What is the appropriate treatment for a 60‑year‑old woman with right‑sided breast carcinoma who underwent neoadjuvant chemotherapy, breast‑conserving surgery and radiotherapy and now has a supraclavicular lymph‑node recurrence?

Treatment for Supraclavicular Lymph Node Recurrence After Breast-Conserving Surgery

For this 60-year-old woman with isolated supraclavicular recurrence after prior breast-conserving surgery and radiotherapy, the optimal treatment is combined modality therapy consisting of radiation therapy (if not previously delivered to this region) plus systemic therapy based on tumor biology, as this approach provides the best chance for long-term disease control. 1

Initial Diagnostic Steps

Biopsy confirmation is mandatory before initiating treatment, as clinical assessment alone cannot distinguish between recurrence, second primary malignancy, or benign pathology. 2, 3

• Perform core needle biopsy or fine needle aspiration of the supraclavicular node 3
• Reassess ER, PR, and HER2 status on the recurrent specimen, as discordance between primary and recurrent tumors occurs frequently 1
• Complete metastatic workup including CT chest/abdomen/pelvis and bone scan (or PET-CT) to exclude distant disease 1
• Brain MRI should be considered in high-risk cases 1

Treatment Algorithm

Local-Regional Therapy

Radiation therapy to the supraclavicular and infraclavicular nodes is the primary local treatment for isolated supraclavicular recurrence. 1

• Deliver 50-60 Gy in standard fractionation (1.8-2.0 Gy per fraction) 2, 4, 5
• Include chest wall and supraclavicular/infraclavicular nodal regions in the radiation field 1
• Use CT-based treatment planning to minimize cardiac and pulmonary exposure 2, 4
• The radiation field should encompass the most caudal lymph nodes surrounding the subclavicular arch and base of the jugular vein 2, 4

Surgical resection may be considered in select cases where the recurrence is technically resectable, though radiation remains the standard approach. 6

• One study showed 5-year overall survival of 46.2% with supraclavicular lymph node dissection versus 37.5% with radiotherapy alone, though this was not statistically significant 6
• Surgery should be followed by radiotherapy if not previously administered 1

Systemic Therapy

Systemic therapy must be administered concurrently or sequentially with local treatment, as supraclavicular recurrence carries high risk for subsequent distant metastases. 1, 5

For ER/PR-Positive, HER2-Negative Disease:

• Consider initial chemotherapy if visceral crisis is present or if prior endocrine therapy was given within 1 year 1
• Otherwise, endocrine therapy is appropriate for non-visceral or asymptomatic disease 1
• Ovarian suppression plus endocrine therapy should be considered in premenopausal women 1

For ER/PR-Negative or Endocrine-Refractory Disease:

• Chemotherapy is indicated 1
• Doxorubicin-based regimens or paclitaxel for 6 courses is the standard approach 5
• Deliver radiation therapy between the 3rd and 4th chemotherapy cycle 5

For HER2-Positive Disease:

• Anti-HER2 therapy should be incorporated based on current breast cancer treatment standards 1

Prognosis and Expected Outcomes

Supraclavicular recurrence represents a serious but potentially curable condition when treated aggressively with combined modality therapy. 5, 7

• Overall clinical response rates of 95% can be achieved with combined chemotherapy and radiotherapy 5
• Median overall survival ranges from 29-48 months with aggressive treatment 5, 7, 8
• 5-year overall survival is approximately 35-46% with combined treatment 5, 6
• Complete remission rates are highest (67-76%) with combined local and systemic therapy versus systemic therapy alone (48%) 7
• Most patients (80-88%) will develop distant metastases within 5 years despite treatment 7, 9

Critical Prognostic Factors

Independent predictors of improved survival include:

• Combined local and systemic salvage treatment (versus systemic therapy alone) 7
• Low tumor grade 7
• Longer disease-free interval from initial diagnosis to recurrence (>2 years) 8
• Achievement of complete remission with treatment 7

Important Clinical Pitfalls

Do not treat supraclavicular recurrence as purely regional disease—it carries systemic implications and requires both local and systemic therapy. 9

• Supraclavicular recurrence should not be managed with local therapy alone, as this results in inferior outcomes 7, 9
• The previously irradiated axilla should not be re-irradiated except in cases of gross residual disease 1
• Treatment decisions should not be delayed—prompt initiation of therapy is associated with better outcomes 1
• If the patient received prior supraclavicular radiation as part of initial treatment, re-irradiation feasibility must be carefully assessed with radiation oncology 1