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Radiation for Chest Wall Recurrences after a Mastectomy

Around 10-20% of women who have a mastectomy will get a local recurrence (see PET scan picture and here) . In 2/3 of these women they will also have distant disease but about 1/3 have local disease only. The 3 most common sites in order: 1. chest wall (near scar), 2. supraclavicular region and 3. axilla. The median time to relapse is usually less than 2 years.

for more on supraclavicular node relapse go here

more images:

The NCCN makes the following statement about local recurrences: "Patients with local recurrence only are divided into those who had been treated initially by mastectomy and those who had received breast-conserving therapy. Mastectomy-treated patients should undergo surgical resection of the local recurrence (if it can be accomplished without heroic surgery) and involved-field RT (if the chest wall was not previously treated or if additional radiotherapy may be safely administered). The use of surgical resection in this setting implies the use of limited excision of disease with the goal of obtaining clear margins of resection. Unresectable chest wall recurrent disease should be treated with RT. Women whose disease recurs locally after initial breast-conserving therapy should undergo a total mastectomy. After local treatment, women with local recurrences should be considered for systemic chemotherapy or hormonal therapy, as is the case for women with systemic recurrences."

Patients developing locoregional recurrence may be treated with a combination of irradiation, surgery, systemic therapy, or hyperthermia. Surgical management may consist of local excision for purposes of debulking or may be extensive (e.g., chest wall resection). Local control of chest wall recurrence was improved with completely excised surgical lesions or tumor size smaller than 3 cm. Chest wall resection has been described as initial management in management of aggressive recurrent tumors. Wide local excision alone, without irradiation, is associated with high rates of local failure and distant relapse. Dahlstrom and co-workers described a 5-year actuarial local control rate of 50% and a 62% overall survival rate with this treatment. The likelihood of further local recurrence appears higher for patients presenting with multiple nodules, as opposed to a single nodule on the chest wall.

In the treatment of chest wall recurrences by irradiation, results from Washington University documented the importance of treating the entire chest wall and not merely a small local field. Other series have confirmed this observation.Several authors have advocated elective irradiation of the upraclavicular area. The series from Washington University showed that elective supraclavicular irradiation reduced the rate of second recurrence in that region from 16% to 5.6% Toonkel observed a 71% probability of local tumor control at 5 years when the chest wall and comprehensive lymphatic drainage regions were treated, compared with only 50% in patients treated to the chest wall or regional lymphatics only; th corresponding 5-year survival rates were 37% and 8%.

Adequate doses are also important in achieving optimal results; adiation doses of 50 Gy should be given to electively treated areas and to recurrent tumors that have been completely excised. For lesions smaller than 3 cm, doses of 60 to 65 Gy should be given. Larger masses require doses of 65 to 75 Gy.  

 
in women with previous breast cancer, if they develop firm nodules or red, itching skin, this may the signs of recurrent breast cancer, if the cancer gets into the dermies of the skin it make clog up the vessless creating an orange peel effect on the skin called peau d'orange



See the Studies Below:
Int J Radiat Oncol Biol Phys 1999 Apr 1;44(1):105-12

Local-regional control of recurrent breast carcinoma after mastectomy: does hyperfractionated accelerated radiotherapy improve local control?

Ballo MT, Strom EA, Prost H, Singletary SE, Theriault RL, Buchholz TA, McNeese MD

Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston 77030, USA.

PURPOSE: Hyperfractionated, accelerated radiotherapy (HART) has been advocated for patients with local-regionally recurrent breast cancer because it is believed to enhance treatment effects in rapidly proliferating or chemoresistant tumors. The study included 148 patients with local-regionally recurrent breast cancer after mastectomy, who were treated with definitive local irradiation and systemic therapy consisting of either tamoxifen, cytotoxic chemotherapy, or both, along with excision of the recurrent tumor when possible. Patients with distant metastases were excluded, except for two patients with ipsilateral supraclavicular nodal metastases. Patients received comprehensive irradiation to the chest wall and regional lymphatics to a median dose of 45 Gy, with a boost to 60 Gy to areas of recurrence. Sixty-eight patients (46%) were treated once daily at 2 Gy/fraction (fx), and 80 (54%) were treated twice daily at 1.5 Gy/fx. Forty-eight patients (32%), who had palpable gross disease that was unresponsive to systemic therapy and/or unresectable, were irradiated. The median follow-up time of surviving patients was 78 months. RESULTS: Overall actuarial local-regional control (LRC) rates at 5 and 10 years were 68% and 55%, respectively. Five- and ten-year actuarial overall survival (OS) and disease-free survival (DFS) rates were 50% and 35%, 39% and 29%, respectively. When once-a-day irradiation was compared to the twice-a-day schedule, no significant differences were seen in LRC (67% vs. 68%), OS (47% vs. 52%), or DFS (42% vs. 36%) for the entire group of patients at 5 years.

