Although mastectomy is associated with excellent local control in most breast cancer patients, chest wall recurrence (CWR) after mastectomy has been noted in up to a third of cases. Jatoi et al found that breast-conserving surgery was associated with a greater odds of locoregional recurrence than mastectomy in a pooled analysis of randomized controlled trials (pooled odds ratio [OR]: 1.561; 95% confidence interval [CI]: 1.289-1.890), locoregional recurrence still occurred in 8.5% of mastectomy patients.1 CWR rates of up to 40% have been reported depending on primary tumor characteristics and initial treatment.2 Even with the addition of adjuvant systemic therapy, CWR remains a significant issue in a considerable proportion of patients (Table 69-1).
Table 69-1 Incidence of Chest Wall Recurrence after Mastectomy and Adjuvant Chemotherapy ||Download (.pdf)
Table 69-1 Incidence of Chest Wall Recurrence after Mastectomy and Adjuvant Chemotherapy
|Study||N||Follow-up||Incidence of CWR|
|NSABP B-1226||1093||5.3 y||9%|
|Ludwig I and II27||818||6 y||15%|
|NSABP B-1126||697||5.3 y||22%|
|ECOG 517730||553||7.7 y||28%|
A number of studies have demonstrated that the addition of postmastectomy radiation therapy (PMRT) may reduce the rate of CWR by up to 70%.3 Although the British Columbia4 and Denmark studies5,6 were criticized for a variety of reasons, the American Society of Clinical Oncology7 and the American Society of Therapeutic Radiology and Oncology8 have both issued guidelines recommending PMRT in patients with tumors larger than 5 cm or with 4 or more positive lymph nodes. Although PMRT is not recommended for node-negative patients with tumors smaller than 5 cm, PMRT remains controversial in the 1 to 3 positive-node group. The finding of the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) that a 20% reduction in 5-year local recurrence risk results in a 5% absolute reduction in 15-year breast cancer mortality may prompt more widespread use of PMRT in these patients.3
The diagnosis of CWR, defined as a breast cancer recurrence in the skin, subcutaneous tissue, muscle, or underlying bone after mastectomy, requires a high index of suspicion. Many CWRs occur within 2 to 3 years after mastectomy, but some have been found more than 10 years later. Careful surveillance of the chest wall after mastectomy is therefore required. Although some CWR present as large fungating masses, most are subtle, often presenting with an asymptomatic nodule in the skin or a slight erythematous rash. More than half of all CWR present as a solitary nodule in the skin; the remainder present as multiple nodules or diffuse disease encompassing the chest wall.9 In 23 to 70% of cases, the recurrence involves the ...