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The incidence of local recurrence correlates with tumor size, the presence and number of involved axillary nodes, the histologic type of tumor, the presence of skin edema or skin and fascia fixation with the primary tumor, and the type of definitive surgery and local irradiation Local recurrence on the chest wall after total mastectomy and axillary dissection develops in as many as 8% of patients When the axillary nodes are not involved, the local recurrence rate is less than 5%, but the rate is as high as 25% when they are heavily involved A similar difference in local recurrence rate was noted between small and large tumors Factors such as multifocal cancer, in situ tumors, positive resection margins, chemotherapy, and radiotherapy have an effect on local recurrence in patients treated with breast-conserving surgery Chest wall recurrences usually appear within the first several years but may occur as late as 15 or more years after mastectomy All suspicious nodules and skin lesions should be biopsied Local excision or localized radiotherapy may be feasible if an isolated nodule is present If lesions are multiple or accompanied by evidence of regional involvement in the internal mammary or supraclavicular nodes, the disease is best managed by radiation treatment of the entire chest wall including the parasternal, supraclavicular, and axillary areas and usually by systemic therapy Local recurrence after mastectomy usually signals the presence of widespread disease and is an indication for studies to search for evidence of metastases Distant metastases will develop within a few years in most patients with locally recurrent tumor after mastectomy When there is no evidence of metastases beyond the chest wall and regional nodes, irradiation for cure or complete local excision should be attempted Patients with local recur-
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been demonstrated Patients whose tumors are ER negative (most younger women) may not be affected by pregnancy To date, no adverse effect of pregnancy on survival of pregnant women who have had breast cancer has been demonstrated, though most oncologists advise against it In patients with inoperable or metastatic cancer (stage IV disease), induced abortion is usually advisable because of the possible adverse effects of hormonal treatment, radiotherapy, or chemotherapy upon the fetus
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Banks E et al Pregnancy in women with a history of breast cancer BMJ 2007 Jan 27;334(7586):166 7 [PMID: 17255571] Dian D et al Quality of life among breast cancer patients undergoing autologous breast reconstruction versus breast conserving therapy J Cancer Res Clin Oncol 2007 Apr;133 (4):247 52 [PMID: 17096124] Salhab M et al Skin-sparing mastectomy and immediate breast reconstruction: patient satisfaction and clinical outcome Int J Clin Oncol 2006 Feb;11(1):51 4 [PMID: 16508729] Soran A et al Breast cancer-related lymphedema what are the significant predictors and how they affect the severity of lymphedema Breast J 2006 Nov Dec;12(6):536 43 [PMID: 17238983]
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Breast reconstruction is usually feasible after standard or modified radical mastectomy Reconstruction should be discussed with patients prior to mastectomy, because it offers an important psychological focal point for recovery Reconstruction is not an obstacle to the diagnosis of recurrent cancer The most common breast reconstruction has been implantation of a silicone gel prosthesis in the subpectoral plane between the pectoralis minor and pectoralis major muscles Alternatively, autologous tissue can be used for reconstruction Autologous tissue flaps are aesthetically superior to implant reconstruction in most patients They also have the advantage of not feeling like a foreign body to the patient The most popular autologous technique currently is the trans-rectus abdominis muscle flap (TRAM flap), which is done by rotating the rectus abdominis muscle with attached fat and skin cephalad to make a breast mound The free TRAM flap is done by completely removing the rectus with overlying fat and skin and using microvascular surgical techniques to reconstruct the vascular supply on the chest wall A latissimus dorsi flap can be swung from the back but offers less fullness than the TRAM flap and is therefore less acceptable cosmetically A silicone implant often is used to increase the fullness with a latissimus dorsi flap Reconstruction may be performed immediately (at the time of initial mastectomy) or may be delayed until later, usually when the patient has completed adjuvant therapy When considering reconstructive options, concomitant illnesses should be considered, since the ability of an autologous flap to survive depends on medical comorbidities In addition, the need for radiotherapy may affect the choice of reconstruction as radiation may increase fibrosis around an implant or decrease the volume of a flap
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