1. 2 years later, she noticed multiple 1. 5 -2 cm
2 years later, she noticed multiple cm. nodular masses at the MRM site.

2. Breast Cancer Recurrence
anytime, mostly occur in the first 3 – 5 years after initial treatment
can come back as a local recurrence (in the treated breast or near the mastectomy scar) or as a distant recurrence somewhere else in the body
most common sites of recurrence include the lymph nodes, the bones, liver, or lungs

3. Factors for recurrence
Lymph node involvement
Tumor size
the larger the tumor, the greater the chance of recurrence.
Hormone receptors
two-thirds of all breast cancers contain significant levels of estrogen receptors, which means the tumors are estrogen receptor positive (ER+)
ER-positive tumors tend to grow less aggressively and may respond favorably to treatment with hormones.
Histologic grade
Grade 4 tumors contain very abnormal and rapidly growing cancer cells
The higher the histologic grade, the greater chance of recurrence.
Nuclear grade
Refers to the rate at which cancer cells in the tumor divide to form more cells
Cancer cells with a high nuclear grade (also called proliferative capacity) are usually more aggressive (faster growing).
Oncogene expression
tumors that contain certain oncogenes may increase a patient's chance of recurrence.

4. Breast Changes
An area that is distinctly different from any other area on either breast
A lump or thickening, in or near the breast or in the underarm, that persists through the menstrual cycle
A change in the size, shape, or contour of the breast
A mass or lump, which may feel as small as a pea
A marble-like area under the skin
A change in the feel or appearance of the skin on the breast or nipple [dimpled, puckered, scaly, or inflamed (red, warm, or swollen)]
Bloody or clear fluid discharge from the nipples
Redness of the skin on the breast or nipple

5. Locoregional recurrence of the breast cancer on the mastectomy site
Impression?
Locoregional recurrence of the breast cancer on the mastectomy site

6. Treatment With previous mastectomy:
Surgical resection of the locoregional recurrence
Appropriate reconstruction
Chemotherapy
Anti-estrogen therapy

7. Biopsy? Yes! to determine the characteristics of the lesion/tumor
to determine the staging of the recurrence
to permit doctors discuss the appropriate management
A current study shows that 10 out of 29 recurrent tumors changed ~ 35%

8. Biopsy Of Recurrent Breast Cancer Can Alter Treatment
Article Date: 20 Mar 2009
A group of doctors from Toronto has recently completed the world's first study that compared original breast cancer tumors with a biopsy of suspected tumors that recurred elsewhere in the body.
found that the biopsy resulted in 20% of the women having a significant change in their treatment
change in drug treatment
change in diagnosis to a benign condition.

9. Biopsy Of Recurrent Breast Cancer Can Alter Treatment
"The results show that cancers may change over time and not respond to treatment that was appropriate for the original cancer,“
principal investigator, Dr. Mark Clemons, a medical oncologist specializing in breast cancer in the Princess Margaret Hospital Cancer Program, University Health Network (UHN).
leading us in a new direction to understand more about why some women don't respond to treatment
this will help us to always deliver the right treatment, to the right patient, at the right time

10. Biopsy Of Recurrent Breast Cancer Can Alter Treatment
29 biopsies of accessible, recurrent tumors taken from women whose breast cancer had spread to bone, skin, lymph nodes, lung or liver
compared the results of the original cancer with the results of the new biopsy by analyzing the predictive markers that influence breast cancer tumor growth - estrogen, progesterone and Her2 status
the presence, absence and/or combinations of these markers become the map oncologists use to determine the most effective treatment for each patient.

11. Biopsy Of Recurrent Breast Cancer Can Alter Treatment
Result:
15 cases was unchanged
10 cases the markers in the cancer changed
3 cases, women originally felt to have metastatic breast cancer had benign disease
1 case, the "recurring" cancer was a different type of cancer, lymphoma which is treated in a very different way to breast cancer.

12. References:
Brunicardi, F. C., et. al.,  Schwart's Manual of Surgery, 8th ed., 2006
Annals of Oncology, Oxford University Press (Doi: /annonc/mdp028)
(American Cancer Society)