Acta Oncologica, 2013; 52: 6672

ORIGINAL ARTICLE

Local recurrence of breast cancer after mastectomy and modern

multidisciplinary treatment

ELINA T. SIPONEN1, HEIKKI JOENSUU2 & MARJUT H. K. LEIDENIUS1

1Breast Surgery Unit,Helsinki University Central Hospital, Helsinki, Finland, and 2Department of Oncology,
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Helsinki University Central Hospital, Helsinki, Finland

Abstract
Background. To study the incidence of local recurrence (LR) of early breast cancer in the ipsilateral thoracic wall after
mastectomy and outcome of patients with LR. Material and methods. A retrospective cohort study based on 2220 consecu-
tive breast cancer patients treated at the Helsinki University Central Hospital, Finland, in 2000 to 2003. A subset of 755
(34.0%) patients had mastectomy which was usually followed by postoperative radiotherapy (51.2%) and/or systemic
adjuvant therapy (79.2%). Results. During a median follow-up of 89 months, 22 (2.9%) patients treated with mastectomy
had LR. The median time to LR was 27 months. None of the 12 patient- or tumour-related standard risk factors studied
Acta Oncol 2013.52:66-72.

were independently associated with LR-free survival in a multivariate model. Six (27.3%) of the 22 patients with LR had
distant metastases diagnosed either prior to or simultaneously with LR. The subset of 16 patients who were diagnosed with
LR without concomitant distant recurrence had five-year breast cancer-specific survival of 77.5% as calculated from the
date of LR detection, and overall survival of 59.2%. Conclusions. LR after mastectomy has become a rare event. Most
women with isolated LR survive for five years after LR.

Local recurrence (LR) of breast cancer in the
ipsilateral thoracic wall after mastectomy is considered
to be associated with an aggressive clinical course
and dismal survival [1]. Yet, relatively favourable five-
year overall survival rates have been reported in
patient populations with isolated LR after mastec-
tomy without concomitant systemic disease ranging
from 43% to 66.4% [24]. Such data may, however,
be subject to biases including a selection bias and the
publication bias. Few population-based data are
available, and the exact locations of cancer recur-
rence after mastectomy and the details of local and
systemic treatments given are rarely captured in
regional and nationwide cancer registries. The rates
of LR could thus be underestimated and the survival
rates overestimated in the current literature.
Besides the skills of the surgical team, adjuvant
treatments likely influence the LR rates substantially.
According to the Early Breast Cancer Trialists
Collaborative Group (EBCTCG) overview, radia-
tion therapy reduces the five-year risk of LR after
mastectomy and axillary lymph node dissection from
23% to 6% in node-positive patients and improves
absolute survival 5.4% at 15 years after breast cancer
detection, and radiotherapy reduces the LR rate from
6% to 2% in node-negative patients but does not
influence survival [5]. Similarly, systemic adjuvant
endocrine therapy reduces substantially the risk of
local recurrences in estrogen receptor (ER)-positive
disease and adjuvant chemotherapy reduces the LR
rate in women under 70 years of age [6]. The mean
absolute reduction in the five-year risk of LR was
20% among women who received systemic therapy
as compared to those who did not [6].
The risk of LR depends also on cancer size and
its biology, the most important single factor probably
being the axillary nodal status. Patients with axillary
lymph node metastases have a greater risk for LR
after mastectomy as compared with those without
nodal metastases [1,79]. The EBCTCG overview
reports as high as 23% risk of LR at five years after
surgery in patients who did not receive postoperative
radiotherapy which contrasts to the LR rates of
5.38% at five-year [9,10] and 6.5% at 10-year [11]

Correspondence: E. T. Siponen, Pivkummuntie 10 A, 02210 Espoo, Finland. Tel: 358 40 5509388. Fax: 358 9 47176301. E-mail: elina.siponen@hus.fi

(Received 5 July 2012 ; accepted 1 August 2012 )

