Breast reconstruction following mastectomy has been shown to have a positive effect on the psychological well-being of women with breast cancer. For patients undergoing mastectomy, options for breast reconstruction include single-stage implant reconstruction, two-stage tissue expander/implant reconstruction, and autologous reconstruction with or without the use of implants. However, regardless of the type of oncologic treatment received or which method of reconstruction is chosen, locoregional recurrence of breast cancer can occur. Approximately 5% of breast cancer patients experience locoregional disease recurrence within 5 years, and this rate increases to 10% to 15% after 10 years (1,2,3,4,5,6). The early detection of a potentially treatable relapse remains the primary objective of continued oncologic surveillance following mastectomy. Some have questioned whether the presence of a prosthetic device and/or autologous tissue can delay detection and/or interfere with the treatment of locoregional recurrence. Furthermore, there is little agreement on the appropriateness of routine radiologic surveillance of these patients, as well as on the surgical management of locoregional recurrence. This chapter outlines the known mechanisms of breast cancer recurrence, its various patterns of clinical presentation, and the timing of presentation of a locoregional recurrence. An overview of the most effective available methods of surveillance is also provided in order to guide the management of locoregional recurrence in the reconstructed breast.

Factors influencing recurrence of breast cancer after mastectomy include the pathologic status of the axillary lymph nodes (7,8,9), the size of the primary tumor, the histologic grade of the tumor, the presence of skin fixation or clinical invasion, gross invasion of deep fascia, ulceration of the skin, breast edema, and the administration of adjuvant therapies, especially radiation (10).

Failure of mastectomy to prevent recurrent breast cancer may be attributable to the minimal yet irreducible percentage of breast tissue that remains after mastectomy. It is presumed that breast cancer recurrence arises from the native breast skin and/or the anterior chest wall itself, either of which may contain residual breast parenchyma or draining lymphatics (10). In fact, it has been shown that residual breast tissue exists in 46% of mastectomized breasts with skin flaps less than or equal to 5 mm thick and in 81% of those with skin flaps greater than 5 mm thick (11). Other proposed mechanisms for local recurrence include transection of the tumor with surgical implantation in the wound, retrograde embolization of the tumor through transected lymphatics, and implantation of tumor cells in the overlying mastectomy skin following needle biopsy (12,13,14).

Some have hypothesized that the presence of a permanent prosthesis may interfere with the body’s immunologic surveillance of recurrent disease (15,16). Others have suggested that more-invasive and/or lengthier surgical procedures, such as the performance of autogenous tissue reconstruction, may result in increased breast cancer recurrence. In other surgical disciplines, invasive procedures have been shown to result in higher levels of immunosuppression compared to less invasive procedures (17). To date, however, no clinical data have been produced that support these hypotheses in the setting of oncologic breast reconstruction.