Chest Wall Recurrence After Mastectomy

A chest wall recurrence is when breast cancer returns after receiving treatment. A chest wall recurrence may involve skin, muscle, and fascia (a thin layer of connective tissue) beneath the site of the original breast tumor, as well as the lymph nodes.

When cancer recurs in the chest wall, it may be classified as local (in the same remaining breast tissue or chest wall), regional (in the nearby lymph nodes) or as a distant metastasis (when cancer has spread to other parts of the body). In some cases, the term "locoregional" is used. This is a combination of "local" and "regional," when recurrence affects either the preserved breast/chest wall or nearby lymph node areas.

If a chest wall recurrence is localized, it is referred to as a nonmetastatic breast cancer recurrence. Risk of recurrence can vary depending on several factors, including the type of breast cancer and types of treatment received.

This article will review symptoms and diagnosis of breast cancer recurrence, as well as potential treatment options and survival outlook with helpful coping tips.

Symptoms

Symptoms may present differently and can vary greatly depending on where the cancer recurs and what type of treatments you have previously received. Always discuss any new or worrisome symptoms with your healthcare provider.

A few examples of breast cancer chest wall recurrence symptoms are:

• A sore or lump felt in the breast/chest
• A discomfort or a pulling sensation in the breast/chest
• Thickened or swollen skin near surgical site
• Changes to nipple appearance or discharge
• Chronic chest pain and/or dry cough
• Severe headache or vision problems

Diagnosis

If your recurrence is visible, a biopsy (removing a sample of tissue for testing) may be done to determine whether it is a breast recurrence or not. If it is positive, oncologists recommend repeating tests to see if it is estrogen receptor-positive, progesterone receptor-positive, or human epidermal growth factor receptor 2-positive, or HER2-positive.

This may seem like a surprising step to take, since these tests were already done when you were originally diagnosed with breast cancer. But in a recurrence, the receptor status of the cancer cells can change, especially if it has been more than a year or two since your mastectomy.

In other words, if you originally had a breast cancer tumor that was estrogen receptor-positive, your tumor cells may have changed and become estrogen receptor-negative. Medically, this is referred to as discordance of a tumor.

A biopsy is recommended, even if your physician is certain that you're dealing with a recurrence of your original cancer. This is done because of discordance, and results can have a great impact on choosing the best treatment options moving forward.

Since a locoregional recurrence can be associated with distant metastases, a workup for staging is often done again and may include a positron-emission tomography (PET) scan to identify if the cancer has spread to other regions of the body.

Treatment

The first step in deciding on treatment is determining if a chest wall recurrence is confined to one area or if additional areas of recurrence, especially distant metastases, are present. Treatment options include the following:

Surgery

Surgery is the mainstay of treatment to remove the area of recurrence. A full thickness resection is recommended when possible and, when done on people who are appropriate candidates, can result in a 41% survival rate after 15 years.

Chemotherapy

If the area of recurrence is too extensive to be removed completely with surgery, chemotherapy may be used first to reduce the size of the tumor so that local treatment is possible. Chemotherapy uses strong medications to kill fast-growing cells, such as cancer cells, in your body. It will also be prescribed if the tumor has metastasized to distant areas of the body.

Around 27% of women with a locoregional recurrence, such as a chest wall recurrence, will have a synchronous distant metastasis.

Radiation Therapy

If radiation therapy (using high-powered radiation to kill and shrink tumors) was not used at the time the original cancer was treated, it is usually used (along with surgery or other methods of removing the tumor) to make sure all cancer cells are treated. Cells may not be seen on imaging, but are assumed to possibly be present.

If radiation therapy was used previously, your radiation oncologist will weigh the possible benefit of this by considering how long it has been since you had radiation therapy and if a reduced dose may be required.

Hormonal Therapy

If the recurrence is estrogen receptor-positive and was previously negative, hormonal therapy will be recommended. This may be the drug tamoxifen, for those who are premenopausal, postmenopausal, or who are premenopausal and have undergone ovarian suppression therapy with an aromatase inhibitor such as Aromasin (exemestane), Arimidex (anastrozole), or Femara (letrozole).

If the tumor is estrogen receptor-positive and your previous tumor was as well, your oncologist will carefully consider your options. When a recurrence occurs when you are on hormonal therapy, the tumor may have become resistant, and a different medication may be recommended.

Targeted Therapy

If your tumor is HER2-positive and your original tumor was HER2-negative, HER2-targeted therapies, such as Herceptin (trastuzumab), will likely be recommended. If your tumor is HER2-positive and was so before, a different HER2 inhibitor may be used.

Proton Therapy

Proton therapy is a relatively new treatment option, and not much research has been done on it thus far. One study showed that proton therapy for chest wall recurrence, when radiation therapy was done for the initial cancer, had acceptable levels of toxicity. Surgery to the chest wall after proton therapy, however, can result in significant problems in wound healing.

Prognosis

The survival rates for breast cancer with a chest wall recurrence can vary greatly depending on several factors. Your oncologist can speak to your individual outlook. There are an increasing number of treatment options available.

Coping

If your breast cancer comes back, it can be discouraging and sometimes more frightening than when you were first diagnosed. Less often, some people may experience a time when their cancer is no longer curable. Despite this, it is still very treatable, and several options now exist that may make it possible to live with breast cancer as a chronic illness.

If you experience a recurrence in your chest wall, it's important to research all your options and consider getting a second opinion so you can be confident you are doing everything possible to beat the cancer.

Summary

Breast cancer recurrence to the chest wall is when cancer that has been treated comes back. Recurrence can happen locally, regionally, or as a distant metastasis. Where the cancer recurs can affect what type of symptoms are present. Many potential treatment options are available. Overall survival varies. Keep in mind, everyone's personal experience and treatment options may be different. Speak with your healthcare team to discuss your best options.