ISSN 0284-186X print/ISSN 1651-226X online 2013 Informa Healthcare
DOI: 10.3109/0284186X.2012.718793

reported in some recent smaller series consisting of
patients with node-positive breast cancer who did
not receive postoperative radiotherapy. Other risk
factors that are associated with an increased risk of
LRs or locoregional recurrences after mastectomy
include a high tumour histological grade [1,8,12],
absence of steroid hormone receptors [1,8], a large
tumour size [1,8,12] and young age at the time of
breast cancer detection [13].
The objective of the present study was to inves-
tigate the incidence of LR of early breast cancer after
mastectomy and multidisciplinary treatment, the risk
factors for LR and patient outcome after LR, since
data from few large studies where modern adjuvant
treatments have been administered are available.
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The study was conducted in a region where virtually
all patients with early breast cancer are treated at a
single university centre which allows population-
based data to be obtained and reduces the risk of a
selection bias.
Patients and methods
Patients
Acta Oncol 2013.52:66-72.
A total of 2220 new primary breast cancer patients
were treated at the Breast Surgery Unit of the
Helsinki University Central Hospital, Helsinki, Finland,
between January 1, 2000 and December 31, 2003.
Altogether 786 (35.4%) out of these 2220 patients
had invasive breast cancer and underwent mastec-
tomy and axillary surgery. Thirty-one patients were
excluded from this cohort of 786 patients, since 23
(2.9%) had distant metastases at the time of surgery
(M1 disease), six (0.8%) died from cardiovascular
causes within one month of surgery and two (0.3%)
patients were lost to follow-up. The remaining
755 patients (34.0% of the 2220 patients) form the
basis of the current study. The patient and tumour
characteristics are provided in Table I. The median
age at diagnosis was 61 years (range, 2496 years).
The study protocol was approved by the Ethics
Committee of the Helsinki University Central
Hospital.
Surgery
All patients underwent either a sentinel node biopsy
(SNB, n 106), axillary lymph node dissection
(n 491) or both (n 158). All patients who had a
SNB underwent a back-up axillary lymph node dis-
section regardless of the findings at the SNB from
January 2000 to May 2000. From June 2000 onwards,
SNB was performed in patients who had clinically
node negative, radiologically unifocal breast cancer
with the largest tumour diameter 3 cm as evaluated
with a breast ultrasound examination. In these
Local recurrences after mastectomy 67
patients axillary lymph node dissection was omitted
whenever the SNB was negative. The median num-
ber of histologically examined axillary lymph nodes
was three (range, 111) in patients who underwent
a SNB only and 16 (range, 652) when axillary
lymph node dissection with or without a SNB was
carried out.
Histopathological evaluation
The mastectomy specimens as well as the SNB and
axillary lymph node dissection specimens were
assessed carefully histologically as described in a
detail elsewhere [14]. The axillary nodal stage was
determined using the 7th edition of the TNM staging
system [15].
Radiation therapy
In general, postmastectomy radiotherapy was given
to patients who had a large primary tumour (pT3 or
pT4) and to patients who had axillary lymph node-
positive cancer (Table II). Radiotherapy was based
on computer-based dose planning and was given
with a linear accelerator with approximately 2 Gy
daily fractions, 5 fractions per week. The cumulative
dose to the thoracic wall and the regional lymphatics
was approximately 50 Gy. The ipsilateral thoracic
wall including the surgical scar was irradiated with
electrons from an anterior field to minimise the doses
delivered to the heart and the ipsilateral lung.
Systemic adjuvant therapy
Systemic adjuvant treatment was selected based on
the patient and disease characteristics. In general,
women with node-positive disease and those consid-
ered to have moderate-to-high risk node-negative
cancer were treated with systemic adjuvant therapy
(Table II). Patients 65 years of age with moderate-
to-high risk cancer, node-negative or node-positive,
received adjuvant systemic chemotherapy. The che-
motherapy regimens used usually included an anthra-
cycline [usually epirubicin as a component of
fluorouracil, epirubicin, cyclophosphamide (FEC)]
or a taxane (usually docetaxel), or both, and usually
consisted of a total of six cycles administered at
three-week intervals. A few patients with HER2-
positive breast cancer received trastuzumab and che-
motherapy within the context of a clinical trial [16].
Premenopausal women with oestrogen receptor ER
and/or progesterone receptor (PR)-positive cancer
received tamoxifen for five years, and postmeno-
pausal women with hormone receptor-positive dis-
ease either tamoxifen or an aromatase inhibitor for
five years. Hormonal therapy was initiated after
chemotherapy.
 68 E. T. Siponen et al.
Table I. Patient and tumour characteristics and the seven-year Kaplan-Meier estimate for local
recurrence rate.

