Unavoidable mastectomy for ipsilateral breast tumour recurrence after conservative surgery: patient outcome

BACKGROUND

In the case of ipsilateral breast tumour recurrence (IBTR) after breast-conserving surgery (BCS), a second conservative surgical approach maybe considered in some motivated patients whereas in others mastectomy is unavoidable.

PATIENTS AND METHODS

From 1997 to 2004, 282 patients presented at the European Institute of Oncology with an operable invasive IBTR after BCS. One hundred and sixty-one (57%) underwent a second conservative surgery, whereas 121 patients (43%) were given a mastectomy and represent the study population. We investigated the prognosis and determined predictive factors of outcome.

RESULTS

Median time from primary breast cancer to IBTR was 41 months (range 5-213). Recurrences were T2-T4 and/or multifocal in 83 cases (68.6%). With a median follow-up of 5 years after mastectomy, 5-year overall survival (OS) and disease-free survival (DFS) were 73.3% [95% confidence interval (CI) 65.0% to 81.6%] and 50.4% (95% CI 40.9% to 59.8%), respectively. At the multivariate analysis, early onset of IBTR, presence of vascular invasion and Ki67 >or=20 of the recurrent tumour were found to significantly affect both DFS and OS.

CONCLUSIONS

In women who need mastectomy for IBTR, early onset of the relapse, high proliferation index and presence of vascular invasion represent the worst prognostic factors.

Is avoiding post-mastectomy radiotherapy justified for patients with four or more involved axillary nodes and endocrine-responsive tumours? Lessons from a series in a single institution

BACKGROUND

Current guidelines for post-mastectomy radiotherapy (PMRT) derive largely from extrapolating information from multicentre trials. The aim of this study was to describe outcomes of patients who underwent mastectomy without radiotherapy in a single institution.

PATIENTS AND METHODS

650 patients had total mastectomy and axillary dissection without PMRT between 1997 and 2001. Median follow-up was 65 months.

RESULTS

5-year cumulative incidence of loco-regional recurrence (LRR) was 6.8% (3.0, 8.1, 9.9% in node negative, 1-3, > or =4 positive nodes, respectively). At the multivariate analysis, positive lymph nodes and endocrine non-responsive tumours were found to shorten LRR disease-free survival. In patients with positive hormone receptors, 5-year cumulative incidence of LRR disease-free survival were 2.3%, 7.6% and 7.6% for node negative, 1-3 and > or =4 positive lymph nodes, respectively. The same figures were 5.9%, 10.3% and 20.0% in patients with endocrine non-responsive tumours.

CONCLUSIONS

patients with endocrine-responsive tumours treated by mastectomy and complete (level III) axillary dissection have a low risk of LRR even if four or more positive lymph nodes are involved, thus giving rise to doubts on the use of PMRT in this subset of patients. On the other hand, PMRT might play a role for patients with negative hormone receptors and four or more positive nodes.

When can a second conservative approach be considered for ipsilateral breast tumour recurrence?

BACKGROUND

Mastectomy is considered the treatment of choice in patients with ipsilateral breast tumour recurrence (IBTR) after breast-conserving surgery (BCS).

PATIENTS AND METHODS

One hundred and sixty-one patients with invasive IBTR who underwent a second conservative approach were retrospectively evaluated in order to describe prognosis, determine predictive factors of outcome and select the subset of patients with the best local control.

RESULTS

Fifty-seven patients (35.4%) relapsed after IBTR. Thirty-four patients (21.1%) had further in-breast recurrences and four patients (2.5%) had skin relapses. Five years cumulative incidence of local relapse was 31.4%. Twenty-four patients (17.8%, 5 years cumulative incidence) died during the follow-up. At the multivariate analysis, recurrent tumour size >2 cm was found to affect local-disease-free survival [hazard ratio (HR): 2.8, 95% confidence interval (CI) 1.2-6.2], whereas Ki-67 >or=20% and time to relapse <or=48 months were associated with disease-free survival (HR: 1.7, 95% CI 1.0-3.1, and HR: 2.1, 95% CI 1.2-3.6, respectively). Absence of oestrogen receptors affected overall survival (HR: 2.5, 95% CI 1.1-6.0). Among 64 patients with recurrent tumour <or=2 cm and time to IBTR >48 months, eight (12.8%, 5 years cumulative incidence) had further local relapses.

CONCLUSIONS

Some patients with IBTR might receive a second BCS, especially when a good local control can be estimated (small recurrent tumour, late relapse), also taking into account patients' preference.