Repeat Breast-Conserving Surgery Versus Salvage Mastectomy for Ipsilateral Breast Tumour Recurrence After Breast-Conserving Surgery in Breast Cancer Patients: A Meta-Analysis

Salvage Therapy for Isolated Local-Regional Breast Cancer Recurrence

The overall number of breast cancer patients at risk of developing local-regional disease recurrence has been increasing due to long-term survivorship from improvements in multimodality breast cancer treatment and a steady increase in breast cancer incidence. Many patients receive radiotherapy as part of definitive multidisciplinary breast cancer treatment, and to date, practitioners have approached reirradiation delivery with reticence due to concern for serious toxicities that may be incurred with high cumulative radiation doses. However, a subset of patients with breast cancer recurrence may benefit from reirradiation for improved locoregional tumor control. An emerging body of evidence has demonstrated promising efficacy and safety of breast cancer reirradiation that are gradually redefining the treatment paradigm. In addition, an increase in systemic therapy options has further optimized the opportunity for successful salvage of breast cancer recurrence. In this critical review, we review breast cancer radiation and systemic therapy salvage options, available data, ongoing studies, and treatment delivery considerations.

Evaluation of normal tissue complications in breast cancer re-irradiation: a meta-analysis study

BACKGROUND

In recent years, evidence has accumulated that a second method of conserving the breast from cancer with re-irradiation as part of treatment may be feasible and safe. Many oncologists are skeptical of breast re-irradiation due to concerns about late complications, so access to quantitative data on the prevalence of breast re-irradiation complications is very important. In this meta-analysis, we determine the prevalence of complications in normal tissue after breast re-irradiation.

MATERIALS AND METHODS

A search was done to recognize qualified studies using EMBASE, MEDLINE, PUBMED, Google Scholar, and Cochrane Collaboration Library electronic databases from 2000 to 2023. In total, ten primary studies were applied in this meta-analysis to estimate the prevalence of complications of disorders, skin fibrosis, and chest pain. Heterogeneity was investigated using the I2 index and the meta-regression to evaluate variables suspected of causing heterogeneity. Statistical analysis and synthesis were performed using Stata 17.

RESULTS

The average dose received by patients who underwent radiation therapy in two stages was 100.32 Gy, and in these patients, the prevalence of skin fibrosis and disorders was 47% (95% CI 71-22%; I2 = 96.76%, P < 0.001) and the prevalence of chest pain was 35% (95% CI 68-8%; I2 = 98.13%, P < 0.001).

CONCLUSIONS

There is little clinical information about the incidence of complications in breast re-irradiation therapy. This meta-analysis presents the prevalence of complications after breast re-irradiation to help radiation oncologists and physicists make better decisions.

Management of Ipsilateral Breast Tumor Recurrence Following Breast Conservation Surgery for Ductal Carcinoma In Situ: A Data-Poor Zone

BACKGROUND

Breast conserving surgery (BCS) is well established for the management of ductal carcinoma in situ (DCIS), but neither randomized trials nor guidelines address management of ipsilateral breast tumor recurrence (IBTR) after BCS for DCIS.

PATIENTS AND METHODS

We identified women treated with BCS for DCIS who developed IBTR as a first event. Between those treated with mastectomy versus re-BCS, we compare the clinicopathologic characteristics, the use of adjuvant radiotherapy (RT) both upfront ("primary RT") and post IBTR ("secondary RT"), of tamoxifen, the rate of third events (local, regional, distant), and both breast cancer specific (BCSS) and overall survival (OS).

RESULTS

Of 3001 women treated with BCS for DCIS (1978-2010), 383 developed an IBTR as a first event (1983-2023) and were treated by mastectomy (51%) versus re-BCS (49%). Compared with re-BCS, mastectomy patients at initial treatment were higher grade (74% versus 59%, p = 0.004), with more frequent primary RT (61% versus 21%, p < 0.001). Third local events were more frequent for re-BCS than mastectomy (16% versus 3%, p = 0.001), but there were no differences in breast cancer specific or overall survival.

CONCLUSIONS

For isolated IBTR following BCS for DCIS and treated by mastectomy versus re-BCS (1) mastectomy was associated with less favorable initial pathology and more frequent use of primary RT, (2) re- recurrence was more frequent with re-BCS, and (3) BCSS and OS were comparable. Our data suggest a wider role for re-BCS and further study of the relationship between secondary RT and the rate of third breast events.

