Breast Cancer: Strategies for the 1990s II

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Management of Local and Regional Recurrence After Mastectomy or Breast -Conserving Treatment Frederick C. Ames, MD, * and Charles M. Balch, MDt Local and regional recurrence continues to present a challenge to the clinician despite advances in early detection and multimodal treatment of primary breast cancer. Local and regional recurrences now include not only failures on the chest wall and in the undissected regional lymph nodes but also in the breast parenchyma itself after breast-conserving surgery and radiation. Although chest wall and regional nodal failures developing after standard radical surgery traditionally carried a poor overall prognosis, patients suffering local failures after breast conservation and radiation now are frequently salvaged. In addition, even patients with chest wall and regional nodal failures may enjoy extended survival, so that treatment for palliation and the occasional long-term survival or cure is an important goal (Fig. 1). On the other hand, because salvage surgery for patients with breast failures after lumpectomy and radiation is often successful, the detection of such recurrences and their prompt treatment is given the highest priority. The treatment for each of these categories of patients involves an understanding of the natural history of disease in the individual patient and the previous treatments received. Overall, the goals of treatment, as for the primary cancer, are an improved quality oflife, the greatest degree of locoregional control, and the best chance of cure. LOCAL RECURRENCE AFTER MASTECTOMY "Local recurrence after mastectomy" refers to recurrence of breast cancer on the chest wall at the site of previous mastectomy either in the skin flaps peripherally or along the surgical scar itself. Proposed etiologies of such recurrences include tumor cells left by inadequate initial resection of the primary tumor, a surgical transection of disease-containing lymphatic channels, or hematogenous spread to the surgical wound. There is evidence From the University of Texas M.D. Anderson Cancer Center at Houston, Houston, Texas *Surgeon and Associate Professor of Surgery, Section of General Surgery, and Robert F. Fly Chair in Surgery tProfessor and Head, Division of Surgery; Chairman, Department of General Surgery; and Senator A.M. Aiken, Jr, Chair Surgical Clinics of North America-Vol. 70, No.5, October 1990

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FREDERICK C. AMES AND CHARLES

M.

BALCH

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20

Advanced relapse O~~-,._~_.~-._~_.-,.-._~~-r-,_~_,._~_.~__,

o

6

12

18

24

30

38

42

48

80

Time in Months Figure 1. Actuarial survival after locoregional recurrence. Patients with recurrences no larger than 5 cm in diameter or resectable nodal disease (n = 33) are compared with those with more advanced recurrences (n = 16).

for all three mechanisms. Regardless of etiology, most patients who suffer chest wall recurrence ultimately develop distant metastases, indicating an overall poor prognosis. 3. 5, 6, 10. 15, 31 The incidence of local recurrence after mastectomy for operable breast cancer (stage I and stage II) averages between 4% and 20% in many series. 9, 10, 12, 17, 30, 32 Several authors have correlated the risk of local recurrence with the initial nodal status and the size of the primary tumor,g, 10, 34 In the B-04 trial of the National Surgical Adjuvant Breast Project (NSABP), however, the local recurrence rate after radical mastectomy was 5% for patients with negative lymph nodes and only 8% for patients with positive lymph nodes. 11 Data on the relation of the estrogen- or progesterone-receptor status as an independent variable predicting local recurrence are inconclusive. Unfortunately, the incidence of local recurrence after mastectomy has been little affected by the use of adjunctive chemotherapy,4, 8,16,25,28 so that local recurrences continue to be a problem. Although historically most patients haVing chest wall recurrences have ultimately had distant metastases, some patients may have long diseasefree intervals after the development of recurrence, and a few can be cured. Some authors have reported that patients who originally had stage I disease lived an average of 7.2 years after recurrence, whereas those who had stage II disease initially lived an average of only 2.5 years. 15 Some patients lived as long as 23 years before developing metastatic disease, highlighting the importance of locoregional control for palliation in these patients. Although other authors have not been able to correlate survival after recurrence with initial stage, they have been able to identify subsets of patients suffering local recurrence who have long-term survival. 3, 10,22,23,24,30 Other authors