Int J Radiat Oncol Biol Phys 1990 Oct;19(4):851-8

Isolated local-regional recurrence of breast cancer following mastectomy: radiotherapeutic management.

Halverson KJ, Perez CA, Kuske RR, Garcia DM, Simpson JR, Fineberg B

Radiation Oncology Center, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63108.

Two hundred twenty-four patients with their first, isolated local-regional recurrence of breast cancer were irradiated with curative intent. Patients who had previous chest wall or regional lymphatic irradiation were not included in the study. With a median follow-up of 46 months (range 24 to 241 months), the 5- and 10-year survival for the entire group were 43% and 26%, respectively. Overall, 57% of the patients were projected to be loco-regionally controlled at 5 years. The 5-year local-regional tumor control was best for patients with isolated chest wall recurrences (63%), intermediate for nodal recurrences (45%), and poor for concomitant chest wall and nodal recurrences (27%). In patients with solitary chest wall recurrences, large field radiotherapy encompassing the entire chest wall resulted in a 5- and 10-year freedom from chest wall re-recurrence of 75% and 63% in contrast to 36% and 18% with small field irradiation (p = 0.0001). For the group with recurrences completely excised, tumor control was adequate at all doses ranging from 4500 to 7000 cGy. For the recurrences less than 3 cm, 100% were controlled at doses greater than or equal to 6000 cGy versus 76% at lower doses. No dose response could be demonstrated for the larger lesions. The supraclavicular failure rate was 16% without elective radiotherapy versus 6% with elective radiotherapy (p = 0.0489). Prophylactic irradiation of the uninvolved chest wall decreased the subsequent re-recurrence rate (17% versus 27%), but the difference is not statistically significant (p = .32). The incidence of chest wall re-recurrence was 12% with doses greater than or equal to 5000 cGy compared to 27% with no elective radiotherapy, but again was not statistically significant (p = .20). Axillary and internal mammary failures were infrequent, regardless of prophylactic treatment. Although the majority of patients with local and/or regional recurrence of breast cancer will eventually develop distant metastases and succumb to their disease, a significant percentage will live 5 years. Therefore, aggressive radiotherapy should be used to provide optimal local-regional control.

Int J Radiat Oncol Biol Phys 1991 Jul;21(2):299-310

The results of radiation therapy for isolated local regional recurrence after mastectomy.

Schwaibold F, Fowble BL, Solin LJ, Schultz DJ, Goodman RL

University of Pennsylvania School of Medicine, Philadelphia, PA.

Between 1967 and 1988 128 patients with isolated local-regional recurrence of breast cancer after mastectomy were treated with definitive radiation therapy. Recurrence was confined to a single site in 108 patients and multiple sites in 20. The chest wall was the most common location (86) and the supraclavicular region was the second most common (20). Surgical treatment for recurrence prior to irradiation consisted of excision of all gross disease in 78 patients and incisional biopsy in 49 patients. Irradiation was directed to the entire chest wall in 19% of patients with isolated chest wall recurrences and to the chest wall and regional nodes in 81%. In patients with isolated nodal failures, treatment was directed to the nodal site and chest wall in 87% and to the regional site alone in 13%. Patients with multiple sites received treatment to the chest wall and regional nodes in all cases. Electively treated sites usually received 4500-5000 cGy. Following excision of chest wall disease, the median dose was 6000 cGy. Gross disease on the chest wall received a median dose of 6100 cGy. Gross disease in nodal sites received a median dose of 5600 cGy; 66 patients received systemic therapy at recurrence. The 5-year actuarial local-regional control was 43%. In a multivariate analysis only the estrogen receptor status of the recurrence remained significant (p = .002). The 5-year actuarial survival was 49% with a relapse-free survival of 24%. In a multivariate analysis for survival, the disease-free interval (p = .007), local regional control (p = .006), and excisional biopsy for recurrence (p = .03) remained significant. In a multivariate analysis for relapse-free survival, the disease-free interval (p = .03), excisional biopsy (p = .0001), and the extent of axillary nodal involvement (p = .007) remained significant. In the subgroup of patients with a disease-free interval greater than or equal to 24 months, excisional biopsy, and local regional control, the 5-year survival was 61% with a relapse-free survival of 59%. This subgroup represents 18% of the entire group and has a relatively good prognosis after recurrence.

