Local therapy or systemic therapy? Which type of recurrent breast cancer is preferred for surgery?

In the just concluded 2020 breast cancer Forum (network meeting) of the oncology branch of the Chinese Medical Association, senior experts and outstanding young scholars from the field of breast cancer gathered together to give a wonderful report and Discussion on the research progress and hot spots of breast cancer. A novel debate link was also designed in this meeting to show more vividly the controversial topics in the diagnosis and treatment of breast cancer 。this paper will summarize one of the debates.breast cancer is the most common malignant tumor in women, and patients with breast cancer still face the risk of recurrence after the first treatment, which leads to the debate in our discussion: what is the preferred treatment for operable recurrent breast cancer.the pros and cons of the debate were Professor Zhu Li, director of Department of breast surgery, Ruijin Hospital Affiliated to Shanghai Jiaotong University Medical College, and Professor Song Chuangui, Department of breast surgery, Union Hospital Affiliated to Fujian Medical University.in Figure 1, the pros and cons of the debate are as follows: Professor Zhu Li (left); Professor Song Chuangui (right) interjects: local treatment is the first choice for operable recurrent breast cancer. Professor Zhu Li pointed out: the recurrence under the contemporary surgical treatment mode is different from the past, and the recurrence probability of local and regional lymph nodes is controlled at less than 1% per year.in the NSABP series and the ACOSOG Z0011 study, the median follow-up data of nearly 10 years showed that the local and regional lymph node recurrence rate was under 6.5%.Figure 2 The recurrence rate of local and regional lymph nodes is significantly reduced. The new version of NCCN guidelines divides local and regional lymph node recurrence into different scenarios, and surgical operation or radiotherapy are recommended as the first choice. Both of them belong to the category of local treatment. Therefore, the guide also recommends that we should carry out local treatment first, and then choose systemic treatment.■ the 2015 disease of the breast guidelines for patients with ipsilateral breast recurrence after breast conserving surgery pointed out that patients with ipsilateral breast recurrence after breast conserving surgery may cause higher local recurrence rate. Therefore, the guideline recommends total mastectomy rather than breast conserving surgery for such patients.of course, this does not mean that breast conserving is totally negated. The European cancer center and relevant studies in Japan have proved that selecting suitable patients (e.g. ER + / HER2 -) patients may still have a good prognosis.total mastectomy and breast conserving surgery are both surgical procedures, so local treatment is still the first choice.Figure 3 In the follow-up study of DBCG from Denmark, 535 patients with chest wall recurrence after mastectomy were selected for local and systemic treatment respectively. Among them, 15% were treated with systematic treatment, and 46% had complete remission (CR), and sustained local control（ The CR rate of surgery plus radiotherapy was 96%, the PLC rate was 58%, and the PLC rate of more than two years was 45%.such relatively large sample studies show that Cr and PLC of surgery alone, radiotherapy and surgery + radiotherapy are better than systemic treatment alone.Figure 4 In addition to these retrospective studies, Professor Zhu Li pointed out that calor is a rare randomized controlled trial (RCT) for local recurrence. All patients in the group received resection of recurrent lesions first, which means that the premise of treatment is to do local treatment first Patients with local treatment were further divided into non chemotherapy group and chemotherapy group.finally, it is concluded that Er - patients after resection of recurrent foci may benefit from adjuvant chemotherapy.this also suggests that local treatment should be selected first.Figure 5 Er negative patients after resection of recurrent foci may benefit from adjuvant chemotherapy ■ regional lymph node recurrence is divided into three different regions.Professor Zhu Li first focused on axillary lymph node recurrence and cited a retrospective analysis in the American Journal of surgery in 2000. in this study, 44 patients with axillary recurrence after breast cancer surgery from 1982 to 1992 were enrolled. Among them, 24 patients underwent surgical treatment, and 17 patients did not. the results showed that the control rate of axillary lymph node recurrence in surgical group was much higher than that in non-surgical group, which indicated that surgical patients were more likely to achieve local disease control, while systemic treatment could not improve local control or distant metastasis. Figure 6. With the increase of sentinel lymph node biopsy rate, the probability of postoperative axillary lymph node recurrence also increases. from 2002 to 2004, 54 patients with axillary recurrence after sentinel surgery were enrolled in the Dutch cancer registry, of which 7 (13%) were accompanied by distant metastasis. In this study, 83% of patients received rescue axillary lymph node dissection (median number of dissections: 3). the survival curve showed that the 5-year overall survival (OS) rate and disease-free survival (DFS) rate of patients were as high as 50%, and the OS of patients without chemotherapy was significantly better than that of patients receiving chemotherapy. these data indicate that patients with axillary recurrence after sentinel surgery have a good prognosis after salvage axillary lymph