Prognostic Factors in 77 Curative Chest Wall Resections for Isolated Breast Cancer Recurrence

According to our retrospective database on CWRs for malignant tumors or radiation ulcers on the chest wall in the period 1986 to 2006, a total of 92 of 229 consecutive patients had undergone CWR for recurrent BC.

CWR was defined as either extended soft tissue resection with broad margins that required reconstruction of the soft tissue component, or full-thickness CWR that included at least one rib or part of the sternum (Fig. 1). Several types of inlay have been used for skeletal reconstruction over the 20-year study period. In the first few years, homologous dura mater has been used (Lyodura, B. Braun, Melsungen, FRG), later to be replaced by polyurethane (Neuropatch, B. Braun, Melsungen, FRG) as an artificial inlay. In some cases, polyglactin (Vicryl, Ethicon) was used. Patients operated on after 2004 received a double-layer polypropylene-polytetrafluoroethylene mesh (Composix). Standard soft tissue reconstruction was performed with pedicled omentoplasty unless primary closure could be achieved. Surgical aspects of the CWR technique at our hospital have been described previously.21

Fifteen of the 92 patients were excluded from this study because the CWR was for palliative reasons, such as fungating ulcers or symptomatic progression of LRR, and the prognosis was reasonable despite the presence of distant metastases and limited life expectancy. The CWR was considered to be potentially curative when preoperative evaluation showed that the resection could be radical and the patient had no evidence of distant metastases. Therefore, at least a computed tomographic scan of the lung and of the liver, a bone scintigraphy, and mammography were performed. Patients who had received previous radiotherapy and/or systemic therapy for this LRR were not excluded from our analysis. Severe complications were defined as those that required prolonged hospitalization or resurgery.

Two clinical end points were set: (1) overall survival (OS) defined as the time from CWR to the date of death or the date of the last visit, whichever occurred first; (2) DFS, defined as the time from CWR to the date of local recurrence, or regional recurrence, or the date of death, or the date of the last visit, whichever occurred first.

Detailed clinical information was obtained from the medical records and pathology reports. Patient, tumor, and treatment characteristics at initial presentation with BC (Table 1) and treatment and outcome factors at the time of CWR (Table 2) were collected.

In 77 patients CWR was performed for recurrent BC that fulfilled our above-described curative-intent criteria. Indications were local recurrence in the chest wall (n = 41) and regional recurrence in the axillary lymph nodes (n = 9), or in the internal mammary lymph nodes (n = 27). The last group of patients is described in detail elsewhere.22

Extensive isolated BC recurrence in the chest wall is difficult to manage. It is a challenge to choose the best local treatment. Evidence-based guidelines for multimodality treatment are not yet available for this heterogeneous group of BC patients. A few reports focus on radiotherapy for all kinds of LRRs after BC and mainly in patients who underwent some type of surgery before radiotherapy was provided.23 In 43% to 68% of the patients, radiotherapy can provide local control, with a reported 5- and 10-year OS of 36% to 61% and 21% to 35%, respectively.5,23‐25 In our opinion, these percentages are relatively high because a large number of patients with a small scar recurrence are included, although prognosis seems to be worse when CWR is performed after the failure of radiotherapy for BC recurrences.26 No differences in outcome were found between surgery and radiotherapy for small isolated lesions of local recurrence, but aggressive multimodality treatment was usually advised.9,10 According to Dutch evidence-based guidelines, surgery is recommended in combination with hormone treatment for estrogen receptor– or progesterone receptor–positive tumors, but the indication for chemotherapy is still unclear.27,28 Several reports showed that CWR is a safe and justifiable procedure with low mortality (0 to 4.5%) and morbidity.12,29‐31 Differences in the type of complications recorded, together with the wide range of scoring systems in the literature, make it difficult to compare the 38% complications found in this study—which varied from slight wound infection that could be treated by antibiotics, to omental necrosis and pyothorax that required additional surgery—with other studies. Mortality in this study is <1% and comparable to data reported in the literature.

The 5-year OS in our study is 25%. Most series reported a 5-year OS of 40% to 60%.16,29,32‐34 The DFS at 5 years is 12% and only a very few series mention their results, varying from 26% to 67% (Table 5).35 The reason for this difference remains unclear, but patient selection could be an explanation. Also, our study covers a large time period, during which aspects of BC treatment changed.

Larger series about CWR for BC make no difference between T4 BC invading the chest wall, local recurrence after mastectomy, axillary lymph node recurrence, internal mammary chain recurrence, or solitary sternal metastasis.5,20,36,37 On the other hand, our median survival of 40 months is comparable with other data. Also in this series, neither the T and N stage nor type of primary surgery, BCT or MRM, were statistically significant prognostic factors. In all series, the survival curve is slightly declining after 5 years. Fifty-one percent of our patients do not develop local recurrence within 5 years; this result has been confirmed in another study (56%).16

Few authors studied the influence of prognostic factors. Age of <35 years, lymph node–negative status at initial presentation, and an interval between initial treatment and CWR of 2 years or 5 years were described as statistically significantly negative prognostic factors for OS and DFS.9,12,16,20,29,30,32,33,35,38,39 The multivariate analysis in this study confirmed prognostic significance of interval (alone) with the best results after 10 years.

If a radical (R0) resection can be expected, CWR should be considered. In this study, the pathologically confirmed R0 resection rate was 64%, which is comparable with another report.30 In the literature, correlations between R1 and R0 resection and DFS or OS never reached significance.25,29 This was probably the result of postoperative radiotherapy in patients with a R1 resection. In discussions on the best local treatment, CWR is preferable to radiotherapy as the first choice because unsuccessful radiotherapy proved to be an important predictive factor for complications at the time of CWR.40 Also, the effect of radiotherapy is less in extended and multifocal LRR, reflected in decreased survival.41

The role of adjuvant systemic therapy after CWR remains unclear, but it may be worth consideration. In 1992, a matched control study on all types of LRR treated with excisional surgery and radiotherapy, whether or not followed by chemotherapy or hormone therapy, showed that OS and DFS were greatly prolonged by adjuvant hormone therapy, but not by chemotherapy.5 Because the previously mentioned study was an older study, it can be expected that with the availability of new drugs and more effective chemotherapy schedules, the prognosis of patients with CWR for LRR of BC will improve.

To our knowledge, this is the largest study on prognostic factors in CWR performed with curative intent for recurrent BC. Our results confirm that CWR is a safe surgical procedure. Surgery is indicated in patients who have isolated BC recurrence, even when surgery means a CWR. The longer the disease-free interval, the better the survival outcome. Adjuvant radiotherapy, and for estrogen receptor–positive tumors adjuvant hormone therapy, is indicated. Neoadjuvant systemic therapy may be taken into consideration on a case-by-case basis. With this regimen, it should be possible to obtain local tumor control in approximately half of the patients and even cure at least 25% of the patients with an isolated extensive recurrence of BC in the chest wall.