專題討論6:乳癌治療之新進展

S6-2
手術Management of Loco-Regional Relapse and Second Primary Cancer
陳訓徹
長庚紀念醫院林口總院乳房外科
台灣乳房醫學會

  Depending on the stage of the disease and the treatment given, between 10%and 35%of women experience an isolated locoregional recurrence (LRR). About 80% of these recurrences happen during the first two years after primary treatment. Various attempts have been made to identify a prognostic profile for patients at risk for LRR. There is an ongoing debate as to whether LRR is generally an indication for poor prognosis or whether resectable LRR is a strictly locally confined reappearance of the disease.

   The systematic review of randomised trials provides insufficient evidence to support systemic treatment in women with loco-regional recurrence of breast cancer. Participation in randomised trials of systemic treatment versus observation is appropriate.Chemotherapy, if assigned, should begin within 4 weeks. The choice of multidrug chemotherapy regimens for at least three cycles or 3 to 6 months are suggested. Estrogen receptor downregulators, aromatase inhibitors, and ovarian suppression are all acceptable alternatives for the required hormonal therapy for estrogen receptor positive (ER+) and/or progesterone positive (PR+) tumors. When radiotherapy is indicated, a dose equivalent to >40 Gy is required.

Radiotherapy can be administered before, during or after chemotherapy.

  Regional nodal recurrence is found in approximately 1-5.4% of early-stage breast cancer patients after mastectomy or breast conservation treatment (BCT).

  A meta-analysis shows that early detection of isolated recurrences in patients without symptoms by routine follow-up or mammography improves survival of patients with breast cancer recurrences (HR = 1.68; 95% CI: 1.48–1.91).

  The aggressive local surgery had proved the survival benefit for local relapse after primary surgery of breast cancer. In Chang Gung Memorial Hospital, Totally, 35 (0.7%) patients with axillary recurrence were identified. The 5- and 10- year overall survival rate were 77.3% and 77.3 % in patient with repeat axillary nodal clearance, however, the 5- and 10- year overall survival rate were 44.0% and 36.7 % in patient without axillary surgery. Surgical management for axillary node recurrence improve survival if intensive lymph node dissection was performed well.

  There were 63 patients who developed a isolated supraclavicular lymph node (SLNM) metastasis among the 3170 primary breast cancer patients between 1990 and 1999. The 5-year overall survival (OS) after SLNM, local relapse and distant metastasis were 33.6%, 34.9% and 9.1%, respectively. Surgical removal of the supraclavicular nodes was a significant better prognostic factor for OS after SLNM (p = 0.0327).