🤶Recurrence Breast cancer

Question 1

What is Recurrent Breast cancer?

Answer 1

LOCAL Recurrence - reappearance of cancer in ipsilateral region of mastectomy site or remnant breast.

REGIONAL Recurrence - tumor recurrence involving axillary, supra & infraclavicular LN.

METASTASIS - reappearance of cancer at outside ipsilateral locoregional area (include contralateral breast & axilla) ± locoregional recurrence.

Question 2

Incidence of Recurrent Breast cancer

Answer 2

Mastectomy: 5 – 10% in 10 years

BCT: 10 – 15% and occur later than MAC

BCS: 35% risk

Question 3

Presentation of Recurrent Breast cancer

Answer 3

Local recurrence (new tumor or true recurrence)

• Diagnosed clinically : Asymptomatic cutaneous/ S.C nodules at or near mastectomy site. Nodules may be multiple / diffuse involvement of chest wall skin.
• Diagnosed by MMG : 50% in BCS patients.

Regional recurrence - 1/3rd will have concurrent regional recurrence

• Asymptomatic or Brachial plexopathy, severe lymphoedema

Metastatic

• Visceral
  
  • Liver - Jaundice, hepatomegaly, ascites, coagulopathy
  • Lung - Pleural effusion
  • Cardiac - Pericardial effusion
  • Brain - Confusion, Seizure, headache, photophobia
• Bone (SRE) - Bone pain, pathological fracture, spinal cord compression, hypercalcemia, viscera crisis (viscera mets with end organ damage).

Question 4

How to manage recurrent Breast cancer?

Answer 4

Review previous treatment - HPE, Staging, Treatment, Adjuvant / Neoadjuvant therapy

Restage !

• Locoregional
  
  • Breast : Biopsy (HPE, ER/PR, HER2 as tumor biology may change), MMG, USG
  • Axilla : USG axilla
• Metastatic
  
  • Visceral : CT TAP/ MRI, PET/CT, Bloods (LFT, FBC, RP)
  • Bone : Bone scan recommended If +ve CT or MRI to look for bone destruction and to differentiate from radiation induced fibrosis.
    
    • Serum Ca, Alb, PO4.
• Operability : ECOG, ASA, ECHO, Lung function test

Question 5

Overview of Recurrent breast cancer management

Answer 5

• MDT
• Individualized approach should be offered.

Question 6

Factor affecting prognosis are the risk factors for recurrence.

Answer 6

Despite aggressive local treatment, large number of patients eventually develops metastases.

• Patient factors: Age ≤ 35 years old.
• Disease: Tumor character (HER2 +, ER/PR –ve, High grade, size) Initial stage (high N), current stage (multiple site, visceral involvement)
• Treatment: Extent of primary surgery (margin involved), no adjuvant treatment, short DFS ≤ 2 years.

Question 7

Recurrece of contralateral breast

Answer 7

• Not considered local, Consider another primary tumor or metastatic disease.

Signs suggestive of primary tumor
- HPE different from primary tumor
- Long DFS ≥ 5 years.
- No locoregional or metastatic symptoms.