The Anatomy of Recurrence
A breast cancer recurrence can be local, regional, or distant.
Local recurrence means the cancer has come back in the remaining breast tissue or, in the case of mastectomy, in the scar. Regional recurrence means it has come back in the nodes in the armpit, or around the collarbone. A distant recurrence is one where the cancer spreads to another organ in the body.
Local recurrences after a lumpectomy are unusual. When they do occur it is usually in the area of the original tumor. The first sign of a local recurrence can be a change in how your breast looks or feels. Once a local recurrence has been diagnosed, your doctor will do tests to see if there are signs of cancer elsewhere in the body. These may include a chest X-ray, CT scan, MRI or PET scan, and blood tests. Only five to 10 percent of women with local recurrence have signs of disease elsewhere.
Local recurrence after mastectomy usually shows up as one or more pea-sized nodules on or under the skin near the scar. It can also appear on the scar itself. After reconstruction, a recurrence can appear at the suture line of the flap or in front of the implant. When it’s in the skin itself, it can be red and raised. It’s usually so subtle the surgeon is likely to think at first that it’s just a stitch that got left in after the operation. Then it gets bigger and needs to be biopsied.
Reconstruction rarely, if ever, hides a recurrence. With implants, the recurrences are in front of the implant. With a flap, the recurrences are not in the flap (tissue from the abdomen) but along the edge of the old breast skin. Approximately 20 to 30% of women with local recurrences after mastectomy have already been diagnosed with metastatic disease and another 20 to 30% will develop it within a few months of diagnosis. Therefore, just as with local recurrences after breast conservation, tests should be done to look for distant disease.
The treatments for a local recurrence are also local. Most commonly the lesion is removed surgically. This will be followed by radiation to the chest wall, if you have not previously had radiation. (Radiation can only be used once on the breast area.) Occasionally larger areas are surgically removed, including sections of rib and breastbone. Although this approach has not been shown to increase survival, it can improve the quality of life by preventing further local spread, which can be difficult to manage.
About 80 to 85% of women with an isolated local recurrence following mastectomy eventually develop distant metastases. This is not because the local recurrence spreads, but rather because the recurrence is an indicator that something in your body has changed and dormant cells are waking up.
A regional recurrence is one that occurs in the lymph nodes under the arm or above the collarbone. This is rare, occurring in only about percent of breast cancers. Further treatment to this area with either surgery or radiation often takes care of the problem, although systemic therapy may also be used. A regional recurrence in lymph nodes elsewhere, such as in the neck or above the collarbone, is more likely to reflect spread of the tumor through the bloodstream.
When a cancer spreads to a different organ, it’s known as a distant recurrence, or metastasis. Contrary to common belief, women with metastasis often live for quite a number of years, with reasonable quality of life. The prognosis for metastatic disease depends on the molecular subtype your recurrence.
We had always assumed that metastases were molecularly the same as the original tumor. But new technologies have shown us this assumption was incorrect. Tumors are not composed of just one kind of cell and metastases may not be the same type as the original. Moreover, metastases can continue to change. For this reason, your doctor will probably biopsy and test the tumor cells at each decision point for new treatments.
As you learn more about your recurrence, you may also want to pursue your options for enrolling in a clinical trial. You can learn more about breast cancer clinical trials for metastatic breast cancer here:
Learn more about metastatic breast cancer and its treatments in Recurrence.