Recurrences in regional nodes following treatment of breast cancer are not uncommon and can be associated with significant psychological and physical morbidity. Recurrence can occur late, particularly for ER positive tumours. Hellman (1994) stated that breast cancer is probably a spectrum disease and challenged the notion that the disease is simply local (Halstedian hypothesis), or simply metastatic at presentation (Fisher hypothesis) and noted that regional disease may be the only site of metastasis in many patients.
In the landmark NSABP-B06 study regional recurrence occurred in 4.6% of patients undergoing a total mastectomy, 8.7% for patients undergoing a lumpectomy and 5.4% for patients undergoing lumpectomy and radiation. Of these, 26%, 30% and 38% occurred after 5-years and 9%, 10% and 15% occurred after 10 years. In the Oxford overview of breast conservation trials, of patients who had lumpectomy alone 35.4% had regional recurrence after 5 years and 5.9% after 10 years.
The treatment of regional node recurrence is complex and should be managed by a multidisciplinary team. Taking a “palliative" approach and simply treating the patient with chemotherapy on the assumption that the disease is “recurrent" or “metastatic" can result in significant under-treatment and the loss of the possibility of cure.
In this presentation, several examples of difficult recurrences that have been treated aggressively with chemotherapy, followed by surgery and then by radiation therapy will be presented, including recurrences in the axilla, interpectoral space (Rotter’s node), internal mammary chain and the opposite axilla.
Treatment of regional node disease can result in long-term remissions and probably “cures” for some patients. Potential under-treatment of the axilla with observation of isolated tumour cells and micrometastases, particularly in patients with mastectomy, may lead to an increased recognition of this problem in the next few years with physical, psychological and potential medico-legal implications.