Prognosis after isolated axillary nodal recurrence following conservative surgery and radiotherapy for early-stage breast carcinoma

Purpose/Objective: To evaluate the long-term prognosis of patients who develop an isolated axillary nodal recurrence (ANR) after breast-conservative surgery (CS) and radiation therapy (RT) for early-stage invasive breast cancer. Little data exist in the literature regarding this topic. Materials/Methods: From 1968-1988, 2,368 patients with clinical stage I-II breast cancer were treated with CS and RT. Isolated ANR was defined as any recurrence in ipsilateral axillary nodes without previous or simultaneous recurrence in the breast, other nodes or distant sites. Isolated ANR occurred in 28 patients (1.2%); these constitute the study population. The median age at initial diagnosis was 57 years (range, 35-86). Eighteen patients (64%) underwent initial axillary dissection that recovered a total of ≥ 6 nodes; among these, the median number of pathologically involved nodes was 0 (range 0-4 nodes). Nine patients (32%) had axillary/supraclavicular RT, and 4 others (14%) had supraclavicular RT without axillary RT. The median dose to the axilla was 50 Gy (range, 45–51) and the median dose to the supraclavicular fossa was 45 Gy (range 43.8–50). Five patients (18%) received adjuvant systemic therapy. Salvage local therapy consisted of axillary surgery (either biopsy or axillary dissection) alone in 16 patients (57%) and axillary RT with axillary surgery in 9 (32%). In 3 patients (11%), salvage local therapy was unknown. Salvage systemic therapy was given to 23 patients (82%), consisting of chemotherapy alone in 6 (21%), hormonal therapy alone in 15 (54%) and both in 2 patients (7%). Subsequent regional nodal recurrence (SRNR) was defined as recurrent disease in ipsilateral axillary, internal mammary, supraclavicular or infraclavicular nodes after ANR without simultaneous breast disease. One patient had persistent axillary disease and is counted as a subsequent axillary failure. Median and 5-year time to distant failure or death estimates and survival estimates were calculated using the Kaplan-Meier method and Greenwood 95% confidence intervals. The median time to ANR from the start of RT was 2.3 years (range, 0–20.8). The median total follow-up time after ANR was 6.2 years (range, 1.1–18.6). Results: Among these 28 patients with isolated ANR, 11 (39%) had no subsequent recurrence of breast cancer. Subsequent axillary recurrence, any SRNR or distant metastasis at any time occurred in 5, 7 and 12 patients, respectively. The first event after ANR was within the regional nodes in 5 (18%), ipsilateral breast (with or without simultaneous distant metastasis) in 4 patients (14%), distant metastasis in 7 patients (25%), in the contralateral breast in 1 patient (4%) and death from other causes in 2 patients (7%). The median time from ANR to distant failure, second malignancy or death was 6.8 years. The actuarial risk of distant failure, second malignancy or death from other causes 5 years after ANR was 44% (CI, 25%–63%). The median survival time from ANR was 9.5 years. At 5 years, 70% (CI, 52%–88%) of patients with isolated ANR were alive. Models of prognostic variables could not be performed given the small number of events. However, regional nodal recurrence occurred as the first site of failure after ANR in 1 of 9 patients (11%) who underwent salvage compared to 4 of 16 (25%) who did not undergo salvage RT. Conclusions: Five years after salvage treatment for an isolated axillary nodal recurrence, 56% of patients were alive without further recurrence. This 5-year result is only slightly less favorable than the outcome following recurrence in the ipsilateral breast after CS + RT in our cohort (65%, CI 59%-70%). Of note, 14% of patients had an ipsilateral breast recurrence noted after ANR. This suggests that patients with an isolated ANR should be evaluated thoroughly at the time of recurrence for ipsilateral breast involvement. We conclude that patients with an isolated axillary node recurrence can have extended disease-free survival.