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MANAGEMENT OF LOCAL AND REGIONAL RECURRENCE

have found that the size and number of recurrences, as well as the diseasefree interval between the initial treatment and local recurrence, may be related to survival. I, 3, 20 Although observations concerning prognostic variables for these patients vary, it seems clear that some patients may enjoy long-term survival or even cure. Therefore, every effort should be made to achieve locoregional control for palliation with the expectation of occasional cures. The principal question facing the clinician is how to achieve and maintain local control and at the same time address the high risk of systemic failure. Local recurrences after mastectomy may be either single or multiple. and may be anywhere in the field of previous dissection. Although a solitary small recurrence in the surgical scar might represent a focus of retained primary tumor incompletely excised at mastectomy, the subsequent natural history in most patients suggests either a diffuse lymphatic or hematologic origin for such metastases, because further local recurrences are the norm. Several authors have therefore employed radiotherapy to the chest wall for such patients. I, 5, 8, 15, 20, 23, 24 Recent reports of patients treated with comprehensive radiation suggest an average overall probability of local control of 40% to 50% at 5 years, with an average 5-year survival rate of approximately 30% to 50%.1,5,20,23,24 Patients with smaller solitary recurrences have a much greater probability of local control and survival. I, 20, 30 Regrettably, however, many patients have or will develop multiple recurrences, and more than one third will develop persistent locoregional disease. Two recent reviews of patients with locoregional recurrences treated at The University of Texas MD Anderson Cancer Center form the basis of our current management of these patients. In an analysis of 255 patients with chest wall and regional nodal recurrences treated before the era of effective systemic polychemotherapy, 194 patients could be treated with curative intent by excision where feasible and radical radiation (more than 4500 rads).5 Thirty-two per cent of these patients were treated only to a single recurrence site and 11% to two sites, and 57% (110 patients) received radiation to the chest wall and regional lymph nodes (Table 1). Overall 36% of patients suffered another recurrence, including 27% of patients treated Table 1. Factors Affecting Survival After Chest Wall Recurrences DISEASE-FREE SURVIVAL

5 Years

10 Years

0 1-3

48 29

24

0.05

~4

11

11 11

0.001

45 10

26 10

0.001

35 13

21 6 34 15

0.01

FACfOR

p

Axillary nodes involved

Chest wall recurrence Single Multiple Recurrence No prior Prior Controlled Uncontrolled

63 34

0.057

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only to the local recurrence site, who had further recurrences in an adjacent unirradiated area that would have been treated by a comprehensive field. The 5-year survival rate for those patients with sustained local control was 63% compared with only 34% for those with uncontrolled locoregional disease. Among patients with histologically negative nodes at the time of mastectomy and only a solitary chest wall recurrence, 78% achieved local tumor control, with a 5-year disease-tree survival rate of 48%. A more recent review of 164 patients with locoregional recurrences treated during the era of multidrug chemotherapy also showed improved control for patients with single chest wall recurrences compared with those with multiple recurrences (Table 2).20 For patients with histologically negative nodes at the time of initial mastectomy, 67% achieved focal tumor control at 5 years, compared with only 24% of patients with four or more positive nodes initially. The disease-free survival rates were 50% at 5 years for patients with histologically negative nodes at the time of mastectomy versus only 6% for patients with four or more positive nodes. An analysis of the groups of patients treated with radiotherapy alone, chemotherapy alone, and a combination of radiation and chemotherapy is difficult, because the groups were dissimilar largely as a result of physician selection. There was no significant difference in the survival rates of the three groups. The group treated with radiation therapy alone included more patients with four or more positive lymph nodes (31%) than did the groups treated with chemotherapy alone (16%) or combined radiotherapy and chemotherapy (19%). Patients treated with chemotherapy alone experienced a locoregional failure rate of 54% compared with 35% in patients treated with radiotherapy alone and 33% in patients treated with both radiotherapy and chemotherapy. Of interest was the observation that patients treated with both radiotherapy and chemotherapy presented with more extensive recurrences. Only 26% of such patients had a solitary chest wall nodule in contrast to 46% of the patients treated with radiotherapy alone and 54% of those treated with chemotherapy alone. Although none of the differences in either locoregional failure or survival rates were statistically significant on retrospective analysis, it appears that the group treated with combined radiation therapy and chemotherapy presented with more advanced recurrences and that combined treatment for such patients may have accounted for the observed locoregional control and survival, which was equal to that of the other two groups with less extensive locoregional recurrences. Our current management of patients with chest wall recurrences after mastectomy is directed at achieving the highest degree of loco regional Table 2. Incidence of Locoregional Failure and Survival After Chest Wall Recurrence TREATMENT

