Zusammenfassung
Das Mammakarzinom gilt als systemische Erkrankung mit für den Krankheitsverlauf bedeutsamer lokoregionaler Komponente. Während es für die brusterhaltende Therapie (BET) beim primären Mammakarzinom allgemein akzeptierten Leitlinien für das operative und strahlentherapeutische Vorgehen gibt, werden Rezidive nach BET unterschiedlich behandelt. Der Hauptgrund für das unterschiedliche Vorgehen ist das Fehlen großer, randomisierter Studien zur Operation, erneuter Bestrahlung und systemischer Therapie. Lokalrezidive treten in 5-15 % bzw. 20-25 % der Fälle 5 bzw. 10 Jahre nach einer BET auf und sind häufiger bei jüngeren Patientinnen, wenn eine extensive intraduktale Komponente vorhanden ist, bei positiven Tumorabsetzungsrändern, axillären Lymphknotenmetastasen, negativen Steroidhormon-Rezeptoren und bei Tumoren mit hoher proliferativer Aktivität. Fernmetastasen nach Lokalrezidiven treten häufiger auf, wenn die Zeit zwischen Primärtherapie (BET) und Lokalrezidiv kürzer ist. Die Diagnose eines Lokalrezidivs nach BET wird wie beim primären Mammakarzinom klinisch, mammografisch und sonographisch gestellt, wobei hier die Kernspintomographie eine sinnvolle Ergänzung darstellt. Die Standardoperation eines Lokalrezidivs ist die einfache Mastektomie, wenn eine Tumorektomie nicht durch eine erneute Bestrahlung ergänzt werden kann. Eine Bestrahlung der Brust nach Exzision eines Lokalrezidives kann im Einzelfall durchgeführt werden, wobei es sich aber stets um eine individualisierte Entscheidung unter Berücksichtigung zahlreicher Faktoren handelt. Die systemische Therapie nach einem Lokalrezdiv wird ebenfalls individuell indiziert. Studien zur Chemotherapie nach einem Lokalrezidiv fehlen, in Bezug auf antihormonelle Therapie gibt es lediglich Hinweise, dass sie sinnvoll sein könnte. Die Durchführung von Therapiestudien bei Patientinnen mit Lokalrezidiven nach BET ist eine der wichtigen Aufgaben bei der Behandlung des Mammakarzinoms insgesamt.
Abstract
In spite of the fact that breast cancer is a systemic disease, local control plays an important role in its management. While surgical, radiotherapeutic and systemic therapy of primary breast cancer are performed according to widely accepted guidelines, the management of ispilateral breast tumor relapse (IBTR) is still a matter of individualised concepts because of the lack of randomised studies. IBTR represents a significant medical problem, since the recurrence rate is 5-15 % after 5 years and 20-25 % after 10 years. Incidence is higher in younger patients, in tumors with an extensive intraductal component, positive tumor margins, axillary lymph node metastases, negative steroid hormone receptors and high proliferative activity. Distant metastases after IBTR occur more often if the interval between primary diagnosis and IBTR is short (e. g. less than 4 years). Diagnosis of IBTR include breast palpation, mammography and breast ultrasound. In addition breast MRI can be used to further differentiate between benign and malignant lesions after breast conservation. Standard therapy in this setting remains mastectomy. Breast-conserving surgery may be considered in the context of clinical trials for patients with certain favorable features. Breast irradiation after secondary breast-conservation can be carried out in some cases. Some local relapses after breast-conserving surgery have a poorer prognosis, and the addition of adjuvant systemic therapy should be considered in addition to mastectomy. The heterogenous nature of locoregional relapses has made it difficult to conduct prospective randomized clinical trials. However, many retrospective data exist, making it possible to recommend rational treatment approaches for these patients.