N (%) 7-year local

Factor (N 755) recurrence rate (%) p (log-rank test)

Age at diagnosis
40 47 (6.2) 6.5%
4054 242 (32.1) 2.5%
5570 245 (32.5) 3.3%
70 221 (29.3) 3.1% 0.442
Axillary lymph node status
pN0 or N0 (i) 341 (45.2) 2.8%
pN1 mi 33 (4.4) 3.3%
pN1 220 (29.1) 2.3%
pN23 160 (21.1) 4.4%
NX 1 (0.1) 0.1% 0.880
T stage
pT1 345 (45.7) 1.8%
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pT2 322 (42.6) 4.4%

pT3 50 (6.6) 2.2%
pT4 36 (4.8) 3.1% 0.245
N.A. 2 (0.3)
Histological grade
1 170 (22.5) 1.2%
2 322 (42.6) 2.7%
3 247 (32.7) 4.4% 0.190
N.A. 16 (2.1)
Histological type
Ductal 425 (56.3) 2.8%
Acta Oncol 2013.52:66-72.

Lobular 210 (27.8) 3.5%

Other 119 (15.8) 2.7% 0.862
N.A. 1 (0.1)
Tumour ER content
Positive 615 (81.4) 2.4%
Negative 133 (17.6) 6.0% 0.059
N.A. 7 (0.9)
Tumour PR content
Positive 449 (59.5) 1.8%
Negative 299 (39.6) 4.9% 0.015
N.A. 7 (0.9)
HER-2 amplification
Absent 581 (77.0) 2.7%
Present 96 (12.7) 5.8% 0.256
N.A. 78 (10.3) 4.1%
MIB-1 proliferation index
Very low or low 358 (47.4) 2.7%
Medium 116 (15.4) 3.7%
High 160 (21.2) 3.4% 0.904
N.A. 121 (16.0)
Tumour biological subtype
ER, HER2 499 (66.1) 2.1%
ER, HER2 45 (6.0) 2.3%
ER, HER2 45 (6.0) 9.5%
ER, HER2 64 (8.5) 4.9% 0.056
N.A. 102 (13.4)
Tumour multifocality
Yes 237 (31.4) 2.3%
No 515 (68.2) 3.1% 0.434
N.A. 3 (0.4)
Extensive intraductal component
Yes 92 (12.2) 2.3%
No 663 (86.8) 3.1% 0.627
Radiotherapy to the thoracic wall
All patients
Yes 387 (51.2) 2.7%
No 363 (48.1) 3.5% 0.746
N.A 5 (0.7)
(Continued )
 Local recurrences after mastectomy 69
Table I. (Continued).

N (%) 7-year local

Factor (N 755) recurrence rate (%) p (log-rank test)

Radiotherapy to thoracic wall,

pN0 disease
Yes 57 (16.7) 1.7%
No 281 (82.4) 3.1% 0.763
N.A 3 (0.9)
Radiotherapy to thoracic wall,
pN1 mi disease
Yes 19 (57.6) 5.6%
No 14 (42.2) 0% 0.414
Radiotherapy to thoracic wall,
pN1 disease
Yes 173 (78.6) 1.8%
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No 46 (20.9) 5.2% 0.628

N.A 1 (0.6)
Radiotherapy to thoracic wall,
pN23 disease
Yes 138 (86.3) 4.9%
No 22 (13.7) 25.0% 0.628
Systemic adjuvant treatment
Yes 596 (78.9) 2.7%
No 157 (20.8) 4.4% 0.340
N.A 2 (0.3)

ER, oestrogen receptor; HER2, human epidermal growth factor receptor-2; MIB-1, an antibody against
Acta Oncol 2013.52:66-72.

Ki-67; N.A., not available; PgR, progesterone receptor.

