Treating DCIS recurrence after already having Lumpectomy+ Rads?

Alli

Hi ladies,

I am disappointed to be here seeking advice after nearly reaching my ten year cancerversary .I had left lumpectomy in 2006 for DCIS with tiny area of IDC-stage 1a, followed by 6 wks of rads. Had biopsy last week for suspicious calcs which proved to be DCIS. Will have MRI on Thursday to determine if there are any other suspicious areas.

I am trying to figure out what options are available. Has anyone had a second lumpectomy in a breast that has previously been radiated? And was radiation given again?

How do the reconstruction options change if I choose mastectomy since I had previously had radiation. Am I limited to some sort of flap recon surg or are implants possible.

I am certain there some others that have been in my situation though I could not find a post with exactly the same issue.

Thank you so much in advance for your help!

Alli

Annette47

I’m not in your position (yet - I’m only 4 years out so it’s possible I could be there eventually), but I did ask about this stuff when I was first diagnosed and deciding on a treatment.

Standard treatment in your case would be a mastectomy. Your reconstruction options would most likely depend on how your skin responded to the radiation and whether it’s completely recovered - I would think a consult with a plastic surgeon would be able to give you more information about that. My understanding is most people in that position end up with a flap, but I have heard of people being okayed for an implant, but it definitely depends on the condition of the skin.

If the area is very small, it’s possible a lumpectomy alone might be an option. Radiation is not given to the same area twice (which is why a mastectomy is standard of care).

Hopefully others will be along with personal experiences. So very sorry you are having to make these decisions.

DCISCarol

Hi, Alli - was looking for posts similar to this. I too was just diagnosed with a recurrence - detected on mammogram (17 years of clear mammos but this one wasn't). Stereotactic core biopsy: DCIS intermediate grade, no necrosis, two microscopic spots of 1 mm each; extent in the biopsy - 1mm; solid form; ER+/PR+

Previously I was diagnosed with DCIS with microinvasion (invasion less than 1 mm). That was 1999; sentinel nodes - 2 and they were negative.

I had lumpectomy/radiation in 1999. Chose not to do tamoxifen.

Mastectomy offered - and I probably would have chosen immediate reconstruction; but got the impression the surgeon thought the lumpectomy might be the easiest way to go and then if it was a lot of DCIS or IDC in the stuff they removed, I'd have a mastectomy.

This time I was thinking it would be mastectomy, but the surgeon said she felt very comfortable with lumpectomy. No rads because of prior radiation. In lumpectomy there was some residual DCIS, 2.5 mm total; intermediate grade, no necrosis. Clear margins (>5mm) all the way around.

This week I have appt. with medical oncologist and surgeon, I like both of them. I think the MO will recommend Aromatase Inhibitors, and don't know about the surgeon. I'm thinking I don't want to do the AIs (just not enough benefit for my low risk versus side effects??) -

So that Is my story - and I'm wondering about other long term survivors who got a recurrence of DCIS only - and what they decided about AIs.

Carol

Moderators

Dear DCISCarol,

Welcome to the BCO community. We are sorry about your recurrence but glad that you chose to reach out to our community. Good luck with your appointments this week and keep us posted on how things go. Stay connected here as you can. It may be a little quiet through the holiday but we are certain that you will find support and good information from our members here on the boards. Let us know if we can help in any way. The Mods

DCISCarol

Thanks for the support. I saw my medical oncologist today - she confirmed the good path report from the lumpectomy. She would recommend hormonal therapy (I knew she would!), and I told her I'd let her know in 2 weeks. Am thinking I might actually try tamoxifen instead of AIs? She didn't care either way about that, and would obviously accept if I didn't want to take anything. I do respect her a lot, and know that if the side effects are not good, that I would quit or take a different one. She said she would recommend 5 years (not 10) and that the effects last an additional 10 years or so. I see the surgeon on Friday.

Anybody here taken Tamo. instead of AIs as first line of defense after DCIS?

THANKS

PoppyJQ

Hi ladies,

I had lumpectomy, chemo and radiation in 2012 for IDC and have been on AI's since then. Was diagnosed with DCIS in the same breast recently. I was advised to have MX since I had the previous radiation. By this point I was ready for a mastectomy as I was tired of the worries, mamo callbacks, biopsies, additional screenings, etc. I decided to have a bilateral MX and am glad I did.

I chose no reconstruction after seeing three plastic surgeons although at first I thought I would absolutely have recon based on how easy my onco and other doctor said it would be. I think they were trying to make everything better at diagnosis! The plastic surgeons all said complication rates for implants with previously radiated skin were high, from 50 to 70 percent. Flap surgery was an option with complication rates dropping but still 30 to 50 percent. I am sure each PS views this differently. For me getting healthy was all I wanted right now, I have so many things I want to do with my life and having a recurrence is yet another wake up call. I can explore flap surgery in the future but dont really think I'll ever want to go through all that it entails.

As far as the tamoxifen/AI's question, when I was given it years ago they said tamoxifen before menopause AI's after menopause. Maybe thats all changed since then, I was after menopause so only offered AI's.

Annette47

I’ve been taking Tamoxifen, not an AI but I am still pre-menopausal. My understanding is that for post-menopausal women, the AI’s are more effective, but the Tamoxifen may be easier to tolerate, so it probably depends on the individual (what their risk factors are both for recurrence and for various side effects of the drugs) which is going to be best. My oncologist initially said “5 years and we’ll talk” but that was right about the time the recommendation for 10 years was first coming out. I suspect he’ll want me to stay on for 10 years (it’ll have been 4 in the spring). If so, even if I do hit menopause at some point during that, which is likely but not guaranteed (I am 49), I would probably just stay on the Tamoxifen as osteoporosis runs more heavily in my family than breast cancer and Tamoxifen is better for your bones.

