Breast Cancer: Local Recurrence

Breast cancer comprises of 18% of all cancers in women. The middle age makes women most vulnerable to Breast cancer (BC). Hormonal levels also play an important role. Long exposure to estrogen as in case of early menarche, late menopause and late first pregnancy increases risk for BC. The oral contraceptive and hormone replacement therapy are also risk factors to some extent. The lifestyle such as obesity, alcohol consumption is also related to BC (Singletary et al 2004; McPherson et al 2000). Local recurrence (LR) is revival of original tumor in ipsilateral breast, chest wall or overlying skin. About 10-20% women face LR after treatment of primary BC. LR is considered early when it occurs within two years of surgery.

Younger age, 35 or below, is a risk factor for revival of BC. In younger women, the recurrence or revival is nearly 10 times compared to women above 60. The risk of cancer revival is lesser in patients' undergone mastectomy (removal of breast) than those undergone breast conservation therapy (BCT). This fact may be used to inform younger patients prior to treatment. The large tumor size, high histological grade, absence of estrogen receptors, margin status and inadequate radiotherapy cause recurrence. It is advised that post BCT adjuvant therapy with hormones or drugs reduce recurrence (Singletary et al 2004; Nutyen et al 2006).

The histological grade and p53 should be considered together as cause of early recurrence. The patients with histological grade 1 (lowest grade) are p53 negative also. As the histological grade increases the presence of p53 also increases.

The tumor size is important determinant for treatment choice. Those having a breast tumor of 4 cm or more should be treated with lumpectomy followed by radiotherapy. The treatment reduces recurrence by a considerable 25%.

The presence very few axillary nodes in surgical specimen indicate inadequate surgery, nodes missed at surgical examination or actually nodes are absent. The absence of nodes in surgical specimen results in early relapse and shorter survival. It is desirable that despite absence of nodes in the specimen, the patient should be given systemic therapy.

The family history is one of the most important risk factor for BC and its recurrence. The mutations in BRCA1 and BRCA2 genes are genetically predisposed and increase incidence of recurrence. It is to be noted here that tumor may appear in same breast but at a different location and should be treated as second primary tumor rather than true recurrence(De Vitta et al 2008).

Over expression of receptors such as HER2 and ER is also a prognostic factor in breast cancer.

Therapy:

The BCT in US is performed by lumpectomy while in Europe it is done by quandrantectomy. In the latter larger section is done reducing local recurrence considerably. The factors discussed above also affect local recurrence after mastectomy . Patients with large primary tumor (>4 cm) are given chemotherapy and surgery followed by radiation treatment. The last treatment should be given in two stages. The 45-50Gy whole breast irradiation followed by a 10-16 Gy boost irradiation to the primary tumor site is given. This boost reduces recurrence by half since most recurrences occur around primary tumor (De Vitta et al 2008; Nutyen et al 2006).

Sources:

DeVita, Vincent T., Lawrence, Theodore S. and Rosenberg, Steven A. (2008). DeVita, Hellman,

and Rosenberg's cancer: principles & practice of oncology, Volume 2 (2^nd Ed., Lippincott Williams & Wilkins)

Iwaya, K., Tsuda, H., Fukutomi, T. Tsugane, S., Suzuki, M. and Hirohashi, S. (1997).

'Histological grade and p53 immunoreactions as indicators of early recurrence of node-

negative breast Cancer.'Jpn J Clin Oncol, Vol., 27, no. 1, pp. 6-12.

McPherson, K.,Steel, C M & Dixon, J M.(2000). 'ABC of breast diseases: Breast cancer

Epidemiology, risk factors, and genetics', BMJ. 321, 624-628.

Singletary, S. Eva, Robb, G. L. and Hortobagyi, G. L. (2004).Advanced therapy of breast disease

(2^ND Ed.) PMPH-USA