Schlüsselwörter
Mammakarzinom - Brusterhaltung - Lokalrezidiv - Diagnose - Therapie
Key words
Breast cancer - ipsilateral breast tumor recurrence - diagnosis - therapy
Literatur
-
1 Costa S D, von Minckwitz G, Scharl A, Kaufmann M, Kreienberg R, Eiermann W, Jänicke F, Zimmermann M. Tumornachsorge und Schmerztherapie. In: Kaufmann M, Costa SD, Scharl A (eds). Die Gynäkologie. Springer, Berlin, Heidelberg, New York 2002; 807-821
-
2
Dershaw D D, McCormick B, Osborne M P.
Detection of local recurrence after conservative therapy for breast carcinoma.
Cancer.
1992;
70
493-497
-
3
Deutsch M.
Repeat high-dose external beam irradiation for in-breast tumor recurrence after previous lumpectomy and whole breast irradiation.
Int J Radiat Oncol Biol Phys.
2002;
53
687-691
-
4
Drew P J, Kerin M J, Turnbull L W, Imrie M, Carleton P J, Fox J N, Monson J R.
Routine screening for local recurrence following breast-conserving therapy for cancer with dynamic contrast-enhanced magnetic resonance imaging of the breast.
Ann Surg Oncol.
1998;
5
265-270
-
5
Dunst J, Eiermann W, Rauschecker H F, Winzer K J, Wörrmann B.
Das lokale Rezidiv beim Mammakarzinom.
Onkologe.
2002;
8
867-873
-
6
Dunst J, Steil B, Furch S, Fach A, Lautenschlager C, Diestelhorst A, Lampe D, Kolbl H, Richter C.
Prognostic significance of local recurrence in breast cancer after postmastectomy radiotherapy.
Strahlenther Onkol.
2001;
117
504-510
-
7
Feyerabend T, Wiedemann G J, Jager B, Vesely H, Mahlmann B, Richter E.
Local hyperthermia, radiation, and chemotherapy in recurrent breast cancer is feasible and effective except for inflammatory disease.
Int J Radiat Oncol Biol Phys.
2001;
49
1317-1325
-
8
Fisher B, Anderson S, Fisher E R, Redmond C, Wickerham D L, Wolmark N, Mamounas E P, Deutsch M, Margolese R.
Significance of ipsilateral breast tumour recurrence after lumpectomy.
Lancet.
1991;
338
327-331
-
9
Fisher B, Costantino J P, Wickerham D L, Redmond C K, Kavanah M, Cronin W M, Vogel V, Robidoux A, Dimitrov N, Atkins J, Daly M, Wieand S, Tan-Chiu E, Ford L, Wolmark N.
Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study.
J Natl Cancer Inst.
1998;
90
1371-1388
-
10
Fisher B, Anderson S, Bryant J, Margolese R G, Deutsch M, Fisher E R, Jeong J H, Wolmark N.
Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.
N Engl J Med.
2002;
347
1233-1241
-
11
Haffty B G, Reiss M, Beinfield M, Fischer D, Ward B, McKhann C.
Ipsilateral breast tumor recurrence as a predictor of distant disease: implications for systemic therapy at the time of local relapse.
J Clin Oncol.
1996;
14
52-57
-
12
Halverson K J, Perez C A, Kuske R R.
Survival following locoregional recurrence of breast cancer. Univariate and multivariate analysis.
Int J Radiat Oncol Biol Phys.
1992;
23
285-291
-
13 Harris J R, Hellman S. Natural history of breast cancer. In: Harris JR, Lippman ME, Morrow M, Hellman S (eds). Diseases of the breast. Lippincott-Raven Publishers, Philadelphia 1996; 387
-
14
Haylock B J, Coppin C ML, Jackson J, Basco V E, Wilson K S.
Locoregional first recurrence after mastectomy: prospective cohort studies with and without immediate chemotherapy.
Int J Radiat Oncol Biol Phys.
2000;
46
355-362
-
15
Hellman S.
Stopping metastases at their source.
N Engl J Med.
