Local recurrence in the breast may be accompanied by distant recurrence. Therefore, all patients who are diagnosed with a local or regional recurrence should have staging scans to rule out distant disease. If these scans are negative, surgical intervention is recommended if the tumor is operable.
In patients who develop an ipsilateral breast recurrence or new primary tumor following prior history of breast conservation with whole breast radiation therapy, further radiation is generally contraindicated. Therefore, the standard surgical treatment of the breast is mastectomy. While there have been case reports of repeat lumpectomy followed by accelerated partial-breast radiation therapy, there are insufficient data to support the long-term safety of this approach. If the tumor is not operable by mastectomy at presentation, neoadjuvant therapy with chemotherapy or hormone therapy may be considered as an initial step.
The approach to the axillary lymph nodes has been an area of debate since the era of SLNB. Nodal staging provides valuable prognostic information, even in the case of a local recurrence. If a patient is clinically node-negative at the time she presents with a local recurrence in the breast, SLNB may be attempted. There is a small body of literature supporting the use of reoperative SLNB in clinically node-negative patients who have an ipsilateral recurrence or new primary following prior breast conservation with SLNB. These studies have found that successful lymphatic mapping is more likely to occur when fewer nodes were removed at the time of the treatment for the index cancer. While lymphoscintography is not strictly required, it may help to identify sites of extra-axillary drainage due to alternate drainage pathways. In patients who have had prior completion axillary lymph node dissection, reoperative SLNB is possible, but less likely to be associated with successful lymphatic mapping. In these cases, axillary exploration is less likely to yield any additional lymph nodes.
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Cox CE, Furman BT, Kiluk JV, et al. Use of reoperative sentinel lymph node biopsy in breast cancer patients. J Am Coll Surg. 2008;207:57-61.
Karam A, Stempel M, Cody HS III, Port ER. Reoperative sentinel lymph node biopsy after previous mastectomy. J Am Coll Surg. 2008;207:543-548.
Kaur P, Kiluk JV, Meade T, et al. Sentinel lymph node biopsy in patients with previous ipsilateral complete axillary lymph node dissection. Ann Surg Oncol. 2011;18:727-732.
Port E, Garcia-Etienne C, Park J, Fey J, Borgen PI, Cody HS 3rd. Reoperative sentinel lymph node biopsy: a new frontier in the management of ipsilateral breast tumor recurrence. Ann Surg Oncol. 2007;14:2209-2214.
Rodrigo Arrangoiz MS, MD, FACS, FSSO 