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Invited Commentary
November 21, 2019

Additional Lumpectomy and Irradiation for In-Breast Recurrence of Cancer—When Less Is More

Author Affiliations
  • 1Department of Radiation Medicine, Oregon Health and Science University, Portland
  • 2Department of Surgery, University of California, Los Angeles
JAMA Oncol. 2020;6(1):82-83. doi:10.1001/jamaoncol.2019.4319

Despite modern surgical and irradiation techniques, approximately 1 in 10 women treated with lumpectomy and irradiation will experience recurrence of breast cancer in the ipsilateral breast (in-breast recurrence). Historically, this event has been managed definitively with mastectomy. However, many local recurrences are small and detected early, and even after a recurrence, long-term survival is achievable.1 Thus, there has been an interest in examining the feasibility of subsequent breast-conserving therapy. Rates of second recurrence after lumpectomy alone for first recurrence are unacceptably high,2,3 similar to those after lumpectomy alone for primary breast cancer. Fears of unacceptable toxic effects have prevented most investigators from pursuing lumpectomy with reirradiation of the whole breast; however, a number of groups reported their experience with a second lumpectomy with partial breast reirradiation (PBrI). Most studies used brachytherapy, and the largest study was the multi-institutional observational Groupe Européen de Curiethérapie and the European Society for Radiotherapy and Oncology (GEC-ESTRO) study.4 In this series, a 5-year second in-breast recurrence rate of 5.2% was reported, with a 5-year distant metastasis rate of 9.6% and overall survival of 88.7%. Regarding the cosmetic outcome, 48% of patients rated their cosmesis as excellent, with the remaining 52% rating it as fair or poor. Although these results are promising and comparable to clinical outcomes after mastectomy for in-breast recurrence, this study included a heterogeneous and incompletely defined patient population (eg, margin status was not reported). Thus, prospective data to better inform outcomes and patient selection are sorely needed.

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