Surgical management of locally advanced and recurrent breast cancer

Considerations for surgical treatment of locoregional recurrences of breast cancer are particularly relevant at a time when many primary breast malignancies are being treated in a more conservative manner. The past experience with local recurrence after radical mastectomy was dismal: every patient with recurrence eventually developed systemic disease. Over 80% of such patients died within 2 years. The observations after local recurrence in patients with modified radical mastectomy are generally the same, although those with better prognostic lesions may have a marked delay in mortality. For patients with partial mastectomy and radiation, there are data which suggest that subsequent mastectomy for "in breast" recurrence may salvage approximately 50% of women and achieve long-term freedom from disease. This is a crucial question which will require more patients and time for confirmation. The author reviews patterns of locoregional recurrence after primary treatment of breast cancer, presents a plan for workup of such patients, and describes prognostic factors. The various treatment options, with their results, are discussed, and their dependency on the initial therapy is stressed. For patients with advanced Stage III primary breast cancer (T4 or N2, N3 lesions) and inflammatory carcinoma, a multimodal approach is proposed, with systemic multidrug chemotherapy as the initial treatment. The interlocking roles of surgical resection of the breast and radiation therapy must be considered, depending on the response to chemotherapy. Algorithms for therapy have been constructed to demonstrate the options.