LOCAL RECURRENCES AFTER BREAST-CONSERVING TREATMENT - AN OPEN PROBLEM

Breast-preserving surgery for tumors of limited size or reduced by neo adjuvant chemotherapy has definitely entered into the practice. Distan t results of controlled studies demonstrated that conservative methods , when correctly indicated and performed, can provide the same results as mutilating procedures, in terms of overall survival. There is gene ral agreement on the fact that conservation bears a major risk of intr abreast recurrences, whose meaning and impact on prognosis are still o pen to debate. Inadequate surgery, i.e., too-limited excision, or the lack of radiotherapy, certainly causes a higher rate of local failures . However, analysis of the patient series reported in the literature p ermits the conclusion that local failures and distant metastasis are e vents partially independent of each other. In other words, there are f actors that are predictive of local recurrence, and not of distant spr ead, and vice versa, and factors that affect both the risks. Uncertain ty about the meaning of local recurrences influences therapeutic attit udes, not only with regard to the choice between total mastectomy and re-resection, when possible, but also with reference to the identifica tion of those local recurrences that merit systemic treatment. As far as the treatment of local failures is concerned, it is too soon to ind icate undisputable guidelines. It is necessary to wait for distant res ults of the many experiences in progress on this issue. On the other h and, since local intrabreast recurrences fortunately are not very freq uent (about 10% at 10 years from first treatment), the accrual of pati ents eligible for clinical trials would take a long time, even for coo perative groups. This is one of the reasons why local failure actually is an open problem. (C) 1996 Wiley-Liss, Inc.