Salvage Breast-Conserving Surgery and Reirradiation With Intraoperative Electrons for Recurrent Breast Cancer: A Multicentric Study on Behalf of Italian Association of Radiotherapy and Clinical Oncology (AIRO)

PURPOSE

Intraoperative radiation therapy with electrons (IOERT) may represent a viable choice for partial breast reirradiation after repeat quadrantectomy for local recurrence (LR) for primary breast cancer (BC) in lieu of mastectomy.

METHODS AND MATERIALS

A database collecting data on partial breast reirradiation with IOERT from 8 Italian centers was set up in 2016 to 2018, providing data on cumulative incidence (CumI) of second LR and survival with a long follow-up.

RESULTS

From 2002 to 2015, 109 patients underwent the conservative retreatment. The median primary BC first LR interval was 11.1 years (range, 2.4-27.7). The median first LR size was 0.9 cm (range, 0.3-3.0), and 43.6% cases were luminal A. Median IOERT dose was 18 Gy (range, 12-21), and median collimator diameter was 4 cm (range, 3-6). Median follow-up duration was 11.7 years (IQR, 7.7-14.6). The second LR CumI was 12.2% (95% CI, 6.8%-19.2%) at 5 years and 32.3% at 10 years (95% CI, 22.8%-42.2%), occurring in the same site as the first LR in about half of the cases. Human epidermal growth factor receptor 2 status and collimator size were independent LR predictors. The 5- and 10-year overall survival rates were 95.2% and 88.3%, respectively, whereas 5- and 10-year BC-specific survival rates were 98% and 94.5%, respectively. The development of a second LR significantly reduced BC-specific survival (hazard ratio, 9.40; P < .001). Grade ≥3 fibrosis rate was 18.9%. Patient-reported cosmesis was good/excellent in 59.7% of the cases.

CONCLUSIONS

Second LR CumI was within the range of the literature but higher than expected, opening questions on radiation field extension and fractionation schedule. Because a second LR worsened the outcome, salvage modality must be carefully planned.

Management of irradiated post-mastectomy wound dehiscence with synthetic electrospun fiber matrix: a case report

Breast-conserving surgery (BCS) is a well-established standard treatment option alternative to mastectomy for patients with early breast cancer that consists of a lumpectomy followed by adjuvant radiotherapy. However, irradiated tissues are at an increased risk of wound healing complications when post-treatment surgical management is required. The management of an irradiated wound dehiscence can be challenging, as it often requires a multimodal treatment approach that includes more invasive interventions when compared to a traditional surgical wound dehiscence. We present a 64 year old female patient with a remote history of right BCS with radiation therapy for early breast cancer 12 years ago, who recently required a simple mastectomy due to ipsilateral breast cancer recurrence. The post-operative course was complicated by dehiscence of the mastectomy wound. After standard wound care therapies failed, her surgical wound successfully healed after treatment with a synthetic electrospun fiber matrix application. Patients with additional comorbidities often do not qualify for invasive reconstructive options; therefore, effective local management options are warranted. This is the first reported case documenting synthetic electrospun fiber matrix efficacy and safety in healing a dehisced surgical wound within a previously irradiated fibrotic area, without the need for further invasive surgical intervention. Larger scale research, such as a prospective cohort study or randomized control trial, is needed to investigate its novel use in irradiated wounds.

REPEATED BREAST-CONSERVING SURGERIES AS REFLECTION OF THE EVOLUTION IN BREAST CANCER TREATMENT (CASE REPORT WITH LITERATURE REVIEW)

The clinical case of a patient with multicentric breast cancer who underwent organ-sparing surgery after neoadjuvant chemo-radiation therapy is presented. An ipsilateral cancer recurrence was diagnosed 8 years after the first operation. The repeated organ-sparing surgery (lumpectomy) was done with a good cosmetic result and without disease progression during 1-year follow-up. The literature review shows that neoadjuvant systemic therapy accounting for molecular subtypes of cancer has radically changed breast cancer surgeries. The evolution of surgical approaches in stage I-II breast cancer patients consists in the de-escalation of surgery from mastectomy to organsparing or oncoplastic surgery, minimally directed surgery, and repeated breast-conserving surgery. De-escalation of surgical interventions in the area of the regional lymphatic collector consists in the transition from total axillary lymphatic dissection to sentinel lymph node biopsy or targeted removal of metastatic lymph nodes. The repeated breast-conserving surgery can be safely performed for ipsilateral recurrence in patients with all molecular subtypes of breast cancer.