Radiotherapy Chemotherapy Combined

*P

=

0.049.

NO. OF PATIENTS

LOCOREGIONAL FAILURE (%)

DISTANT METASTASIS (%)

5-YEAR DISEASEFREE SURVIVAL (%)

57 50 57

35* 54* 33

60

22 37 33

48

63

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MANAGEMENT OF LOCAL AND REGIONAL RECURRENCE

control and at the same time recognizing the high risk of subsequent systemic failure. From our data and those of others, it appears that the risk of subsequent recurrence on the chest wall is sufficiently high even in patients with solitary recurrences to warrant the use of radical radiation followed by surgical excision wherever feasible. At least 5000 rad is delivered to the chest wall plus the supraclavicular and internal mammary lymph nodes if they have not previously been treated. In all patients, there remains a high risk of subsequent systemic failure, and we currently recommend adjuvant systemic therapy, considering these patients to have stage IV breast cancer without evidence of disease (stage IV NED). For healthy premenopausal or postmenopausal patients, we currently recommend an aggressive regimen using 5-Huorouracil, doxorubicin, and cyclophosphamide. In elderly (over 75 years) or infirm patients whose disease is estrogen-receptor positive, tamoxifen is given. Patients who have multiple chest wall recurrences in general receive systemic chemotherapy first followed by interval radiation therapy with or without surgical excision, where feasible, in a regimen similar to that used for advanced primary breast cancer. 19 Where adjuvant systemic therapy has previously been used, an alternate drug regimen is initiated at the time of recurrence. In patients who do not achieve any response, we currently are considering alternative regimens of experimental drugs or intensification treatment with bone marrow rescue. In those patients who have persistent recurrence without any evidence of distant metastases, radical chest wall resection is sometimes indicated. 26 Over the past 10 years, 27 patients have undergone radical resection of recurrent breast cancer on the chest wall with myocutaneous Hap repair, including 18 patients with full-thickness chest-wall resection (Table 3). This was a diverse group of patients, many of whom had failed multimodality therapy. The average hospital stay was 18 days with no in-hospital deaths. Nine patients who had tumors that could be excised completely obtained an average survival of 46 months. The remaining 18 patients had either distant metastases or extensive recurrence with positive resection margins but underwent radical excision of a painful, foul-smelling, fungating mass with only limited palliation and relief of symptoms expected. In this group of patients, interestingly, the average hospitalization was only 23 days, and the average survival was over 20 months. Overall, palliation was judged fair to good in these patients, in whom the primary goal was to relieve debilitating symptoms. TREATMENT OF REGIONAL NODAL RECURRENCES Recurrences in the regional lymphatics after primary treatment, although uncommon, may develop in the axilla or subclavicular nodes, the supraclavicular nodes, or the internal mammary chain. Table 3. Survival After Radical Excision of Chest Wall Recurrence MEAN HOSPITAL STAY

MEAN SURVIVAL

POSTOPERATTVESTATUS

NO. OF PATIENTS

(DAYS)