Int J Radiat Oncol Biol Phys 1998 Oct 1;42(3):495-9

Radiation therapy for chest wall recurrence of breast cancer after mastectomy in a favorable subgroup of patients.

Hsi RA, Antell A, Schultz DJ, Solin LJ

Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia, USA.

Of 71 patients with an isolated local-regional recurrence of breast cancer after mastectomy, 18 were identified who met the following favorable selection criteria: 1) a disease-free interval after mastectomy of 2 years or more, 2) an isolated chest wall recurrence, and 3) tumor size < 3 cm or complete excision of the recurrent disease. All 18 patients were treated with local-regional irradiation between 1967 and 1988. Radiotherapy (RT) was delivered to the chest wall to a median total dose of 60 Gy (range 30-66 Gy). Four patients received adjuvant chemotherapy and six patients received adjuvant hormonal therapy. RESULTS: With a median follow-up of 8.4 years, nine of 18 patients were alive and free of disease. The 10-year actuarial overall and cause-specific survivals were 72% and 77%, respectively. The 10-year actuarial relapse-free survival and local control were 42% and 86%, respectively. CONCLUSION: Treatment for a local-regional recurrence of breast cancer after mastectomy in a favorable subgroup of patients results in a high rate of long-term survival as well as excellent local control. Aggressive treatment is warranted in this favorable subgroup of patients.

Radiother Oncol 1988 Jul;12(3):177-85

Isolated local-regional recurrence following mastectomy for adenocarcinoma of the breast treated with radiation therapy alone or combined with surgery and/or chemotherapy.

Mendenhall NP, Devine JW, Mendenhall WM, Bland KI, Million RR, Copeland EM 3d

Radiation Therapy, University of Florida College of Medicine, Gainesville 32610-0385.

The results of radiation therapy alone or combined with surgery and/or chemotherapy are reported for 47 patients who presented with local and/or regional recurrence without evidence of distant metastases following initial management of adenocarcinoma of the breast with radical or modified radical mastectomy (43) or simple mastectomy (4). Patients were treated between October 1964 and March 1983 at the University of Florida; all have a 2-year minimum follow-up and 42/47 (89%) have had follow-up for greater than or equal to 5 years. The overall actuarial local-regional control rates were 80% at 2 years, 68% at 5 years, and 61% at 10 years. The 5-year actuarial local-regional control rates by site and extent of disease were as follows: single chest wall nodule, 92%; multiple chest wall nodules, 49%; regional lymph nodes, 66%; and multiple sites, 64%. The 5- and 10-year actuarial determinate disease-free survival rates for all patients were 41 and 17%, respectively. The 5- and 10-year actuarial survival rates for all patients were 50 and 34%, respectively.

Int J Radiat Oncol Biol Phys 1986 Dec;12(12):2061-5

Radiation therapy for local-regional recurrent breast carcinoma.

Deutsch M, Parsons JA, Mittal BB

One hundred seven women with recurrent breast carcinoma involving the chest wall and/or regional lymph node regions were treated with radiotherapy between 1970 and 1979. Local-regional tumor was the initial and only evidence of recurrent breast carcinoma in all cases. Forty-seven patients had their disease confined to the chest wall alone and sixty (56%) patients had chest wall involvement as some component of their local-regional recurrent disease. Within five years after the initial mastectomy, 80.5% of recurrences were manifested. All patients had radiotherapy to at least the site of involvement. Eighty-four patients (78.5%) had a complete response. The absolute 5-year survival of all patients following local-regional recurrence was 34.6%. Five year survival was 29% in those patients who had recurrence within 5 years of the original mastectomy. For those patients whose local-regional recurrence occurred after a 5-year disease-free interval, the subsequent 5-year survival was 57%. For patients with recurrence confined to the chest wall, subsequent 5-year survival was 48.9%. Patients who had supraclavicular involvement as part of their local-regional recurrence had only a 16.1% 5-year survival. The majority of patients developed distant metastasis. Twenty-two patients developed carcinoma of the contralateral breast following local-regional recurrence. Five year survival following local-regional recurrence was only 4.3% for patients whose initial treatment for their primary breast carcinoma was surgery and adjuvant chemotherapy. For those patients whose primary breast carcinoma was treated by surgery alone or surgery and post-operative radiotherapy, the 5-year survival following local-regional recurrence was over 40%.

Int J Radiat Oncol Biol Phys 1983 Jan;9(1):33-9

The significance of local recurrence of carcinoma of the breast.

