It appears that early IBTR is a significant predictor for distant metastases. Whether early breast tumor relapse is a marker for or cause of distant metastases remains a controversial and unresolved issue. Implications for adjuvant systemic therapy at the time of breast relapse are discussed.

Background. Conservative surgery (CS) and radiation therapy (RT) as an alternative to mastectomy is controversial in patients with two or more lesions in the same breast. The authors reviewed their experience with CS and RT in the management of patients with synchronous ipsilateral breast cancer (SIBC). Methods. Of 1060 patients treated with CS and RT at the authors' facilities before December 1988, 13 (1.2%) presented with SIBC. All lesions were identified macroscopically and confirmed microscopically as carcinoma. After excision, patients were treated with radiation to the breast for a median tumor bed dose of 65 Gy, and regional lymphatics were treated as clinically indicated to a median dose of 48 Gy. These cases were retrospectively reviewed. Results. As of February 1992, with a median follow‐up of 71 months, the 5‐year actuarial survival rate of the 13 patients was 81%. Three of the 13 (23%) had an ipsilateral breast recurrence, resulting in a 72‐month actuarial breast recurrence rate of 25%, compared with a rate of 12% in our singular lesion population. Two of these patients remain alive, no evidence of disease at 135 and 93 months after diagnosis. The third patient had chest wall progression and died with metastatic disease at 64 months. Invasive lobular histology and three separate lesions were identified in two of the three patients with subsequent local recurrence. Conclusions. The local recurrence rate in conservatively treated patients with SIBC is greater than that seen in patients with single lesions, but because of the small sample size, significant conclusions are not possible. Although the data are limited on this subject, these results support consideration of CS and RT as an option in the management of selected patients who favor a breast conservation management approach. Cancer 1993; 72:137–42.

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For selected patients, axillary lymph node dissection appears to have little influence on subsequent management and long-term outcome. These data suggest that it is time to reassess the role of axillary lymph node dissection in patients who undergo conservative surgery and radiation therapy.

Between 1962 and 1984, a total of 433 patients were treated at Yale-New Haven Hospital with conservative surgery and radiation therapy (CS + RT) to the intact breast. As of January 1990, with a minimum assessable follow-up of 5 years and a median follow-up of 8.21 years, there have been a total of 50 breast recurrences resulting in a 5-year actuarial breast recurrence rate of 8%. Of all clinical factors tested, young age was the most significant prognostic factor for local recurrence (P less than .03). In addition, patients with pathologically involved lymph nodes were noted to have a lower local recurrence rate than patients with pathologically negative axillae (P less than .05). These findings were especially notable given the fact that the node-positive group had a higher percentage of T2 tumors and a higher percentage of patients in the young age group. These paradoxical findings, however, may be explained by the fact that 88% of the node-positive patients underwent adjuvant systemic therapy in the form of either systemic chemotherapy or hormonal therapy, while only 8% of node-negative patients underwent any adjuvant systemic therapy. When analyzed as a function of adjuvant therapy, those patients receiving adjuvant therapy had a lower local recurrence rate than those patients not receiving adjuvant therapy (P less than .08). We conclude that adjuvant systemic therapy impacts on the ipsilateral breast recurrence rate in patients treated with CS + RT. The implications of this study in light of the widespread use of adjuvant systemic therapy are discussed.