(MONTHS)

No residual disease Residual or metastases Total

9 18 27

9.7 23.1 18.6

46.1 20.7 29.2

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Recurrence in the axilla after formal lymph node dissection (at least levels I and II) is rare. In the report of the NSABP B-06 trial comparing total mastectomy and axillary dissection (modified radical mastectomy) with segmental mastectomy and axillary dissection with or without radiation, overall only 2.5% of patients suffered an axillary failure. 12 In the earlier NSABP B-04 trials, the rate of failure in the axilla for patients undergoing radical mastectomy was 1. 4% if the nodes were clinically negative and 1% if the nodes were clinically positive. l l In this same trial, supraclavicular recurrences developed after radical mastectomy in 1.1% of patients with clinically negative lymph nodes initially and 5.1% of patients with clinically positive lymph nodes initially. There were no reports of failures in the sub clavicular or parasternal lymph nodes. The addition of radiation therapy to the regional lymphatics in one arm of that trial effectively eliminated regional nodal failures, with only one recurrence (supraclavicular) among 546 eligible patients who underwent radiation for both clinically negative and clinically positive axillae. In the B-06 trial, a total of 2.3% of patients had recurrences in the supraclavicular lymph nodes, and only 4 of 1855 eligible patients developed parasternal recurrences. 12 Patients receiving radiotherapy were treated to the breast only, without radiation to the supraclavicular or internal mammary lymph nodes. It is clear, therefore, that regional recurrences rarely follow standard primary treatment with formal axillary dissection for either stage lor II breast cancer. This is rather surprising in view of the known overall incidence of internal mammary lymph node metastases among patients with stage I and II breast cancer, which averages 15% to 20%.33 The treatment of regional lymph node recurrences depends on the nature of previous treatment and is directed toward achieving locoregional control while addressing the increased risk of systemic failure. Except for moveable axillary recurrences, which are uncommon, surgical resection of regional nodal recurrences usually is not feasible. This is especially true for parasternal recurrences, which usually represent internal mammary lymph nodes that have eroded through the intercostal spaces. For the most part, our current plan of management is similar to that for multiple chest wall recurrences. We initiate systemic therapy with subsequent loco regional therapy depending on the response and previous treatment. Mobile disease that can be excised is resected when feasible. More often, interval radiation is used at the site of recurreqce and at the other nodal basins at risk (supraclavicular and internal mammary nodes). If an axillary recurrence involves extranodal connective tissue, the axilla is treated as well. For patients who have previously received radiation, either to the breast as a component of breast conservation or to the chest wall or lymphatic areas after mastectomy, chemotherapy usually is the initial treatment. Residual disease that can be excised cleanly is resected when feasible. Only recurrences that can be excised cleanly with an acceptable morbidity should be resected. Internal mammary recurrences, because of their nature, usually require full-thickness chest-wall resection, which, although technically possible, is rarely indicated. Survival rates after nodal recurrences following axillary dissection for breast cancer are poor and reflect the tumor biology expected in patients

MANAGEMENT OF LOCAL AND REGIONAL RECURRENCE

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with multiple positive lymph nodes. Although the incidence of subsequent systemic failure is high among these patients, a long disease-free state can be achieved in some patients, so that every reasonable effort is made to achieve locoregional control and to treat potential systemic failure. Patients who previously received adjuvant systemic therapy are offered either second-line drugs or high-dose chemotherapy with bone marrow rescue in an ongoing clinical trial. For patients who have undergone primary treatment for breast cancer that did not include axillary dissection and who develop axillary recurrences, formal axillary dissection is indicated. Our current recommendation for such patients, however, is induction systemic chemotherapy prior to axillary dissection in a regimen similar to that used for advanced primary breast cancer. 19 Axillary radiation would be used in this setting only if it had not been given previously and if more than one level of lymph nodes was positive or there was connective tissue involvement. In patients who have undergone primary breast-conservation treatment with radiotherapy to the breast, radiation to the supraclavicular lymph nodes or internal mammary area usually is not possible because it would entail overlapping fields.