1997;
337
996-997
-
16
Heywang-Kobrunner S H, Schlegel A, Beck R, Wendt T, Kellner W, Lommatzsch B, Untch M, Nathrath W B.
Contrast-enhanced MRI of the breast after limited surgery and radiation therapy.
Comput Assist Tomogr..
1993;
17
891-900
-
17
Hölzel D, Engel L, Schmidt M, Sauer H.
Modell zur primären und sekundären Metastasierung beim Mammakarzinom und dessen klinische Bedeutung.
Strahlenther Onkol.
2001;
177
10-24
-
18
Huang E, Buchholz T A, Meric F, Krishnamurthy S, Mirza N Q, Ames F C, Feig B W, Kuerer H M, Ross M I, Singletary S E, McNeese M D, Strom E A, Hunt K K.
Classifying local disease recurrences after breast conservation therapy based on location and histology: new primary tumors have more favorable outcomes than true local disease recurrences.
Cancer.
2002;
95
2059-2067
-
19
Katz A, Buchholz T A, Thames H, Smith C D, McNeese M D, Theriault R, Singletary S E, Strom E A.
Recursive partitioning analysis of locoregional recurrence patterns following mastectomy: implications for adjuvant irradiation.
Int J Radiat Oncol Biol Phys.
2001;
50
397-403
-
20
Katz A, Strom E A, Buchholz T A, Theriault R, Singletary S E, McNeese M D.
The influence of pathologic tumor characteristics on locoregional recurrence rates following mastectomy.
Int J Radiat Oncol Biol Phys.
2001;
50
735-742
-
21 Kaufmann M, von Minckwitz G. Früherkennung und Prävention des Mammakarzinoms. In: Kaufmann M, Costa SD, Scharl A (eds). Die Gynäkologie. Springer, Berlin, Heidelberg, New York 2002; 580-585
-
22 Kaufmann M, Scharl A. Operative Therapie des Mammakarzinoms. In: Kaufmann M, Costa SD, Scharl A (eds). Die Gynäkologie. Springer, Berlin, Heidelberg, New York 2002; 676-694
-
23
Kim S H, Simkovich-Heerdt A, Tran K N, Maclean B, Borgen P I.
Women 35 years of age or younger have higher locoregional relapse rates after undergoing breast conservation therapy.
J Am Coll Surg.
1998;
187
1-8
-
24
Leborgne F, Leborgne J H, Ortega B, Doldan R, Zubizarreta E.
Breast conservation treatment of early stage breast cancer: patterns of failure.
Int J Radiat Oncol Biol Phys.
1995;
31
765-775
-
25 Mackay G J, Bostwick J. Breast reconstruction. In Harris JR, Lippman ME, Morrow M, Hellman S (eds). Diseases of the Breast. Lippincott-Raven Publishers, Philadelphia 1996; 601-619
-
26
Mullen E E, Deutsch M, Bloomer W D.
Salvage radiotherapy for local failures of lumpectomy and breast irradiation.
Radiother Oncol.
1997;
42
25-29
-
27
Newman L A, Kuerer H M, Hunt K K, Kroll S S, Ames F C, Ross M I, Feig B W, Singletary S E.
Presentation, treatment, and outcome of local recurrence after skin-sparing mastectomy and immediate breast reconstruction.
Ann Surg Oncol.
1998;
7
620-626
-
28
Newman L A, Hunt K K, Buchholz T, Kuerer H M, Vlastos G, Mirza N, Ames F C, Ross M I, Singletary S E.
Presentation, management and outcome of axillary recurrence from breast cancer.
Am J Surg.
2000;
180
252-256
-
29 Rauschecker H, Clarke M, Gatzemeier W, Recht A. Systemic therapy for treating locoregional recurrence in women with breast cancer. Cochrane Database Syst Rev 2001; 4: CD002195
-
30
Resch A, Fellner C, Mock U, Handl-Zeller L, Biber E, Seitz W, Potter R.
