Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1054_Библиотеки_им_академика_М_И_Перельмана

Recurrence of any kind is a predictor for a poorer prognosis, with one additional breast can­cer death at 15years for every four patients who had a locoregional recurrence 10 years after breast conserving surgery [9]. As with the treat­ment of the initial breast cancer, the outcome of treatment of recurrence is related to the extent at the time of rst diagnosis, with a 5-year Distant Disease-free Survival (DDFS) of 67% in patients

[17], even patients with positive sentinel nodes may not undergo completion axillary surgery.

Following breast conserving surgery, IBTR is most often identied during routine surveillance mammography, although some patients identify subtle changes in the breast in the interval between mammograms. There are two distinct types. True recurrences occur in or close to the bed of the previously treated primary tumour and have similar tumour biology. This type of recur­rence is associated with positive tumour margins, aggressive tumour biology (high grade, triple negative), lympho-vascular invasion, and exten­sive DCIS (Fig. 34.1a–c). On the other hand, some recurrences occur in a different quadrant of

The majority of patients who have breast con­servation will have had radiotherapy as part of their primary breast cancer treatment. Although some patients with early disease may have been treated with a partial breast irradiation technique, the majority will have had whole breast radio­therapy. Following radiotherapy, breast tissue may be brosed, with compromised microvascu­lar architecture, and skin may be thickened or oedematous. Most of the available data regarding surgical complications after breast radiotherapy is related to autologous or implant-based whole breast reconstruction [34]. Implant-based recon­struction has a signicantly higher complication rate in previously irradiated patients, with some improvement if autologous tissue such as an LD ap is used in addition to the implant. Pooled data shows that the failure rate of implants after radiotherapy is about 14%, and in general this technique is not recommended. The gold stan­dard post-radiotherapy is autologous reconstruc­tion, which appears to be safe, with a ap loss rate of 3%, compared to about 1.5% in non­irradiated patients. There is very little published information on surgical techniques that should be recommended for breast re-conservation follow­ing radiotherapy. A few small case series report the outcome of cosmetic surgery such as breast reduction or mastopexy in patients who have had radiotherapy, with anecdotal evidence of increased surgical complications, including fat necrosis and wound dehiscence [35]. With this

The surgical management of isolated chest wall recurrence following mastectomy is re­excision of the chest wall nodule with a negative margin. In addition, chest wall radiotherapy is recommended for patients who did not receive radiotherapy in the primary setting [28].

Other possible approaches include a combina­tion of radiation with hyperthermia, which improved local control and clinical response in a prospective RCT [45], or concurrent chemora­diotherapy [46].

Continuation of endocrine therapy is recom-