Chest Wall Recurrence After Mastectomy

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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 localized, 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 10 years post-surgery.

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 like a surprising step to take, since these tests were already done when you were originally diagnosed with breast cancer. 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.

A biopsy is also recommended, even if your physician is certain that you're dealing with a recurrence of your original cancer. This is done because of discordance, and results can have a great impact on choosing the best treatment options moving forward.

Since a locoregional recurrence can be associated with distant metastases, a workup for staging is often again done and may include a positron emission tomography (PET) scan to identify if the cancer has spread to other regions of the body.

Treatment

The first step in deciding on treatment is determining if a chest wall recurrence is confined to one area or if additional areas of recurrence, especially distant metastases, are present. Treatment options include the following.

Surgery

Surgery is the mainstay of treatment to remove the area of recurrence. A full thickness resection is recommended when possible and, when done on people who are appropriate candidates, can result in a 41 percent survival rate after 15 years, according to a 2018 study.

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. Chemotherapy will also be prescribed if the tumor has metastasized to distant areas of the body.

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.

Radiation Therapy

If radiation therapy was not used at the time the original cancer was treated, it is usually used (along with surgery or other methods of removing the tumor) to make sure all cancer cells are treated; cells may not be seen on imaging, but are assumed to possibly be present.

If radiation therapy was used previously, your radiation oncologist will weigh the possible benefit of this by considering how long it has been since you had radiation therapy and if a reduced dose may be required.

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, postmenopausal, or who are premenopausal and have undergone ovarian suppression therapy with an aromatase inhibitor such as Aromasin (exemestane), Arimidex (anastrozole), or Femara (letrozole).

If the tumor is estrogen receptor-positive and your previous tumor was as well, your oncologist will carefully consider your options. When a recurrence occurs when you are on hormonal therapy, the tumor may have become resistant and a different medication may be recommended.

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 so before, a different HER2 inhibitor may be used.

Proton Therapy

Proton therapy is a relatively new treatment option, and not much research has been done on it thus far. One 2017 study did find that proton therapy for chest wall recurrence, when radiation therapy was done for the initial cancer, had acceptable levels of toxicity. Surgery to the chest wall after proton therapy, however, 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 now be changing with the introduction of better treatment options.

The amount of time elapsed between the initial breast cancer and the locoregional recurrence plays an important role in survival.

In those who have a chest wall recurrence within three years of the original diagnosis, the survival rate is around 30 percent, whereas those who have a recurrence after three years may have a 70 percent or higher chance of survival.

Coping

If your breast cancer comes back, it can be even more frightening than when you are first diagnosed. Part of this is that 27 percent of chest wall recurrences are associated with distant metastases, which means that the cancer is no longer curable. Despite this, it is still very treatable, and several options now exist that may make it possible to live with breast cancer as a chronic illness.

If you experience a recurrence in your chest wall, it's important to research all your options and consider getting a second opinion so you can be confident you are doing everything possible to beat the cancer.

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