Follow-up survival was calculated from the date of breast sur-

gery to the date of first detection of LR censoring
Planned follow-up visits took place at one, three and
patients who did not have LR on the date of the last
five years after breast surgery. Whenever there was
follow-up visit or the date of death. Breast cancer
concern of cancer recurrence the patients had an
specific-survival (BCSS) was calculated from the
access to an outpatient unit of the hospital which
date of surgery to the date of death considered to be
treats almost all (over 95%) breast cancer patients
caused by breast cancer censoring patients who were
and their recurrences diagnosed in the region. The
alive and those who died from an intercurrent cause
data on cancer recurrence and survival were col-
on the date of death. Overall survival was calculated
lected from the hospital records and from the Finn-
from the date of surgery to the date of death from
ish Cancer Registry that has a coverage approaching
any cause censoring patients who were alive on the
to 100% [17].
date of the last follow-up visit. Life tables were con-
Physical examination, blood cell counts and blood
structed according to Kaplan-Meier method and the
chemistry, and a bilateral mammogram with or with-
survival between the groups was compared with the
out breast ultrasound examination were performed
log-rank test or the Cox proportional hazards model.
at the planned visits and whenever considered indi-
P-values are two-tailed.
cated. When a recurrence was suspected, an isotope
bone scan and computed tomography were usually
carried out as the initial staging examinations. After Results
the first five years, follow-up was continued at a
Sites of breast cancer recurrence and survival
local health-care centre or at a private health-care
company based on the patient preference. The median follow-up time after breast surgery was
89 months (range, 2130 months). The seven-year
breast cancer-specific survival was 85.9% and over-
Statistical analysis
all survival 74.5% in the cohort of 755 patients
LR was defined as any cancer recurrence in the ipsi- treated with mastectomy. A total of 114 (15.1%)
lateral thoracic wall, and locoregional recurrence as patients died from breast cancer and 100 (13.2%)
any cancer recurrence in the ipsilateral thoracic patients from an intercurrent or unknown cause
wall, in the regional lymphatics or in both. LR-free (Table III).
 70 E. T. Siponen et al.
Table II. Radiotherapy and systemic adjuvant treatments given. 29 months (range, 2130 months) as calculated from
Axillary nodal the date of surgery.
status Treatment N (%) A recurrence in the ipsilateral axilla was detected
in seven (0.9%) patients, two of these occurred con-
Radiotherapy
pN0 None 281 (82)
comitantly with a LR in the ipsilateral thoracic wall.
Thoracic wall only 51 (15) The median time to recurrence in the ipsilateral
Thoracic wall and lymph nodes 6 (2) axilla was 48 months (range, 13124 months) from
Lymph nodes only 0 (0) the date of breast surgery. Ipsilateral supraclavicular
Not available 3 (1) recurrence was found in eight (1.1%) patients, one
pN1 or pN1mi None 57 (23)
of these concomitantly with a LR. The median time
Thoracic wall only 12 (5) to a supraclavicular recurrence was 28 months (range,
Thoracic wall and lymph nodes 180 (71) 159 months).
Lymph nodes only 3 (1) Contralateral breast cancer was detected in 35
Not available 1 (1) (4.6%) patients and distant metastases in 133 (17.6%)
patients. Eleven (50%) of the 22 patients with LR
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pN2 or pN3 None 21 (13)

Thoracic wall only 6 (4) had distant metastases diagnosed either prior to
Thoracic wall and lymph nodes 132 (83) LR (n 2), concomitantly with LR (n 4) or after
Lymph nodes only 1 (1) LR (n 5). Distant metastases as the first event
(without a locoregional recurrence) occurred 113
Systemic adjuvant treatment
pN0 None 133 (39)
(15.0%) patients.
Endocrine therapy 124 (36)
Chemotherapy 39 (11)
Endocrine and chemotherapy 44 (13) Risk factors for local recurrence
Chemotherapy and trastuzumab 1 (1)
Patients with PR-negative cancer had a 4.9% seven-
Acta Oncol 2013.52:66-72.