MANAGEMENT OF BREAST RECURRENCES AFTER BREAST-CONSERVING SURGERY The reported incidence of recurrence after breast-conserving surgery and radiation for operable breast cancer ranges from 1% to 2% of patients treated per year over follow-up periods of 5 to more than 15 years. 7, 12, 14, 18,26, 29 The recurrence rates for patients undergoing segmental mastectomy without radiation are much higher, from 37% for patients with negative axillary lymph nodes to 43% for patients with positive axillary lymph nodes at 8 years' follow-up. 13 Recurrences after breast conservation with or without radiation usually are localized and in the region of the initial tumor excision. Unfortunately, however, approximately 10% to 15% of breast recurrences will be either diffuse or will involve the skin, which sometimes presents with an inflammatory-type picture. 13, 18, 26, 29 In general, the usual treatment for breast recurrence after breast conservation is total mastectomy, although some series suggest that some patients with small isolated recurrences (especially lesions less than 2 cm) may be treated safely by wide local re-excision. 21 The reported 5-year survival rates for patients having salvage treatment for localized recurrences range from approximately 50% to more than 80% (Table 4). Few lO-year data are available, but survival rates exceeding 50% have been reported. 21 Only limited data are available for patients with diffuse or extensive disease involving skin or subcutaneous lymphatics, but the prognosis clearly is much more uncertain, with survival rates at 5 years as low as 13% reported in one series. I8 Overall, it seems clear from most series that the characteristics of the recurrent tumor, including the size of the invasive component and the presence or absence of skin invasion, in large part determine the risk of subsequent systemic failure. 1, 18, 21, 29 Our guidelines for treating patients with breast recurrence after breast-

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Table 4. Survival After Localized Breast Recurrences Following Breast Conservation and Radiation NUMBERS OF SERIES

PERCENT SURVIVAL

Patients

Recurrence

5 Years

10 Years

436 518 278

24 56

81*

NA NA NA 64* NA NA

Clarke et al (1985)1 Fourquet et al. (1989)14 Haffty et al. (1989)18 Kurtz et al. (1988)21 Recht et al. (1988)26 Stotter et al. (1989)29

1245 747 536

31 118

84 55

73t 48t 79* 63*

63t

*Disease-free survival. tOverall survival. NA = data not available in article.

conserving surgery are determined by the stage of the recurrence. Patients with isolated recurrences and no apparent skin invasion on clinical examination or mammography undergo total mastectomy. In our patients, axillary dissection is carried out at the time of primary treatment. Patients who are referred with breast recurrence who have not previously had axillary dissection undergo such dissection at the time of salvage mastectomy, because approximately one third will have nodal metastases. Adjuvant systemic chemotherapy is planned as we would in the case of primary breast cancer on the basis of the size, nuclear grade, and other prognostic features of the recurrence. Patients who present with more advanced recurrence (diffuse disease or skin involvement) are treated as are those with advanced primary breast cancer with induction systemic chemotherapy and interval mastectomy after three cycles of treatment. 19 Subsequent chemotherapy is guided by the response to induction chemotherapy, with another regimen being used for patients whose tumor does not respond. A recent review of patients treated for local breast recurrence after breast-conserving surgery and radiation at The University of Texas System Cancer Center revealed an actuarial survival rate at 5 years of 63%29 (Table 1). Sixteen of the fifty-five patients experiencing local recurrence in that review had an advanced recurrence, and of those, seven have already developed metastases after a median interval of only 5 months. The remaining nine patients with advanced recurrences have been followed a median of only 11 months but remain free of disease. A number of patients have undergone breast reconstruction after salvage mastectomy follOWing breast conserving and radiation. Our observations agree with those of others that no unusual complications have been observed in these patients. 1 Our preference is to reserve immediate breast reconstruction for patients who have earlier-stage recurrences and whose disease is stable. In general, we prefer breast reconstruction using myocutaneous flaps, most commonly the transrectus abdominis myocutaneous flap. In some patients, the irradiated tissues have not responded normally to tissue expansion, which now is reserved for patients in whom there is little radiation change and whose tissues are very pliable.