Toonkel LM, Fix I, Jacobson LH, Wallach CB

One hundred twenty-one patients with local or regional recurrence of carcinoma of the breast without evidence of distant metastases were treated with megavoltage radiation therapy. All patients had radical or modified radical mastectomy as their initial treatment. The 10 year survival probability of this group of patients is 26%, with a local control probability of 46%. Within this group of patients with recurrent disease, factors found to be associated with a poorer prognosis include peripheral nodal recurrence, advanced initial disease stage and short disease free interval. Contrary to expectation, patients with recurrence within the mastectomy scar (as opposed to chest wall recurrence wide of the scar) or a history of previous radiotherapy had poorer local control rates (although not statistically significant), without effect upon overall survival. Comprehensive radiation therapy (peripheral lymphatic plus chest wall) enhanced the local control rate for the entire group and the survival probability for patients with isolated chest wall recurrence compared with limited radiation therapy fields. (Five year survival probability: chest wall irradiation only = 27%; chest wall and peripheral lymphatic = 54%). Patients given systemic therapy at the time of local recurrence showed no survival benefit. Aggressive, comprehensive radiation therapy is indicated for locally recurrent breast cancer. More effective systemic therapy is needed, especially for higher risk patients.

Int J Radiat Oncol Biol Phys 1997 Mar 1;37(4):853-63

Locoregional recurrence of breast cancer following mastectomy: always a fatal event? Results of univariate and multivariate analysis.

Willner J, Kiricuta IC, Kolbl O

Department of Radiation Oncology, University of Wurzburg, Germany.

Between 1979 and 1992, 145 patients with their first isolated locoregional recurrence of breast cancer following modified radical mastectomy without evidence of distant metastases were treated at the Department of Radiation Oncology of the University of Wurzburg. Thirty-nine percent of patients (n = 67) had had postmastectomy radiotherapy, representing 7% of patients who had received routine postmastectomy irradiation at our institution. Systemic adjuvant hormonal therapy had been applied in 24% and systemic chemotherapy in 19% of patients. Several combinations were used. Treatment of recurrences consisted of surgical tumor excision in 74%, megavoltage irradiation in 83%, additional hormonal therapy in 41%, and chemotherapy in 12% of patients, employing different combinations. Local control in the recurrent site was achieved in 86%. Median follow-up for patients alive at the time of analysis was 8.9 years after recurrence. Eighty-two of the 145 patients (57%) developed distant metastases within the follow-up period. Metastases-free rate was 42% at 2 years and 36% at 10 years following recurrence. With development of distant metastases, the survival rate deteriorated. Recurrences appeared within the first 2 years from primary surgery in 56% of patients, and in 89% within 5 years. Overall, 2-year and 5-year survival rates following local-regional recurrence were 67% and 42%, respectively. Univariate analysis revealed statistically significant worsening of survival rates for pT3 + 4 primary tumors, primary axillary lymph node involvement, tumor grading 3 + 4, lymphatic vessel invasion, blood vessel invasion, tumor necrosis, negative estrogen (ER) and progesterone (PR) hormonal receptor status, postmastectomy chemotherapy and hormonal therapy, short time to recurrence (< 1 year), combined recurrences and supraclavicular site of recurrence, non-scar recurrence, size of the largest recurrent nodule > 5 cm, multiple recurrent nodules, no surgical excision of recurrence, small target volume of irradiation, chemotherapy for recurrence, and no local control within the recurrence site. The 2-year and 5-year survival rates ranged from 68% to 94%, and from 33% to 65%, respectively, in the favorable subgroups compared to 2-year and 5-year survival rates ranging from 20% to 59% and 0% to 35%, respectively, in the unfavorable subgroups. Multivariate analysis showed that site of recurrence and number of recurrent nodules have the strongest influence on postrecurrence survival, but time to recurrence, age at time of recurrence, local control in recurrent site as well as primary pT and axillary status, and the presence of tumor necrosis in the primary tumor specimen showed additional independent influences on survival. Thus, we identified a highly favorable subgroup of patients with a single chest wall or axillary recurrent nodule (in a patient aged > 50 years), a disease-free interval of > or = 1 year, pT1-2N0 primary tumor, and without tumor necrosis, and whose recurrence is locally controlled. This group (12 patients) had 5- and 10-year survival rates of 100% and 69%, respectively. CONCLUSION: We conclude that locoregional recurrence of breast cancer following mastectomy is not always a sign of systemic disease. Our data support previous findings, that subgroups with favorable prognosis exist and they still have a chance for cure, demanding comprehensive local treatment.