Introduction
Therapy of ipsilateral breast tumor recurrence
Definition of selection criteria for a second BCS
The DEGRO expert panel suggests the following selection criteria for a second breast conserving approach
Isolated ipsilateral breast tumor recurrence |
Limited size (< 2–3 cm) |
Unifocal disease on ultrasound, mammography, and MRI |
Age ≥ 50 years |
Long interval between primary treatment and recurrence (≥ 48 months) |
Patient preference for a second breast conservation followed by radiotherapy |
A second breast conservation is technically feasible and will result in acceptable cosmetic results |
Brachytherapy after BCS for IBTR
External beam radiotherapy after BCS for IBTR
Intraoperative radiotherapy after BCS for IBTR
Toxicity assessment/cosmetic outcome of repeat irradiation for IBTR
Conclusions of the DEGRO expert panel for the therapy of ipsilateral breast cancer recurrences
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Although mastectomy is regarded as the standard of care for patients with IBRT, in a subset of patients, PBI after second BCS is an appropriate alternative to mastectomy (Table 1).
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This approach yields high breast preservation rates and does not seem to compromise oncologic safety.
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If a second breast conservation is performed, additional irradiation should be mandatory, particularly in patients who have not received previous irradiation.
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In the case of reirradiation, the largest experience base to date exists for multicatheter BT.
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There is only limited information about the effectiveness of EBRT or IORT, which should be preferentially performed in clinical trials.
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Prospective studies are needed to clearly define selection criteria, long-term local control, and toxicity.
Study/year | Number of Patients | Median follow-up (months) | Local recurrence rate (%) | 5-year overall survival (%) |
---|---|---|---|---|
Kurtz [43] 1989 | 55 | 51 | 32 | NR |
Abner [44] 1993 | 16 | 39 | 31 | 81 |
Salvadori [45] 1999 | 57 | 73 | 19 | 85 |
Voogd [46] 1999 | 16 | 52 | 38 | NR |
Ishitobi [47] 2011 | 78 | 40 | 21 | NR |
Gentilini [48] 2012 | 161 | 81 | 29 | 84 |
Study/year | Number of patients | Median follow-up (months) | RT technique | Repeat RT dose (Gy) | Grade 3/4 toxicity (%) | Local control (%) | Overall survival (%) |
---|---|---|---|---|---|---|---|
Deutsch [40] 2002 | 39 | 51.5 | EBRT | 50 | NR | 77 | 78 |
Kraus [41] 2007 | 15 | 26 | IORT | 20 | 0 | 100 | 93 |
Chada [38] 2008 | 15 | 36 | BT | 30 or 45 | 0 | 89 | 100 |
Guix [42] 2010 | 36 | 89 | BT | 30 | 0 | 89a
| 97a
|
Kauer [37] 2012 | 39 | 57 | BT | 50 | 17b/0 | 93 | 87 |
Hannoun [35] 2013 | 217 | 46.8 | BT | LDR 46 PDR 50.4 HDR 32 | 11 | 93a
| 76a
|
Treatment of local recurrence after mastectomy
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An isolated chest wall recurrence should be completely resected (R0).
Definition and patterns of recurrence
Treatment of resectable recurrences in radiation-naive patients
Treatment of unresectable recurrences in radiation-naive patients
Therapy of locoregional recurrences after mastectomy in previously irradiated patients
Reirradiation with or without regional hyperthermia
Study | Patients n= | Initial dose (Gy) | RT technique | Repeat dose (Gy) | Complete remission (%) | Toxicity grade (%) |
---|---|---|---|---|---|---|
Delanian [79] | 11 | 45–65 | BT | 60 | 81.8 | II/III 45 IV 9 |
Harms [75] | 58 | 36–70 | BT | 2 × 20 | 79.3 | III 60b
IV 7 |
Laramore [69] | 13 | 40–50 | EBRT | 40–50 | 61.5 | III 0 IV 0 |
Phromratanapongse [71] | 44 | 35–66 | EBRT + HT | 16–56 | 40.9 | III 25 IV NR |
Li [80] | 41 | 58 | EBRT | 43 | 56 | IV 8 |
Jonesa [60] | 52 56 | NR | EBRT EBRT + HT | 30–66 60–70 | 42.3 66.1 | III 2 III 5 |
Kouloulias [81] | 15 | 60 | EBRT + HT | 30.6 | 20 | III NR IV 7 |
Linthorst [73] | 198 | 48 | EBRT + HT | 8 × 4 | 78c
| III/IV 11.9d
|
Linthorst [78] | 248 | 49 | EBRT + HT | 8 × 4 | 39c
| III 1d
|
Conclusions of the DEGRO expert panel for the therapy of locoregional recurrences after mastectomy
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Multimodality therapy including systemic therapy, surgery, and radiation +/− hyperthermia achieves a high rate of local control and can be curative with long-term survival in a subset of patients.
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Patients with an isolated locoregional recurrence after mastectomy should undergo surgical resection. Postoperative radiation therapy to the chest wall is mandatory and regional nodal irradiation (RNI) is strongly advised.
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In radiation-naive patients, the chest wall and regional lymph nodes should be treated with doses of 50–50.4 Gy (1.8–2 Gy per day). A boost dose of 10 Gy may be applied. Further dose escalation does not seem to improve treatment results.
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In previously irradiated patients with a high risk of a second local recurrence after surgical resection or in patients with unresectable recurrences, reirradiation should be strongly considered. Indication and dose concepts depend on the time interval to first radiotherapy, presence of late radiation effects, and concurrent or sequential systemic treatment.
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In the absence of severe radiogenic stigmata and an appropriate time interval (> 1 year), reirradiation with doses between 45 and 50 Gy is recommended, but should not exceed cumulative doses of 100–110 Gy3 (2-Gy3 equivalent dose).
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Particularly in previously irradiated patients, combination with hyperthermia can further improve tumor control.
Regional recurrences and isolated supraclavicular lymph node recurrences
Axillary recurrence
Isolated supraclavicular lymph node recurrence
Conclusions of the DEGRO expert panel for the treatment of axillary or supraclavicular lymph node recurrence
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Isolated axillary and supraclavicular recurrences from breast cancer are uncommon and may follow any stage of disease. Of the affected patients, 50–65 % develop distant metastases.
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To date, only retrospective data concerning the treatment of regional nodal recurrence are available.
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Durable disease control is best achieved with multimodality therapy including surgery and radiotherapy. Approximately one third of patients with an axillary breast cancer recurrence can be cured with multimodal therapy.
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Radiation therapy significantly improves local control and should be applied whenever feasible.