MANAGEMENT OF LOCAL AND REGIONAL RECURRENCE

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SUMMARY Locoregional failures after primary treatment for breast cancer include a diverse group of lesions that represent different categories of failures with various prognoses. Although patients with chest wall recurrences and regional nodal failures after traditional radical surgery have a poor prognosis, many patients can still achieve a significant degree of palliation and even long-term survival or cure with carefully orchestrated multimodal treatment. In patients who have breast failures after breast-conservation surgery and radiation, long-term salvage and cure can be achieved for the majority with prompt detection and appropriate treatment, which, like treatment for primary breast cancer, includes a consideration not only of local control but also of the risk of subsequent systemic failure and its need for treatment.

REFERENCES 1. Aberizk WJ, Silver B, Henderson IC, et al: The use of radiotherapy for treatment of isolated locoregional recurrence of breast carcinoma after mastectomy. Cancer 58:12141218, 1986 2. Beck TM, Hart NE, Woodard DA, et al: Local or regionally recurrent carcinoma of the breast: Results of therapy in 121 patients. J Clin Oncol 1:400-405, 1983 3. Bedwinck 1M, Lee J, Fineberg B, et al: Prognostic indicators in patients with isolated local-regional recurrence of breast cancer. Cancer 47:2232-2235, 1981 4. Bonadonna G, Valagussa P, Rossi A, et al: Ten-year experience with CMF-based adjuvant chemotherapy in resectable breast cancer. Breast Cancer Res Treat 5:95-115, 1985 5. Chen KK, Montague ED, Oswald MJ: Results of irradiation in the treatment of locoregional breast cancer recurrence. Cancer 56:1269-1273, 1985 6. Chu FCH, Lin F, Kim JH, et al: Locally recurrent carcinoma of the breast: Results of radiation therapy. Cancer 37:2677-2681, 1976 7. Clarke DH, Le MG, Sarrazin D, et al: Analysis oflocal-regional relapses in patients with early breast cancers treated by excision and radiotherapy: Experience of the Institut Gustave-Roussy. Int J Radiat Oncol Bioi Phys 11:137-145, 1985 8. Danoff BF, Coia LR, Cantor RI, et al: Locally recurrent breast carcinoma: The effect of adjuvant chemotherapy on prognosis. Radiology 147:849-852, 1983 9. Deck KB, Kern WHo Local recurrence of breast cancer. Arch Surg 111:323-325, 1976 10. Donegan WL, Perez-Mesa CM, Watson RF: A biostatistical study of locally recurrent breast carcinoma. Surg Gynecol Obstet 122:529-540, 1966 11. Fisher B, Redmond C, Fisher ER, et al: Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med 312:674-681, 1985 12. Fisher B, Redmond C, Poisson R, et al: Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 320:822-828, 1989 13. Fisher ER, Sass R, Fisher B, et al: PathologiC findings from the National Surgical Adjuvant Breast Project (Protocol 6) II: Relation of local breast recurrence to multicentricity. Cancer 57:1717-1724, 1986 14. Fourquet A, Campana F, Zafrani B, et al: Prognostic factors of breast recurrence in the conservative management of early breast cancer: A 25-year follow up. Int J Radiat Oncol Bioi Phys 17:719-725, 1989 15. Gilliland MD, Barton RM, Copeland EM III: The implications of local recurrence of breast cancer as the first site of therapeutic failure. Ann Surg 197:284-287, 1983 16. Griem K, Henderson IC, Gelman R, et al: The role of radiotherapy in patients receiving adjuvant chemotherapy after mastectomy: Results of a randomized trial [abstract). Proc Am Soc Therapeutic Radiol Oncol 11(suppl):151, 1985

