Lokal Bölgesel Rekürrensde Cerrahi Tedavi
Özet
Meme kanserinde lokal, bölgesel veya lokorejyonel nükslerin yönetimi, prognozu doğrudan etkileyen ve mutlaka multidisipliner bir yaklaşım gerektiren karmaşık bir süreçtir. Mastektomi sonrası gelişen göğüs duvarı nükslerinde, uzak metastaz olasılığı yüksek olduğundan ve hastalık daha agresif seyrettiğinden öncelikle sistemik tarama yapılmalıdır; uygun olgularda geniş cerrahi rezeksiyon ve flep/greft rekonstrüksiyonları tercih edilir. Meme koruyucu cerrahi (MKC) sonrasındaki yerel nükslerde ise standart yaklaşım mastektomi olmakla birlikte, özellikle 50 yaş üstü, unifokal tümörü olan ve nüks süresi 48 ayı geçmiş seçilmiş hastalarda tekrar MKC ve parsiyel reradyoterapi güvenle uygulanabilmektedir. Bölgesel lenf nodu nüksleri, göğüs duvarı nükslerine kıyasla daha kötü bir prognoza sahip olup sıklıkla aksiller, supraklavikuler veya internal mamaryan odaklarda izlenir. Aksiller nükslerde daha önce aksiller diseksiyon yapılmamışsa diseksiyon tamamlanır veya nüks eksizyonu yoluna gidilirken, izole supraklavikuler nükslerde cerrahinin teknik zorlukları ve yüksek metastaz riski nedeniyle tedaviye öncelikle sistemik ajanlarla başlanması, lokorejyonel kombine terapilerin entegre edilmesi önerilmektedir. Tedavi kararlarında hastanın yaşı, biyomarker alt tipleri ve geçmiş radyoterapi öyküsü kritik rol oynamaktadır.
The management of local, regional, or locoregional recurrences in breast cancer is a complex process that directly affects prognosis and strictly requires a multidisciplinary team approach. In chest wall recurrences occurring after mastectomy, systemic screening must be performed first due to the higher probability of distant metastasis and a worse prognosis; wide surgical resection and flap/graft reconstructions are preferred in eligible cases. Although mastectomy remains the standard choice for local recurrences after breast-conserving surgery (BCS), repeat BCS combined with partial re-irradiation can be safely performed in carefully selected patients, particularly those over 50 years old with unifokal tumors smaller than 2 cm and a recurrence interval exceeding 48 months. Regional lymph node recurrences carry a worse prognosis compared to chest wall recurrences and are frequently detected in axillary, supraclavicular, or internal mammary sites. Axillary dissection is completed or excision is performed in axillary recurrences depending on the prior surgical staging, whereas systemic therapy is recommended as the initial step for isolated supraclavicular recurrences due to surgical technical difficulties and high metastatic association, followed by combined locoregional therapies. Patient age, biomarker subtypes, and prior radiotherapy history play a critical role in shaping personalized treatment strategies.
Referanslar
Gerber B, Freund M, Reimer T. Recurrent breast cancer. Deutsches Arzteblatt International. 2010; 107(6):85-91. doi: 10.3238/arztebl.2010.0085.
Harms W, Geretschlager A, Cescato C, et al. Current treatment of isolated locoregional breast cancer recurrences. Breast Care. 2015;10(4):265-271. Doi: 10.1159/000439151
Liubota RV, Zotov AS, Vereshchako RI, et al. Risk factors of the invasive breast cancerlocoregional recurrence. BioMed Research International. 2015. doi.org/10.1155/2015/789646
Wapnir I, Khan A. Current strategies fort he management of locoregional breastcacer recurrence. Oncology. 2019; 33(1):19-25
Buchholz TA, Ali S, Hunt K. Multidisciplinary management of locoregional recurrent breast cancer. Journal of Clinical Oncology. 2020;38(20):2321-2327. doi:10.1200/JCO.19.02806
Giuliano AE, Ballman K, McCall L, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: Long-term follow-up from the American college of surgeons oncology group(Alliance) ACOSOG Z0011 Randomized trial. Annals of Surgery. 2016;264(3): 413-420. doi:10.1097/SLA 0000000000001863
Voinea SC, Sandru A, Blidaru A. Management of breast cancer locoregional recurrence. Chirurgia. 2017;112(4):429-435. doi:10.21614/chirurgia.112.4.429
Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Annals of Surgical Oncology. 2014;21(3):704-716. doi:10.1245/s10434-014-3481-4.
Vinh-Hung V, Verschraegen C. Breast-conserving surgery with or without radiotherapy: pooled-analysis for risks of ipsilateral breast tumor recurrence and mortality. Journal of the National Cancer Institute. 2004;96(2):115-121. doi: 10.1093/jnci/djh013.
Huang J, Tong Y, Chen X, et al. Prognostic factors and surgery for breast cancer patients with locoregional recurrence: An analysis of 5202 consecutve patients. Frontiers in Oncology. 2021;11:763119. doi: 10.3389/fonc.2021.763119
Nielsen HM, Overgaard M, Grau C , et al. Sudy of failure pattern among high-risk breast cancer patients with or withoutpostmastectomy radiotherapy in addiyion to adjuvant systemic therapy: Long-ter results from the Danish breast cancercooperative group DBCG 82b and c randomized studies. Journal of Clinical Oncology. 2006; 24(15):2268-2275. doi: 10.1200/JCO.2005.02.8738
Zhao X, Tang Y, Wang S, et al. Radiation Oncology. 2020; 15:212. doi: 10.1186/s13014-020-01637
Jacobson JA, Danforth DN, CowanKH, et al. Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer. New England Journal of Medicine. 1995;332(14):907-911. doi: 10.1056/NEJM199504063321402.
Kuo SH, Huang CS, Kuo WH,et al. Comprehensive locoregional treatment and systemic therapy for postmastectomy isolated locoregional recurrence. International Journal of Radiation Oncology, Biology, Physics. 2008; 72(5):1456-1464. doi: 10.1016/j.ijrobp.2008.03.042.
Marta GN, Hijal T, Carvalho HA. Reirradiation for locally recurrent breast cancer. Breast. 2017;33:159-165. doi: 10.1016/j.breast.2017.03.008.
Fattahi S, Ahmed S, Park S, et al. Reirradiation for locoregional recurrent breast cancer. Advances in Radiation Oncology.2021;6(1):1-9. doi: 10.1016/j.adro.2020.100640.
Gentilini O, Botteri E, Veronesi P, et al. Repeating conservative surgery after ipsilateral breast tumor reappearance: criteria for selecting the best candidates. Annals of Surgical Oncology. 2012;19:3771-3776. doi: 10.1245/s10434-012-2404-5.
Walstra C, Schipper R, Poodt I, et al. Repeat breast-conserving therapy for ipsilateral breast cancer recurrence:A systematic review. European Journal of Surgery. 2019;45(8):1317-1327. doi: 10.1016/j.ejso.2019.02.008.
Arthur D, Winter K, Kuerer H, et al. NRG Oncology RTOG 1014: 1 Year Toxicity Report From a Phase II Study of Repeat Breast Preserving Surgery and 3D-Conformal Partial Breast Re-Irradiation (3D-CRT PBrI) for In-Breast Recurrence. International Journal of Radiation Oncology, Biology, Physics. 2017;98(5):1028-1035. doi: 10.1016/ijrobp.2017.03.016.
Pedersen AN, Moller S, Steffensen KD, et al. Supraclavicular recurrence after early breast cancer: a curable condition? Breast Cancer Research and Treatment. 2011;125(3):815-822. doi: 10.1007/S10549-010-0918-8.
