breast cancer

Between January 1970 and December 1978, 149 breast cancer patients with isolated chest wall recurrences developing after initial curative treatment (mastectomy with or without postoperative irradiation) were referred to the University Clinic for Radiotherapy and Radiobiology of Vienna. Following radiotherapy, survival was analysed in 134 patients with regard to the amount of disease in the chest wall at the time of treatment and local tumour control. Patients with "subclinical" disease (after excision of solitary recurrences) had a median survival time of 55 and 50 months for controlled and uncontrolled disease in the entire chest wall, respectively. The corresponding survival times for patients with "macroscopic" chest wall disease was 36 and 25 months, respectively. Local tumour control within the irradiated field was 69% for patients with subclinical disease and 49% for patients with macroscopic tumour manifestation. Freedom from tumours in the entire chest wall could be achieved in 41% of patients with subclinical and 24% of patients with macroscopic disease. The 5-year survival rate for patients with subclinical disease, with tumour control in the entire chest wall is 53%. Of all 134 patients, 22% survived 5 years from the time of local recurrence.