Locally recurrent breast cancer: pulse dose rate brachytherapy for repeat irradiation following lumpectomy a second chance to preserve the breast.
Radiology.
2002;
225
713-718
-
31
Rouzier R, Extra J M, Carton M, Falcou M C, Vincent-Salomon A, Fourquet A, Pouillart P, Bourstyn E.
Primary chemotherapy for operable breast cancer: incidence and prognostic significance of ipsilateral breast tumor recurrence after breast-conserving surgery.
J Clin Oncol.
2001;
19
3828-3835
-
32
Sadowsky N L, Semine A, Harris J R.
Breast imaging: a critical aspect of breast-conserving therapy for carcinoma of the breast.
Cancer.
1990;
65
2113-2116
-
33
Salvadori B, Marubini E, Miceli R, Conti A R, Cusumano F, Andreola S, Zucali R, Veronesi U.
Reoperation for locally recurrent breast cancer in patients previously treated with conservative surgery.
Br J Surg.
1999;
86
84-87
-
34
Schuck A, Konemann S, Matthees B, Rube C E, Reinartz G, Hesselmann S, Micke O, Schafer U, Willich N.
Radiotherapy in the treatment of locoregional relapses of breast cancer.
Br J Radiol.
2002;
75
663-669
-
35
Sinn H P, Anton H W, Magener A, von Fournier D, Bastert G, Otto H F.
Extensive and predominant in situ component in breast carcinoma: their influence on treatemnt results after breast-conserving therapy.
Eur J Cancer.
1998;
34
646-653
-
36
Smith T E, Lee D, Turner B C, Carter D, Haffty B G.
True recurrence vs. new primary ipsilateral breast tumor relapse: an analysis of clinical and pathologic differences and their implications in natural history, prognoses, and therapeutic management.
Int J Radiat Oncol Biol Phys.
2000;
48
1281-1289
-
37
Taylor M E.
Breast cancer: chest wall recurrences.
Curr Treat Options Oncol.
2002;
3
175-177
-
38
van Dongen J A, Voogd A C, Fentiman I S, Legrand C, Sylvester R J, Tong D, van der Schueren E, Helle P A, van Zijl K, Bartelink H.
Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer 10801 trial.
J Natl Cancer Inst.
2000;
92
1143-1150
-
39
van der Zee J, van der Holt B, Rietveld P J, Helle P A, Wijnmaalen A J, van Putten W L, van Rhoon G C.
Reirradiation combined with hyperthermia in recurrent breast cancer results in a worthwhile local palliation.
Br J Cancer.
1999;
79
483-490
-
40
van Tienhoven G, Voogd A C, Peterse J L. et al .
Prognosis after treatment for loco-regional recurrence after mastectomy or breast conserving therapy in two randomized trials (EORTC 10801 and DBCG -82TM).
Eur J Cancer.
1999;
35
32-38
-
41
Veronesi U, Marubini E, del Vecchio M. et al .
Local recurrences and distant metastases after conservative breast cancer treatments: Partly independant events.
J Natl Cancer Inst.
1995;
87
19-27
-
42
Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, Aguilar M, Marubini E.
Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.
N Engl J Med.
2002;
347
1227-1232
-
43
Voogd A C, Nielsen M, Peterse J L, Blichert-Toft M, Bartelink H, Overgaard M, van Tienhoven G, Andersen K W, Sylvester R J, van Dongen J A. Danish Breast Cancer Cooperative Group. Breast Cancer Cooperative Group of the European Organization for Research and Treatment of Cancer .
Differences in risk factors for local and distant recurrence after breast-conserving therapy or mastectomy for stage I and II breast cancer: pooled results of two large European randomized trials.
J Clin Oncol.
2001;
19
1688-1697
PD Dr. Dr. Serban D. Costa, Ärztlicher Direktor
Klinik Bad Trissl · Fachklinik für Onkologie
Bad-Trissl-Straße 73
83080 Oberaudorf
Email: s.costa@klinik-bad-trissl.de
