Patient Detail (Breast Cancer Community)


Patient Name: S*** ,44 Female,
Last Seen : 46 Mins Ago
Views : 26
Past Activity: Need second opinion for Breast cancer treatment.
Summary of Case Smita Sharma 24 Feb 1974, Homemaker Currently based in Singapore. Sep 2015: Left Mastectomy performed with implant and nipple sparing. Background to this : 1. Regular mammogram suggests calcification in UOQ in Left Breast 2. Mammogram Guided core biopsy reveals presence of DCIS stage zero. 3. Mastectomy with nipple sparing done with reconstruction using a silicone implant. All procedure completed in one surgery. High nuclear grade . 4. No radiation / Chemo suggested. Temoxifin was considered but not recommended as side effects were more than benefits. Oct 2017: Nipple / skin removed in backdrop of 1. A minor wound / scratch on the left nipple was observed in may – jun 2017 and it did not heal for a long time. 2. Aug 17, Ultrasound shows no suspicious results. 3. Sep 17, MRI fails to reveal any suspicious activity. 4. 29 Sep 2017, Punch Biopsy reveals DCIS stage zero. 5. 3 OCT, 2017 – Surgery for excision of nipple. Tumour type DCIS – high nuclear grade 6. Tamoxifin was recommended but was optional. Hence did not take. May 2018: Radical Mastectomy performed. 1. Slight pain was felt near the sternum and also a small ball (size of moong dal / 2x2 mm) was felt. 2. Ultra sound was done and 2 lesions were noted close to the implant. 3. Ultrasound guided breast biopsy reveals invasive ductal carcinoma. 4. Biopsy classifies these as non ER / PR negative HER2+, whereas histopathology reveals it is 60% ER, 10%PR, 90% HER2+ 5. Histopathology findings also reveals the there were not 2 but 3 node and also multi foci. The largest size is 0.8 cm. 6. Lymph nodes negative , pet-ct scan negative (no metastasis) Diagnosis, advised treatment and our concerns Diagnosis: 1. Tumour size = 0.8 cm, invasive, ductal, grade 3 2. Lymph node 0 out of 9 3. Metastasis absent It classifies as grade 1a kind of malignancy. Given that the tumour is ER60%, PR10% and HER2 20% , it’s best to take a combination of Chemo & Harmonal therapy. Radiotherapy to be considered and 5 – 10 years of Tamoxifin is also suggested. Possible treatment options: 1. TCH six cycles at interval of 3 weeks + Herceptin to continue for one year 2. Weekly Paclitaxel for 12 weeks + Herceptin for one year. Doctor has shown preference for treatment 2 mentioned above. In both cases Tamoxifin will be required. Additionaly Radiation therapy might also be required after consulting with radiation experts. Concerns: 1. At time of First Surgery, Ultrasound had indicated one tumour but it turned out to be two reasonably large tumours. A tumour of size of 1.7X0.6x0.5 cm got undetected. 2. In 2017, ultrasound as well as MRI did not detect any abnormality but again a ductal carcinoma in-situ was found after surgery. 3. In May 2018 again when biopsy was done in biopsy it turned out to be ER/PR negative and only Her positive, whereas in actual biopsy the outcome is ER60%, PR10% and HER2 20%. We are concerned that the tumour has a tendency to hide and it very smart. How do we ensure that we are eliminating all chances of its recurrence? What could we have potentially done earlier and more importantly what should we do to ensure that it does not come back again ?
Reply:
Reply:

Dear Patient,

I am really sorry to hear about your health issues. But I should compliment you for your meticulous presentation of your history. You have done it very well and it has made things easy and very objective for me to answer.

This is what I have understood this far. You had an incidentally detected high grade ductal carcinoma in situ (DCIS) in September 2015 for which you had a nipple sparing mastectomy with implant reconstruction. You were advised Tamoxifen but no further treatment was done. You were disease free for two years and in September 2017 you had a recurrence of DCIS in the preserved nipple areola (USG and MRI breast were negative), for which you had a surgical excision and complete removal of the nipple, following which no further treatment was done.

My 2018 you developed painful nodules in mid chest and USG picked up two lesions close to implant. Biopsy was suggestive of invasive duct carcinoma. You underwent a left radical mastectomy. The tumor is grade 3. There is discrepancy in ER / PR / Her2neu report between initial biopsy and later pathology of the surgical specimen. There is also a discrepancy between numbers of reported nodules in USG versus pathology. The pathology did not show nodal metastasis (0/9) and PET CT did not reveal any systemic metastasis.

(Guess I have got most of what you have said; correct me if I have missed something)

Now about your concerns.

