2 years later, she noticed multiple 1.5 -2 cm. nodular masses at the MRM site.

Breast Cancer Recurrence

• anytime, mostly occur in the first 3 – 5 years after initial treatment

• can come back as a local recurrence (in the treated breast or near the mastectomy scar) or as a distant recurrence somewhere else in the body

• most common sites of recurrence include the lymph nodes, the bones, liver, or lungs

Factors for recurrence• Lymph node involvement • Tumor size

– the larger the tumor, the greater the chance of recurrence. • Hormone receptors

– two-thirds of all breast cancers contain significant levels of estrogen receptors, which means the tumors are estrogen receptor positive (ER+)

– ER-positive tumors tend to grow less aggressively and may respond favorably to treatment with hormones.

• Histologic grade – Grade 4 tumors contain very abnormal and rapidly growing cancer cells– The higher the histologic grade, the greater chance of recurrence.

• Nuclear grade– Refers to the rate at which cancer cells in the tumor divide to form more cells– Cancer cells with a high nuclear grade (also called proliferative capacity) are usually

more aggressive (faster growing). • Oncogene expression

– tumors that contain certain oncogenes may increase a patient's chance of recurrence.

Breast Changes

• An area that is distinctly different from any other area on either breast

• A lump or thickening, in or near the breast or in the underarm, that persists through the menstrual cycle

• A change in the size, shape, or contour of the breast• A mass or lump, which may feel as small as a pea• A marble-like area under the skin• A change in the feel or appearance of the skin on the breast

or nipple [dimpled, puckered, scaly, or inflamed (red, warm, or swollen)]

• Bloody or clear fluid discharge from the nipples• Redness of the skin on the breast or nipple

Impression?

Locoregional recurrence of the breast cancer on the mastectomy site

Treatment

• With previous mastectomy:– Surgical resection of the locoregional recurrence– Appropriate reconstruction– Chemotherapy– Anti-estrogen therapy

Biopsy?

• Yes!– to determine the characteristics of the

lesion/tumor– to determine the staging of the recurrence– to permit doctors discuss the appropriate

management• A current study shows that 10 out of 29 recurrent

tumors changed ~ 35%

Biopsy Of Recurrent Breast Cancer Can Alter Treatment

• Article Date: 20 Mar 2009• A group of doctors from Toronto has recently

completed the world's first study that compared original breast cancer tumors with a biopsy of suspected tumors that recurred elsewhere in the body.

• found that the biopsy resulted in 20% of the women having a significant change in their treatment– change in drug treatment – change in diagnosis to a benign condition.

• "The results show that cancers may change over time and not respond to treatment that was appropriate for the original cancer,“

• principal investigator, Dr. Mark Clemons, a medical oncologist specializing in breast cancer in the Princess Margaret Hospital Cancer Program, University Health Network (UHN).

• leading us in a new direction to understand more about why some women don't respond to treatment

• this will help us to always deliver the right treatment, to the right patient, at the right time

Biopsy Of Recurrent Breast Cancer Can Alter Treatment

• 29 biopsies of accessible, recurrent tumors taken from women whose breast cancer had spread to bone, skin, lymph nodes, lung or liver

• compared the results of the original cancer with the results of the new biopsy by analyzing the predictive markers that influence breast cancer tumor growth - estrogen, progesterone and Her2 status

• the presence, absence and/or combinations of these markers become the map oncologists use to determine the most effective treatment for each patient.

Biopsy Of Recurrent Breast Cancer Can Alter Treatment

• Result:– 15 cases was unchanged– 10 cases the markers in the cancer changed– 3 cases, women originally felt to have metastatic

breast cancer had benign disease– 1 case, the "recurring" cancer was a different type

of cancer, lymphoma which is treated in a very different way to breast cancer.

Biopsy Of Recurrent Breast Cancer Can Alter Treatment

References:

• Brunicardi, F. C., et. al., Schwart's Manual of Surgery, 8th ed., 2006

• www.medicinet.com • Annals of Oncology, Oxford University Press

(Doi:10.1093/annonc/mdp028) • www.cancer.org (American Cancer Society)