pN1 or pN1mi None 17 (7) year risk for LR as compared to a 1.8% risk in
Endocrine therapy 88 (35) patients with PR-positive tumour in a univariate
Chemotherapy 32 (13) survival analysis (p 0.015), and patients with
Endocrine and chemotherapy 115 (45) ERnegative breast cancer tended to have a greater
Chemotherapy and trastuzumab 1 (1) risk compared to patients with ER-positive cancer
pN2 or pN3 None 7 (4)
(6.0% vs. 2.4%, p 0.059).Tumour biological groups
Endocrine therapy 45 (28) formed by tumour ER and HER2 expression also
Chemotherapy 22 (14) tended to be associated with LR. Patients with either
Endocrine and chemotherapy 83 (52) the ER, HER2 phenotype (9.5%) or the ER,
Chemotherapy and trastuzumab 2 (1) HER2 phenotype (4.9%) had a higher risk as com-
pared to the ER, HER2 (2.1%) and the ER,
HER2 (2.3%) phenotypes (p 0.056, Table I).
Twenty-two 22 (2.9%) patients had a LR and When these three factors (PR, ER, the biological
34 (4.5%) a locoregional recurrence during the group) were entered into a Cox multivariate model
follow-up. The seven-year LR-free survival was as covariables, none of the factors was independently
96.9% and locoregional recurrence-free survival associated with LR-free survival. Age at diagnosis,
95.4%. The median time to LR was 27 months tumour site in the breast, histological type or grade,
(range, 187 months) and to locoregional recurrence axillary lymph node status or administration of sys-
temic adjuvant treatment were not associated with
the LR rate.
Table III. Events recorded.
Event N (%)
Survival after LR
Any locoregional recurrence 34 (4.6)
Ipsilateral thoracic wall (local recurrence) 22 (2.9) The seven-year breast cancer-specific survival rate of
Regional recurrence 15 (2.0) patients without LR during the follow-up was 86.9%
Ipsilateral axilla 7 (0.9)
and that of the patients with LR 56.7% (p 0.0001),
Ipsilateral supraclavicular nodes 8 (1.1)
Contralateral breast 35 (4.6) and the seven-year overall survival figures were
Distant metastases 133 (17.6) 75.7% and 45.5%, respectively (p 0.001).The median
Death 214 (28.3) follow-up time after LR was 38 months (range, 1103
Breast cancer 114 (15.1) months). The five-year breast cancer-specific survival
Intercurrent cause 89 (11.8)
rate after LR as calculated from the date of LR detec-
Unknown cause 11 (1.5)
tion was 54.8% and five-year overall survival 42.5%.