  1. USG missed a tumour of 1.7 cms size: Ultrasound examination is dependent on the operator and machine resolution, therefore not as robust as a MRI Breast. I note that you are young (44 years) and premenopausal. In younger people the breast is denser compared to an older post menopausal lady and therefore a small lesion may be missed. Moreover you had a silicon implant the second time the USG was done which again could have added to the confusion. An MRI is always better in people of your age, to have clarity and objectivity on the issues of number and size of lesions in breast. In 2017 you did have a MRI Breast; I am unable to explain why it did not pick up the DCIS lesions. I am assuming it might have been due to the technique used, use of lower resolution sequences or absence of contrast enhancement. Your radiologist would be able to answer that better than me. The report in the pathology however is the gold standard and therefore should be given more weightage.
  2. Discrepancy in biopsy report: There can be 3-4 % discordance between the needle biopsy and the surgical specimen. It also could be tumour heterogeneity between the three different nodules. We can make that out only if we do the ER / PR and Her2neu in each of the nodules.
  3. Tumour trying to hide: I am not really sure whether it is a case of the tumour being smart and trying to hide or is it whether the tests are unable to pick them up at a very early stage! However I am convinced that you are getting the standard treatment for the given scenario. This is a local recurrence and therefore I would agree with your oncologist in going ahead with chemotherapy and Trastuzumab. The weekly Paclitaxel (for 12 doses) with Trastuzumab (to complete one year) would be my choice too since it is the best for early ER PR Her2neu positive disease. The chemotherapy has to be followed by Radiation treatment and extended Tamoxifen. The Radiation treatment, Tamoxifen and Trastuzumab will overlap.
  4. Ensure No recurrence: The extended Tamoxifen treatment is a good way of trying to avoid a recurrence. But to be practical no doctor could ever give you a complete guarantee of no recurrence.
  5. What could have been done differently: Looking back it is easy to say you should have done things differently but truthfully you would have received the same sort of advices if you were at any other centre. You could have taken Tamoxifen at the onset, very well understanding the risk of endometrial and thrombotic issues, but most patients do refuse tamoxifen treatment if informed about the adverse effects, which you too did.
  6. What for future: Please go ahead with the planned chemotherapy and the Trastuzumab treatment followed by Radiation and Tamoxifen which we believe should keep you going without trouble.

Please feel free to write back to me f you have any further queries.

 

My Best

Wesley M Jose

Medical Oncologist

Replied by: WESLEY M JOSE MBBS,MD,DNB,MNAMS, FIACM, PGDIM,MD,DNB,MNAMS
Reply: <p>Dear Patient,</p><p>I am really sorry to hear about your health issues. But I should compliment you for your meticulous presentation of your history. You have done it very well and it has made things easy and very objective for me to answer.</p><p>This is what I have understood this far. You had an incidentally detected high grade ductal carcinoma in situ (DCIS) in September 2015 for which you had a nipple sparing mastectomy with implant reconstruction. You were advised Tamoxifen but no further treatment was done. You were disease free for two years and in September 2017 you had a recurrence of DCIS in the preserved nipple areola (USG and MRI breast were negative), for which you had a surgical excision and complete removal of the nipple, following which no further treatment was done.</p><p>My 2018 you developed painful nodules in mid chest and USG picked up two lesions close to implant. Biopsy was suggestive of invasive duct carcinoma. You underwent a left radical mastectomy. The tumor is grade 3. There is discrepancy in ER / PR / Her2neu report between initial biopsy and later pathology of the surgical specimen. There is also a discrepancy between numbers of reported nodules in USG versus pathology. The pathology did not show nodal metastasis (0/9) and PET CT did not reveal any systemic metastasis.</p><p>(Guess I have got most of what you have said; correct me if I have missed something)</p><p><strong>Now about your concerns.</strong></p><ol><li><strong><span style="text-decoration:underline;">USG missed a tumour of 1.7 cms size</span></strong>: Ultrasound examination is dependent on the operator and machine resolution, therefore not as robust as a MRI Breast. I note that you are young (44 years) and premenopausal. In younger people the breast is denser compared to an older post menopausal lady and therefore a small lesion may be missed. Moreover you had a silicon implant the second time the USG was done which again could have added to the confusion. An MRI is always better in people of your age, to have clarity and objectivity on the issues of number and size of lesions in breast. In 2017 you did have a MRI Breast; I am unable to explain why it did not pick up the DCIS lesions. I am assuming it might have been due to the technique used, use of lower resolution sequences or absence of contrast enhancement. Your radiologist would be able to answer that better than me. The report in the pathology however is the gold standard and therefore should be given more weightage.</li><li><strong><span style="text-decoration:underline;">Discrepancy in biopsy report</span></strong>: There can be 3-4 % discordance between the needle biopsy and the surgical specimen. It also could be tumour heterogeneity between the three different nodules. We can make that out only if we do the ER / PR and Her2neu in each of the nodules.</li><li><strong><span style="text-decoration:underline;">Tumour trying to hide</span></strong>: I am not really sure whether it is a case of the tumour being smart and trying to hide or is it whether the tests are unable to pick them up at a very early stage! However I am convinced that you are getting the standard treatment for the given scenario. This is a local recurrence and therefore I would agree with your oncologist in going ahead with chemotherapy and Trastuzumab. The weekly Paclitaxel (for 12 doses) with Trastuzumab (to complete one year) would be my choice too since it is the best for early ER PR Her2neu positive disease. The chemotherapy has to be followed by Radiation treatment and extended Tamoxifen. The Radiation treatment, Tamoxifen and Trastuzumab will overlap.</li><li><strong><span style="text-decoration:underline;">Ensure No recurrence</span></strong>: The extended Tamoxifen treatment is a good way of trying to avoid a recurrence. But to be practical no doctor could ever give you a complete guarantee of no recurrence.</li><li><strong><span style="text-decoration:underline;">What could have been done differently</span></strong>: Looking back it is easy to say you should have done things differently but truthfully you would have received the same sort of advices if you were at any other centre. You could have taken Tamoxifen at the onset, very well understanding the risk of endometrial and thrombotic issues, but most patients do refuse tamoxifen treatment if informed about the adverse effects, which you too did. </li><li><strong><span style="text-decoration:underline;">What for future</span></strong>: Please go ahead with the planned chemotherapy and the Trastuzumab treatment followed by Radiation and Tamoxifen which we believe should keep you going without trouble.</li></ol><p>Please feel free to write back to me f you have any further queries.</p><p>&nbsp;</p><p>My Best</p><p>Wesley M Jose</p><p>Medical Oncologist</p>

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