Chest Wall Recurrence After Mastectomy for Breast Cancer

Treatment Options and Prognosis

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breast cancer cells with a recurrence in the chest wall
STEVE GSCHMEISSNER/Science Photo Library/Getty Images

A chest wall recurrence is breast cancer that returns after a mastectomy. A chest wall recurrence may involve skin, muscle, and fascia beneath the site of the original breast tumor, as well as lymph nodes. When cancer recurs in the chest wall, it may be classed as a locoregional recurrence, or it may be linked to distant metastasis. If a chest wall recurrence is an isolated recurrence, it is referred to as a non-metastatic breast cancer recurrence.

Around 5 percent of women who have had a mastectomy will have a regional recurrence over the next 10 years.

It can be incredibly confusing to research chest wall recurrence. What statistics are right? Why do the treatments seem to contradict each other? For the purposes of this article, we are talking about people who have had a mastectomy. If cancer recurs in the breast after a lumpectomy, that is fairly different.

Symptoms

A chest wall recurrence may be first seen as a sore that doesn't heal, and possibly drains. There may be discomfort or a pulling sensation.

Diagnosis

If your recurrence is visible, a biopsy may be done to determine whether it is a breast recurrence or not. If it is positive, oncologists recommend repeating tests to see if it is estrogen receptor positive, progesterone receptor positive, or HER2 positive. This may seem surprising after these were already tested, but in a recurrence, the receptor status of the cancer cells can change, especially if it has been more than a year or two since your mastectomy.

In other words, if you originally had a breast cancer tumor that was estrogen receptor positive, your tumor cells may have changed and become estrogen receptor negative. Medically, this is referred to as "discordance of a tumor."

Some people may be surprised that a biopsy is recommended if your physician is certain it is a recurrence of your original cancer.

It is because of discordance that this is done, and can have a great impact on choosing the best treatment options.

Since a locoregional recurrence such as a chest wall recurrence can be associated with distant metastases, a work-up for staging is often again done and may include a PET scan looking for other regions of spread in the body.

Treatments

As with your original diagnosis of breast cancer, treatment of a recurrence usually combines a few treatments. Treatments can be broken down into:

  • Systemic treatments: These are treatment that address cancer cells anywhere in your body, and includes chemotherapy, targeted therapies, hormonal therapies, and some of the newer treatments available in clinical trials such as PARP inhibitors and more.
  • Local treatments: These treatments affect cancer where it originates (or spreads) but doesn't address cancer cells elsewhere in the body. Examples include radiation therapy, surgery, and proton therapy.

The first step is determining if a chest wall recurrence is an isolated recurrence, or if additional areas of recurrence, especially distant metastases are present.

Chest Wall Recurrence Plus Distant Metastases

If there is also evidence of distant metastases, treatments for metastatic breast cancer will be the primary approach.

These may include. Local treatments may also be used to control the cancer in the chest wall as discussed below. According to a 2018 study around 27 percent of women with a locoregional recurrence, such as a chest wall recurrence, will have a synchronous distant metastasis.

Isolated Chest Wall Metastases (Non-Metastatic Recurrence)

If there is no evidence of distant metastatic disease on testing (no evidence of the cancer having spread to the bones, lungs, liver, brain, or other regions), local treatment to remove the recurrence is the goal of treatment. Since a tumor that has spread to the chest wall has also essentially "declared its intent" to spread to other regions of the body, systemic treatments are also important.

Before treating the tumor, it's important for a "re-biopsy" to be done in order to determine the receptor status of the recurrence. Options include:

Chemotherapy

If the area of recurrence is too extensive to be removed completely with surgery, chemotherapy may be used first to reduce the size of the tumor so that local treatment is possible.

Radiation Therapy

If radiation therapy was not used at the time the original cancer was treated, this is usually used (along with surgery or other methods of removing the tumor) to make sure all cancer cells are treated (cells that cannot be seen on imaging but are assumed to possibly be present. If radiation therapy was used previously, your radiation oncologist will weight the possible benefit considering how long it has been since you had radiation therapy, and if a reduced dose may be required.

Surgery

Surgery is the mainstay of treatment to remove the area of recurrence. As noted above, chemotherapy may be needed to reduce the size of the tumor before surgery, and radiation therapy is often used after surgery.

A full thickness resection is recommended when possible, and when done on people who are appropriate candidates, resulted in a 41 percent survival rate after 15 years according to a 2018 study.

Hormonal Therapy

If the recurrence is estrogen receptor positive and was previously negative, hormonal therapy will be recommended. This may be tamoxifen, for those who are premenopausal, or, for those who are postmenopausal or are premenopausal and have undergone ovarian suppression therapy, an aromatase inhibitor such as Aromasin (exemestane), Arimidex (anastrozole), or Femara (letrozole). If the tumor is estrogen receptor positive and your previous tumor was estrogen receptor positive, your oncologist will carefully consider your options. When a recurrence occurs when you are on a hormonal therapy, the tumor may have become resistant. A different medications may be recommended, or

Targeted Therapy

If your tumor is HER2 positive and your original tumor was HER2 negative, HER2 targeted therapies such as Herceptin (trastuzumab) will likely be recommended. If your tumor is HER2 positive and was also HER2 positive before, a different HER2 inhibitor may be used.

Proton Therapy

Proton therapy is a relatively new treatment option, and we don't have many studies. One 2017 study did find that proton therapy for chest wall recurrence, when radiation therapy was done for the initial cancer, had acceptable toxicity. Surgery to the chest wall, however, after proton therapy, can result in significant problems in wound healing.

Prognosis

The overall 10 year survival rate for breast cancer with a chest wall recurrence is around 50 percent, but that may be changing now with better treatment options. The amount of time elapsed between the initial breast cancer and the locoregional recurrence plays an important role in survival, with those who have a chest wall recurrence within 3 years of diagnosis poorer (around 30 percent), whereas those who have a recurrence after 3 years, the survival rate may be 70 percent or higher.

Coping

If your breast cancer comes back, it can be even more frightening that when you are first diagnosed. Part of this is that 27 percent of chest wall recurrences are associated with distant metastases (metastatic breast cancer) which means that the cancer is no longer curable. Yet, even if a cancer is not curable, it is still very treatable, and several options exist.

For those who have an isolated locoregional recurrence, full thickness removal of the tumor may result in long term survival for many who are candidates for this treatment.

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