Silicone Shell Breast Implants in Patients Undergoing Risk-Reducing Mastectomy With a History of Breast-Conserving Surgery and Adjuvant Radiotherapy: A Long-term Study

BACKGROUND

Indications for breast-conserving surgery and adjuvant radiotherapy (BCSAR) in patients with breast carcinoma are increasing, as are indications for risk-reducing mastectomy (RRM) in healthy subjects. Most of these cases are reconstructed with silicone shell breast implants (SSBIs).

OBJECTIVES

The aim of this work was to study complications of SSBIs in breast reconstruction in patients undergoing RRM with previous BCSAR.

METHODS

A prospective cohort study was designed. The study group included cases of RRM reconstructed with SSBI in patients who had previously undergone BCSAR in the same breast. The control group consisted of patients with high-risk breast cancer who had undergone RRM and immediate SSBI reconstruction without previous BCSAR.

RESULTS

There was a history of BCSAR in 15.8% of cases. The first SSBI used in immediate reconstruction after RRM was replaced in 51.5% of cases with a mean [standard deviation] survival of 24.04 [28.48] months. BCSAR was significantly associated with pathological capsular contracture (P = .00) with this first SSBI (37.5% vs 5.9%). Of the cases requiring the replacement of the first SSBI, 44.23% suffered failure of the second SSBI, with a mean survival of 27.95 [26.53] months. No significant association was found between the consecutive development of capsular contracture in the second SSBI and a previous history of BCSAR (P = .10).

CONCLUSIONS

BCSAR prior to RRM reconstructed with an SSBI is associated with a significant increase in pathological capsular contracture. Patients should be warned of the high rate of SSBI complications and reconstruction failure. Polyurethane-coated implants may provide an alternative in cases in which alloplastic reconstruction is considered in patients with previous BCSAR.

LEVEL OF EVIDENCE: 3

A Systematic Review and Meta-Analysis on the Role of Repeat Breast-Conserving Surgery for the Management of Ipsilateral Breast Cancer Recurrence

INTRODUCTION

The standard surgical management of ipsilateral breast cancer recurrence (IBCR) in patients previously treated with breast-conserving surgery (BCS) and radiotherapy (RT) is mastectomy. Recent international guidelines provide conflicting recommendations. The aim of this study was to perform a systematic literature review and meta-analysis of the oncological outcomes in patients with IBCR treated with repeat BCS (rBCS).

METHODS

The MEDLINE and EMBASE databases were searched for relevant English-language publications, with no date restrictions. All relevant studies providing sufficient data to assess oncological outcomes (second local recurrence [LR] and overall survival [OS]) of rBCS for the management of IBCR after previous BCS and RT were included (PROSPERO registration CRD42021286123).

RESULTS

Forty-two observational studies met the criteria and were included in the analysis. The pooled second LR rate after rBCS was 15.7% (95% confidence interval [CI] 12.1-19.7), and 10.3% (95% CI 6.9-14.3) after salvage mastectomy. On meta-analysis of comparative studies (n = 17), the risk ratio (RR) for second LR following rBCS compared with mastectomy was 2.103 (95% CI 1.535-2.883; p < 0.001, I² = 55.1%). Repeat RT had a protective effect (coefficient: - 0.317, 95% CI - 0.596 to - 0.038; p = 0.026, I² = 40.4%) for second LR. Pooled 5-year OS was 86.8% (95% CI 83.4-90.0) and 79.8% (95% CI 74.7-84.5) for rBCS and salvage mastectomy, respectively. Meta-analysis of comparative studies (n = 20) showed a small OS benefit in favor of rBCS (RR 1.040, 95% CI 1.003-1.079; p = 0.032, I² = 70.8%). Overall evidence certainty was very low.

CONCLUSIONS

This meta-analysis suggests rBCS could be considered as an option for the management of IBCR in patients previously treated with BCS and RT. Shared decision making, appropriate patient selection, and individualized approach are important for optimal outcomes.