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Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
(Email: p.camp{at}partners.org; ycolson{at}partners.org).
The article by Friedel and colleagues [1] reports their retrospective analysis of 63 patients who underwent full thickness chest wall resection and reconstruction for locally recurrent breast cancer. It would be best to start with what this article is not (ie, it is not a prospective review of the efficacy, safety, and appropriate role for full thickness chest wall resection in the setting of recurrent breast cancer). This article is a report of the 21-year review of records from the authors' institution, which does an admirable job of defining the descriptive characteristics of those patients who underwent chest wall resection for recurrent disease, as per their criteria for this retrospective review. The domain of thoracic surgery has clearly demonstrated that chest wall surgery is a safe operation and allows for resection of chest wall extensions. It seems logical that these authors, as well as others, are applying this knowledge for tumors that extend into the chest, rather than out. However, it does not prove that this technique distinctly provides survival benefits or reduces morbidity for those undergoing chest wall resections. In fact, the results noted in their article seem to conflict with known trends within breast and thoracic surgery, including age and survival. It seems plausible that the selection criteria evolved, as did the learning curve, and this may have played a role in outcomes as well as complications. In the end it would have been useful to know the denominators for the patient population from which this article was drawn.
In this review, the authors have confirmed what others have shown in that it is feasible to perform wide-field, radical resections for recurrent cancer of the breast so that patients with reasonable preoperative risk are likely to have acceptable morbidity and mortality.
However, it is not the descriptive data within this document that provide the most important contribution to the surgical literature, but rather it is their observations. Too long has the erosion of a tumor into an anatomic region outside of a surgeon's expertise been the potential limiting factor to the possible resectability of a tumor. Although the authors do not achieve statistical or demonstrable conclusions to support their suppositions, they raise a vital question: "With the appropriate preoperative evaluation, staging, and collaboration, can a multidisciplinary team of surgeons bring a summed level of expertise to the table that can improve survival and quality of life to this patient population that was previously without acceptable treatment options?" It is time for the issue of recurrent breast cancer with chest wall extension to be elevated to the level of a multicenter trial so that "proof of concept" articles can focus on the clinically relevant issues of improved survival, optimal treatment paradigms, and improved quality of care.
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