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17. Haagensen CD, Stout AP: Carcinoma of the breast I: Results of treatment. Ann Surg 116:801-813, 1942 18. Haffty BG, Goldberg NB, Fischer D, et al: Conservative surgery and radiation therapy in breast carcinoma: Local recurrence and prognostic implications. Int J Radiat Oncol BioI Phys 17:727-732, 1989 19. Hortobagyi GN, Ames FC, Buzdar AU, et al: Management of stage III primary breast cancer with primary chemotherapy, surgery and radiation therapy. Cancer 62:25072516, 1988 20. Janjan NA, McNeese MD, Buzdar AU, et al: Management oflocoregional recurrent breast cancer. Cancer 58:1552-1556, 1986 21. Kurtz JM, Amalric R, Brandone H, et al: Results of wide excision for mammary recurrence after breast-conserving therapy. Cancer 61:1969-1972, 1988 22. Magno L, Bignardi M, Micheletti E, et al: Analysis of prognostic factors in patients with isolated chest wall recurrence of breast cancer. Cancer 60:240-244, 1987 23. Mendenhall NP, Devine JW, Mendenhall WM, et al: Isolated local-regional recurrence following mastectomy for adenocarcinoma of the breast treated with radiation therapy alone or combined with surgery and/or chemotherapy. Radiother Oncol 12:177-185, 1988 24. Patanaphan V, Balazar OM, Poussin-Rosillo H: Prognosticators in recurrent breast cancer: A 15-year experience with irradiation. Cancer 54:228-234, 1984 25. Rao AR, Murthy AK, Hendrickson FR, et al: Analysis of risk factors for loco-regional failure in stage II (T1NIMO and T2N1MO) breast cancer treated with mastectomy and adjunctive chemotherapy [abstract). Proc Am Soc Therapeutic Radiol Oncol l1(suppl): 151, 1985 26. Recht A, Schnitt SJ, Connolly JL, et al: Prognosis following local or regional recurrence after conservative surgery and radiotherapy for early stage breast carcinoma. In t J Radiat Oncol BioI Phys 16:3-9, 1988. 27. Shah JP, Urban JA: Full thickness chest wall resection for recurrent breast cancer involving the bony chest wall. Cancer 35:567-574, 1975 28. Stefanik D, Goldberg R, Byrne P, et al: Local-regional failure in patients treated with adjuvant chemotherapy for breast cancer. J Clin Oncol 3:660-665, 1985 29. Stotter AT, McNeese MD, Ames FC, et al: Predicting the rate and extent oflocoregional failure after breast conservation therapy for early breast cancer. Cancer 64:2217-2225, 1989 30. Tomin R, Donegan WL: Screening for recurrent breast cancer: Its effectiveness and prognostic value. J Clin Oncol 5:62-67, 1987 31. Toonkel LM, Fix I, Jacobson LH, et al: The significance of local recurrence of carcinoma of the breast. Int J Radiat Oncol BioI Phys 9:33-39, 1983 32. Valagussa P, Benadonna G, Veronesi U: Patterns of relapse and survival following radical mastectomy. Cancer 41:1170-1178,1978 33. Veronesi U, Cascinelli N, Greco M, et al: Prognosis of breast cancer patients after mastectomy and dissection of internal mammary nodes. Ann Surg 202:702-707, 1985 34. Zimmerman KW, Montague ED, Fletcher GH: Frequency, anatomical distribution and management of local recurrences after definitive therapy for breast cancer. Cancer 19:67-74, 1966

Address reprint requests to Frederick C. Ames, MD Section of General Surgery The University of Texas M. D. Anderson Cancer Center 1515 Holcombe Boulevard Houston, Texas 77030

Management of local and regional recurrence after mastectomy or breast-conserving treatment.

Locoregional failures after primary treatment for breast cancer include a diverse group of lesions that represent different categories of failures wit...
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