When Is Surgery Preferred for Recurrent Breast Cancer?

What Is Recurrent Breast Cancer?

Disease returning after surgery and preventive treatment for early breast cancer is called recurrent breast cancer in this context.

Which Imaging Tests Precede Treatment Decisions for Recurrence?

In recurrent breast cancer, to establish the extent of disease throughout the body before treatment, PET-CT is performed. Brain symptoms or suspicious liver findings may also require brain and/or liver MRI because PET-CT may be inadequate there. Ultrasound, bone scintigraphy and other CT methods may also assess extent.

Should Biopsy Be Repeated Before Treating Recurrent Breast Cancer?

In local recurrence and/or metastasis , when detected, often warrants checking for altered tumor biology and ensuring the right treatment plan through repeat biopsy as recommended.

Recurrence early after preventive treatment, within the first year, generally shows more aggressive biology. Recurrence one year or later tends to be more indolent and more hormone-sensitive.

Should Tumor Tests, Circulating Tumor Cells and Circulating Tumor DNA Be Assessed Before Treatment?

Before treating recurrence, liquid biopsy may assess circulating tumor cells, CEA and Ca 15.3, cancer markers that, if initially elevated, can be repeated to monitor disease and treatment response.

Circulating tumor DNA may identify cancer-cell mutations to select individualized targeted treatments. Social security institutions do not reimburse circulating tumor-cell and tumor-DNA precision medicine tests. If desired, discuss benefits and harms with the patient and perform when necessary if the patient accepts payment.

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What Is Locally Recurrent Breast Cancer?

Recurrence at the breast surgical site is diagnosed as locally recurrent breast cancer . It may occur within a breast treated conservatively, soft tissue at the mastectomy site, breast and/or axillary skin, subcutaneous tissue and/or axillary lymph nodes.

Should Surgery Be Preferred for Local Recurrence?

If recurrence is limited to the previous surgical site and PET-CT shows no distant metastases, surgical removal is preferred in suitable patients.

After breast-conserving surgery, recurrence often leads to mastectomy. Axillary surgery depends on examination, imaging of lymph nodes and the original axillary procedure.

After mastectomy, if recurrence adheres to surrounding tissue and complete removal without residual cells is difficult, preoperative options include chemotherapy, targeted drugs, hormonal therapy, radiotherapy with concurrent hyperthermia (heat treatment) . For local recurrence several years after initial treatment, life-saving, curative-intent treatments are prioritized.

What Is Recurrent Multiple-Metastatic Breast Cancer?

Recurrence may remain at the surgical site or involve organs such as bone, liver and lung. Multiple metastases in one organ or metastases in multiple organs define multiple-metastatic breast cancer. Complete elimination is not the goal; a cure is currently impossible in this setting. Drug treatment is preferred to relieve symptoms, improve quality of life and extend survival.

What Is Recurrent Oligometastatic Breast Cancer?

Recurrence in one or several organs with small metastatic sites numbering 1-3 is called recurrent oligometastatic breast cancer . Treatment generally resembles multiple-metastatic disease. After good responses to 4-6 months of drug treatment, remaining shrunken metastases may receive local surgery, SBRT, cryoablation, RFA or microwave treatment. Comprehensive benefit studies are lacking; information is limited to personal experience and patient series.

What Is Recurrent Solitary Metastatic Breast Cancer?

If recurrence affects one organ and PET-CT finds only one metastasis, this is called a solitary breast cancer metastasis . It differs from multiple-metastatic disease. Particularly with recurrence after one year, local treatment by site may include surgery, SBRT, cryoablation, RFA or microwave treatment, with systemic drug treatment added.

Who Should Receive Salvage Surgery for Recurrent Breast Cancer?

1. Patients with limited local recurrence are offered salvage surgery before drug treatment or after tumor-reducing treatment using drugs, radiotherapyor concurrent hyperthermia and radiotherapy. Plastic surgery support may help difficult cases.
2. Surgery may be offered for solitary metastases in liver, lung or brain. Recurrence within the first year after treatment requires caution because aggressive biology is likely. Consider surgery carefully, preferring other local approaches when possible. Hormone-sensitive solitary metastases recurring at least one year after preventive treatment may be operated on after thorough benefit-harm discussion with the patient, considering team experience and skill.

Who Should Receive Palliative or Preventive Surgery?

1. Bone metastases with high fracture risk may require surgery to prevent vertebral, arm or leg fractures, maintain mobility and prevent bedridden status. Comprehensive fracture-risk assessment is vital in recurrent metastatic breast cancer, particularly with bone involvement. Goals are symptom relief, quality of life and longer survival. Without a cure, keeping patients mobile and preventing fracture-related confinement are major aims. Vertebroplasty, radiation of metastases and bone-protective bisphosphonates benefit patients at fracture risk.
2. Spinal cord compression and/or severe brain edema from recurrent metastases may require decompression to improve quality of life and prevent paralysis. Radiotherapy added to systemic treatment also helps prevent regional problems.

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What Are Bone Metastases? Why Do Cancers Spread to Bone and How Are They Treated?