Location and Control of Local Disease Predict Overall Survival and Distant Metastases Free Survival in Patients with Ipsilateral Breast Tumor Recurrence after Breast Conserving Therapy for Stage I/II Breast Cancer
Reviewer: Voika BarAd, MD
Abramson Cancer Center of the University of Pennsylvania
Ultima Vez Modificado: 17 de octubre del 2005
Presenter: Y. Chen Presenter's Affiliation: Radiation Oncology, Massachusetts General Hospital, Boston, MA Type of Session: Scientific
The best approach to ipsilateral breast tumor recurrence after breast conserving surgery and radiation has not been established.
Studies have shown that patients with ipsilateral breast tumor recurrence have a higher risk of distant failure and poorer survival.
The outside-of-tumor bed recurrences appear to have better prognosis than in-tumor-bed recurrences. This study evaluates the pattern and prognosis of ipsilateral breast tumor recurrence, in patients treated with breast conserving therapy.
Materials and Methods
1280 patients with early stage invasive breast cancer were treated with breast conserving therapy between 1980- 2000.
The median age was 59.7 years (32-78).
The median follow up was 9 years (12- 220 months).
The median dose of irradiation was 60 Gy (50 Gy whole breast and 10 Gy tumor bed boost).
The ipsilateral breast tumor recurrences were detected by mammography, physical examination or both.
72 patients developed ipsilateral breast tumor recurrence; 8 patients had concurrently distant metastasis; 64 patients only had isolated local recurrence.
From 64 patients with only ipsilateral breast tumor recurrence 52 patients (81%) had in-tumor-bed recurrences and 12 patients (19%) had outside-of tumor bed recurrences.
The rate of in-tumor-bed recurrences was 2.5%, 4%, 6% compared with outside-of-tumor bed recurrences 0.3%, 1.3%, 2% at 5, 10, and 15 years.
Mean time to outside-of-tumor bed recurrences was 67 months, vs. a shorter time to in-tumor-bed recurrences of 56 months.
Median survival time after in-tumor-bed recurrences was only 39 months, compared to 60 months after outside-of-tumor bed recurrences.
The entire cohort has overall survival of 92%, 81%, and 73% at 5, 10, 15 years.
Disease free survival was 87.5%, 74%, 65% at 5, 10, 15 years.
Distant metastasis free survival was 87.5%, 74% and 65% at 5, 10, 15 years.
Distant metastasis free survival was 96.8% for mammography detected recurrences vs 52% in clinically detected local recurrences.
Patients whose ipsilateral breast tumor recurrence was controlled with salvage therapy had 84.6% 10 years survival, compared with 21.4% for persistent local disease and 6.7% for subsequent distant metastases.
A multivariate analysis shown that the short interval to ipsilateral breast tumor recurrence < 3 years and clinically symptomatic recurrence were associated with poorer prognosis.
On multivariate analysis, the site of recurrence and surgical salvage were favorable prognostic factors.
Local failure within the primary tumor bed occurs sooner after breast conserving therapy and results in significantly lower overall survival and distant metastasis free survival.
The outside-of-tumor bed recurrences were rare during the first year after breast conserving therapy.
This study showed that the control of local failure affects overall survival time after recurrence.
It is important to distinguish true tumor bed recurrence from outside of tumor recurrence for more accurate assessment of prognosis and the choice of treatment in patients with ipsilateral breast tumor recurrence.
Breast conservation therapy undoubtedly represents substantial progress for a better quality of life for women with early stage breast cancer.
However lumpectomy is associated with a substantial proportion, approximately 10-20%, of local recurrence in long- term follow-up studies even after accounting for postoperative radiotherapy.
The risk of failure includes margin status, young age, and extensive intraductal component.
This study, and another retrospective study, demonstrated that control of the local failure dramatically affects survival time after recurrence.
Selecting women for breast- conserving therapy and achieving margin control can reduce ispsilateral failures and in this way the long term outcome in patients with early breast cancer.
Oct 1, 2014 - IBTR! version 2.0 -- a Web-based nomogram to predict ipsilateral breast tumor recurrence after breast-conserving therapy -- may be accurate in most patients with a low-to-moderate risk but overestimates risk in some higher-risk patients, according to a study published online Jan. 4 in the Journal of Clinical Oncology.