Sixteen (72.7%) of the 22 patients with ipsilateral
chest wall recurrence did not have prior or concom-
itant distant recurrence. Five (31.3%) of these
16 patients developed distant metastases after detec-
tion of the LR during a median follow-up of
61 months (range, 1103 months), and three died
from breast cancer and three from an intercurrent
cause during the follow-up. The five-year breast
cancer-specific and overall survival rates of the
16 patients with isolated chest wall recurrence were
77.5% and 59.2%, respectively, as calculated from
the date of detection of the recurrence. The
six patients who had distant metastases diagnosed
either prior to or simultaneously with LR died from
breast cancer within one to 14 months detection of
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the chest wall recurrence.
Discussion
Ipsilateral chest wall recurrences were infrequent
after mastectomy in this series of breast cancer
patients who were frequently treated also with post-
operative radiotherapy and systemic adjuvant thera-
pies. This finding, based on a population-based
Acta Oncol 2013.52:66-72.
series, is supported by several other studies [1,8,9,18].
The LR rate was low even in pN2 or pN3 disease
(4.4%), which contrasts with the five-year LR risk of
12% in N23 patients who had postmastectomy RT
and the five-year LR risk of 26% in N23 patients
without RT reported in the EBCTCG overview [5].
Modern radiation therapy and systemic adjuvant
treatments reduce LR substantially [5,6], and many
of the studies included in the EBCTCG overview are
old and date back to times when these treatments
were used less frequently, the radiation therapy tech-
niques were suboptimal as considered from the pres-
ent standards, and the endocrine and chemotherapies
available were less effective.
Besides radiation therapy and adjuvant treat-
ments, also quality of surgery and pathological
assessment of the tissue specimens are likely of key
importance. For example, in the Helsinki metropoli-
tan area where the current patients were treated, the
quality of surgery and pathology have improved after
the year of 2000 due to centralisation of breast can-
cer surgery resulting in improved accuracy in cancer
staging and a mastectomy technique where little or
no breast tissue is left in the chest wall. During the
first years of the 21st century, remastectomy, an
operation carried out to remove both the LR and the
residual breast tissue left behind in the primary oper-
ation performed in the 1990s, was not uncommon.
At present, such surgery is rare in our unit.
In a univariate survival analysis a lack of proges-
terone receptors in the breast tumour was signifi-
cantly associated with an increased risk for LR,
Local recurrences after mastectomy 71
and tumour ER-negativity and the ER/HER2
and ER/HER2 biological types showed a similar
tendency. Yet, none of these factors had independent
influence on the risk in a multivariate analysis. Nei-
ther a poor histological grade of differentiation nor
a high tumour MIB-1 cell proliferation index cor-
related with the risk of LR in the present study. These
findings need to be viewed with some caution, since
the number of LRs was small in the present series
despite the relatively large size of the cohort, and
multiple testing may also have a role. The small num-
ber of events coupled with administration of adjuvant
treatments tailored to the patient risk profile may
have prevented detection of some clinically impor-
tant associations.
The current study was conducted in a region
where virtually all breast cancer recurrences are
captured.
Patient selection likely influences the rate of LRs
observed. Young women have a higher rate of locore-
gional recurrence than older women. In a recent
series from the MD Anderson hospital, young age
was the only independent predictor of locoregional
recurrence in patients who had pN0 or pN1 cancer
when postmastectomy radiotherapy was not given
[13]. In the present study the seven-year LR rate was
6.5% in patients under 40 years of age at the time
of breast cancer diagnosis compared to 2.53.3%
in older patients. Postoperative radiation therapy
reduces the risk of LR substantially also in women
who are diagnosed with breast cancer at a young age.
In our earlier study on patients younger than 35 the
LR rate after mastectomy was 15% without radio-
therapy and only 1% with postmastectomy radio-
therapy [19]. Similarly, Beadle et al. reported a
10-year LR rate of 12.5% after mastectomy in
patients under the age of 35 treated without postop-
erative radiotherapy, whereas the LR rate was 7.0%
in similar patients after radiotherapy [20].
The outcome of patients with LR after mas-
tectomy has been regarded sinister, and also in the
present series LR was associated with a survival dis-
advantage. However, in the subset of patients with
LR but without concomitant or prior distant recur-
rence survival was relatively favourable, the five-year
breast cancer-specific and overall survival as calcu-
lated from the date of detection of the chest wall
recurrence being 77.5% and 59.2%, respectively. In
previous studies five-year overall survival after iso-
lated LR is 4344% in series dating back to the
1980s and 1990s [2,3]. A somewhat better five-year
survival rate of 66.4% was reported in a study where
the patients were treated from 1990 to 2005 [4].
These and the current data suggest that the outcome
of patients with isolated thoracic wall recurrence may
be slowly improving, but this conclusion needs to
 72 E. T. Siponen et al.
be viewed with caution due to several confounding
factors. These include improved imaging to detect
distant recurrence, and it is not known whether the
biological aggressiveness of the LRs that are not
eradicated by modern adjuvant treatments is similar
to the LRs that surface when solely local therapies
are given.
Conclusions
We conclude that LR is a rare event after mastectomy
carried out with appropriate techniques and when
modern radiation therapy and adjuvant systemic
treatments are frequently used. Most women with
isolated chest wall recurrence survive for five years
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overview of the randomised trials. Lancet 2005;35:
1687717.
[7] Taras A, Thorpe J, A Morris, Atwood M, Lowe K, Beatty J.
Second Place Tie ResidentsCompetition: Irradiation effect
after mastectomy on breast cancer recurrence in patients
presenting with locally advanced disease. Am J Surg 2011;
201:6037.
[8] Bijker N, Rutgers E, Peterse J, van Dongen J, Hart A,
Borger J, et al. Low risk of locoregional recurrence of primary
breast carcinoma after treatment with a modification of the
halsted radical mastectomy and selective use of radiotherapy.
Cancer 1999;85:8:177381.
[9] Gentilini O, Botteri E, Rotmensz N, Intra M, Gatti G,
Silva L, et al. Is avoiding post-mastectomy radiotherapy
justified for patients with four or more involved axillary
nodes and endocrine-responsive tumours? Lessons from a
series in a single institution. Ann Oncol 2007;18:13427.
[10] Cosar R, Uzal C, Tokatli F, Denizli B, Saynak M, Turan N,

after local recurrence, but this group of patients still
face a high risk for distant metastases.
[11]
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
[12]
The study was supported by a grant from the
Helsinki University Central Hospital Research Fund
and also by a grant from Doris and Kurt Palander
Acta Oncol 2013.52:66-72.
et al. Postmastectomy irradiation in breast in breast cancer
patients with T12 and 13 positive axillary lymph nodes: Is
there a role for radiation therapy? Radiat Oncol 2011;6:28.
Botteri E, Gentilini O, Rotmensz N, Veronesi P, Ratini S,
Fraga-Guedes C, et al. Mastectomy without radiotherapy:
Outcome analysis after 10 years of follow-up in a single insti-
tution. Breast Cancer Res Treat Epub 2012 Apr 26.
Yildirim E, Berberoglu U. Can a subgroup of node-negative
breast carcinoma patients with T12 tumor who may benefit
from postmastectomy radiotherapy be identified? Int J Radiat
Oncol Biol Phys 2007;68:4:10249.

Foundation. With this statement all authors mentioned
in this study disclose that there are no financial or
personal relationships with other people or organisa-
tions that could inappropriately influence this work.
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