What are the treatment options for a patient with breast cancer recurrence after partial mastectomy?

Treatment for Breast Recurrence After Partial Mastectomy

The standard treatment for local breast recurrence after partial mastectomy (breast-conserving surgery) is total mastectomy, which achieves excellent local control (95%) and favorable long-term survival outcomes. 1

Primary Surgical Management

Mastectomy is the definitive standard treatment for isolated local recurrence following breast-conserving therapy 1:

• Simple total mastectomy is the standard surgical approach, providing 95% local-regional control after salvage surgery 1, 2
• Immediate breast reconstruction can be considered as an option 1
• Radiotherapy should generally not be used as primary treatment except in specific cases where mastectomy is not feasible 1

When Breast-Conserving Surgery Might Be Considered

Repeat breast-conserving surgery is only an option if 1:

• The patient explicitly refuses mastectomy, OR
• Mastectomy is technically impossible

Critical caveat: Patients choosing repeat breast conservation must be informed of the high risk of subsequent recurrence 1. This approach should be considered suboptimal, as salvage mastectomy provides superior local control (88% at 5 years) compared to breast-conserving salvage procedures (64% at 5 years) 3.

Systemic Adjuvant Therapy After Salvage Surgery

Hormone Therapy

If estrogen receptors are present, adjuvant hormone therapy is recommended 1:

• Tamoxifen is indicated for ER-positive recurrent disease 4
• This applies regardless of menopausal status 1

Chemotherapy Considerations

The role of adjuvant chemotherapy after isolated local recurrence remains uncertain 1:

• Chemotherapy efficacy is unknown in this setting and should ideally be considered only within randomized clinical trials 1
• However, chemotherapy may be beneficial for patients with unfavorable prognostic features 2
• Consider systemic therapy based on the biology and extent of recurrent disease, particularly for early recurrences or those with adverse features 1

Management of Unresectable or Advanced Local Recurrence

For inflammatory or locally advanced uncontrolled recurrence 1:

• There is no established standard treatment 1
• Chemotherapy should be considered first, followed by radiotherapy if possible 1
• Chemotherapy is particularly appropriate for inflammatory recurrence 1
• Radiotherapy can be used if chemotherapy is contraindicated 1
• Attempt mastectomy after downsizing with systemic therapy if the lesion becomes operable 1

Regional Recurrence Management

For regional nodal recurrence 1:

• Axillary recurrence: Surgical resection if possible plus radiation therapy to chest wall, supraclavicular, infraclavicular nodes, and axilla 1
• Supraclavicular recurrence: Radiation therapy to chest wall and supraclavicular/infraclavicular nodes if possible 1
• Internal mammary node recurrence: Radiation therapy to chest wall, supraclavicular/infraclavicular nodes, and internal mammary nodes 1

Prognostic Factors and Expected Outcomes

Favorable Prognostic Indicators

The interval to recurrence is the most important prognostic factor 5, 3:

• Late recurrences (>5 years) have 84% 5-year survival 3
• Early operable recurrences <2 cm confined to the breast have 74% 5-year survival 3

Overall Survival After Salvage Mastectomy

Following salvage mastectomy for isolated breast recurrence 2, 6:

• 5-year overall survival: 84% 2
• 5-year disease-free survival: 59% 2
• Initial clinical tumor size is the only significant prognostic factor for survival 2

Histology of Recurrence Matters

The histology of recurrent tumor significantly impacts subsequent outcomes 6:

• No further recurrences occurred in patients with purely non-invasive or predominantly non-invasive disease with only focal invasion 6
• 55% 5-year actuarial further recurrence rate for predominantly infiltrating tumors 6

Supportive Care

Psychosocial support should be integrated throughout management 1:

• Psychological support may be required at various stages 1
• Social support should be provided routinely to help patients and families 1
• Patient rehabilitation groups can contribute to psychosocial support 1

Critical Clinical Pearls

• 93% of isolated breast recurrences are operable at presentation 3
• Only 10 of 181 patients (5.5%) with recurrence had prior or concomitant distant metastases 3
• 65% of recurrences occur in the vicinity of the original tumor, but as time interval increases, more recurrences appear in separate quadrants 2
• After 5 years, 54% of recurrences are in a separate quadrant, suggesting new primary tumors rather than true recurrences 2
• No pathologic factors reliably predict for localized vs. extensive disease at salvage mastectomy, reinforcing mastectomy as the preferred approach 2