node dissection. Figure 7 patients with axillary recurrence after sentinel surgery had a good prognosis after rescue axillary lymph node dissection. In this case, Professor Zhu Li also cited a retrospective study published in the Journal of breast cancer research and treatment in 2011. this study retrospectively analyzed the data of 305 patients with supraclavicular lymph node recurrence after early breast cancer from 1977 to 2003. The results showed that compared with conventional treatment, local treatment (radiotherapy ± surgery) combined with systemic treatment can achieve higher progression free survival (PFS) and OS, which means that local treatment is more favorable even for supraclavicular lymph node recurrence Status. figure 8 local treatment also plays a more favorable role in the recurrence of supraclavicular lymph nodes. Finally, Professor Zhu Li summarized the different situations of local recurrence and regional lymph node recurrence of breast cancer from the perspective of evidence-based and guidance, and believed that we still preferred local treatment, followed by systemic treatment. Figure 9: from the summary of evidence-based and guidelines: systemic treatment is preferred for operable recurrent breast cancer ■ recurrent breast cancer belongs to advanced breast cancer. Professor Song Chuangui first pointed out that recurrent breast cancer belongs to advanced breast cancer, and breast cancer itself belongs to a systemic disease. According to Fisher theory, local regional lymph node recurrence is a local manifestation of distant metastasis Previous studies have shown that recurrent breast cancer has obvious adverse prognosis characteristics. Even if it is local recurrence, the incidence of late distant metastasis is still high and the long-term prognosis is poor. Therefore, systemic drug therapy should be chosen as the main means. Figure 10 recurrent breast cancer has obvious adverse prognosis characteristics. Professor Song Chuangui pointed out: under the current treatment mode, systemic treatment plus local treatment can obtain better long-term survival. previous studies have shown that the 5-year recurrence free and overall survival of patients receiving systemic therapy plus local area therapy are significantly better than those of patients receiving direct local treatment. Figure 11 Systemic therapy plus local treatment can achieve better long-term survival. Professor Song Chuangui also used the calor study as evidence, pointing out that the importance of systemic treatment (chemotherapy) was emphasized in the calor study. This study indeed provides a clinical treatment model that can be used for reference, that is, surgery followed by chemotherapy, but calor research can not prove that systemic treatment after surgery Treatment is better than initial systemic therapy. we know that the calor study was designed 17 years ago. Is our current therapeutic thinking changed? The results of the latest phase III trial e21108 from 2020asco showed that early local treatment failed to improve survival and health-related quality of life. Figure 12 Local treatment failed to improve the survival and health-related quality of life. However, the University of North Carolina (UNCC) team analyzed the clinical and pathological data of patients diagnosed with breast cancer from 2011 to 2017 in the prospective uncm metastatic breast cancer clinical database. The results showed that the survival rate of recurrent and metastatic breast cancer (dmbc) was lower than that of newly diagnosed metastatic breast cancer (rmbc), Therefore, more attention should be paid to systemic therapy for recurrent and metastatic breast cancer. Figure 13 The survival rate of recurrent and metastatic breast cancer (dmbc) is lower than that of newly diagnosed metastatic breast cancer (rmbc). ■ with the concept of "neoadjuvant" and molecular typing, Professor Song Chuangui proposed the concept of "neoadjuvant": Taking the potential systemic spread of breast cancer as the evaluation index of rescue treatment effect, and selecting the effective tumor index The whole body rescue treatment plan, as far as possible to kill those potential tumor cells that have been spread throughout the body, reduce the risk of metastasis of other organs. at the same time, in the era of molecular typing, systemic salvage therapy can also effectively improve the prognosis of recurrent and metastatic advanced breast cancer. to sum up, Professor Song Chuangui believes that recurrent breast cancer belongs to advanced breast cancer, so systemic treatment should be the first choice. Local surgery can not improve the long-term survival of patients. and with the development of science and technology and the deepening of research, we can use the concept of "new assistant" and molecular typing method to provide information for patients whether to operate in the later stage. finally, Professor Song Chuangui stressed that our treatment concept needs to be updated with the times, from the traditional systemic treatment after surgery to systemic therapy ± surgery. Professor Zhu Li and Professor Song Chuangui brought us a new debate. The two professors expounded their own views and arguments, and also provided new ideas for the treatment of operable recurrent breast cancer. although they are both positive and negative, their ultimate goal is to find a more reasonable and effective clinical treatment scheme, improve the prognosis of patients, and improve the survival period. Therefore, there is no so-called victory or defeat, it is just the collision and exchange of knowledge. after listening to the wonderful debate of the two experts, do you have your own answers? Welcome to leave a message for discussion!