Alli

I met with the PS and BS yesterday and what has been suggested is BM/skin and nipple sparing followed 2 weeks later by implant placement above the muscle and use of Alloderm. The rationale for the 2 week delay is that the PS wants to see how my previously radiated skin heals. If it shows any signs of necrosis, then we would pursue plan B which would include Lat flap and tissue expander placed under the muscle.

Has anyone experienced this 2 week delay between surgeries to assess the skin's ability to heal and indicate if implant placement is likely to work?

DCIS Carol- I was recommended Tamox for 5 yrs after my first diagnosis at 36yo and premenopausal. I only took it for about 2 yrs due to hating the SE and wanted to have another baby. In the end, we ended up not getting pregnant and I never resumed taking it. regretting that decision now with my recurrence 10 yrs later.

Alli

malvernmama

Hi Alli. I just joined this website today and I'm glad to find this thread. I'm sorry about your recurrence. But good to know that it is still just DCIS.

I am in a similiar situation, except my recurrence happened just 2.5 years after my first DCIS diagnosis. In 2014 I had a lumpectomy + 33 days of radiation + Tamoxifen for 5 years. I was 43. I stopped Tamoxifen in Oct of this year when during a routine mammo they found microcalfications on the same lumpectomied breast.

I had a skin-sparing mastectomy. Lost the nipple. I had immediate reconstruction using Mentor silicone implants. I tried to go with a TRAM flap implant but because I had radiation, they couldn't use tissues from the right side of my abdomen, leaving only the un-radiated side. I didn't have enough "fat" to reconstruct an entire breast. And I only have an A cup originally. With the immediate reconstruction there were concerns about the quality of my skin because of previous radiation just 2 years ago. So I ended up with a much smaller implant that doesn't match my original breast at all. I could have opted for tissue expanders, but I didn't want to deal with another surgery months after. So I just did it all in one go last Nov 2nd. It's been five weeks and I feel like I have recovered well. I am doing some therapy on my arm to regain total movement range. I can't wait to start pilates again.

I am er/pr positive again. And I have seen two oncologists who both think that I shouldn't resume Tamoxifen because it didn't stop my recurrence. And it happened so soon. Only 2.5 years after. Both are suggesting AI such as Arimidex. But because I am still perimenopausal (I'm 46 now), I would need injections to kill my ovaries. Sigh.

I am very confused at this point. I have a friend who was er/pr+ DCIS about 13 years ago, and she didn't do any hormone therapy at all. And she is fine up to now. So Im actually thinking of not doing any hormone therapy this time. But with a seemingly aggressive type (grade 3), I think this is not a good idea.

If anyone has experience with using AI, ovarian suppression - for DCIS, perimenopausal... would love to hear from you. Thanks.

Moderators

Hi malvernmama, and welcome to Breastcancer.org!

We're sorry you have to be here, but we're really glad you found us. Thanks for joining and posting and we hope you get some answers to your questions soon. Please let us know if there's anything we can do to help while you navigate the boards.

Looking forward to hearing more from you soon!

--The Mods

Alli

malvernmama,

I'm sorry you have had to deal with a recurrence so soon. Glad you found BC.org This site has truly been a blessing to have during my BC journeys.

I think my PS expects to run into complications with my skin healing and that is the reason for no immediate recon. I am worried about increased risk of infection having 2 surgeries so close together. I am just trying to gain all the knowledge I can and also trust in my doctors that they know what the best course is in my situation.

Did you lose the nipple due to healing issues or was that the plan to start with? I'm sorry that the implant size was not what you had anticipated. I guess it would be an option down the road to have a revision if you choose to.

I honestly don't think that I will have to take Tamoxifen or AIs since I'm having the BMX unless some invasive cancer is found during surgery. I have not asked that question yet. I am also 46 and pre menopausal, ER/PR +

I have not met others that have taken AIs while pre/peri menopausal. Injections to suppress you ovaries doesn't sound pleasant either.

I'm sure the docs can lay out the risks/benefits for you for to help make a good decision.

There is a forum on this board about hormonal therapies and I bet you can find others with this same scenario there.

Best wishes to you!

Alli

Kartessa

15 years ago I was diagnosed with DCIS. I had a lumpectomy followed by radiation. Last year, I found a lump near the original site, was told that it was probably scar tissue, yesterday went for my annual mammogram, they saw something, decided I needed to do an ultra sound, and of course that led to a biopsy. My Dr. asked me why I hadn't felt the lump, I was so shocked that I didn't say anything but I thought it was scar tissue. Now I am waiting for the results. Just needing to talk to someone who might understand.

JoniB

Some surgeons may offer a second lumpectomy with iort at time of surgery. This would depend on size and characteristics of second malignancy. Not all surgeons will offer this option.

kkuziel

Just had biopsy for calcifications. Nurse navigator, from previous diagnosis, said if this is something I would need a mastectomy, which I had assumed. My timing of this stuff is horrendous. Second time in four years I'm looking at a possible diagnosis right before Christmas. Have appointment on December 22. Merry Christmas to me, not. My suggestion to anyone, and to myself from now on, is move your mammogram away from the holidays. Talk about taking the fun out of the season. Hoping for the best, very concerned I might be getting a "lump of coal" again this year.

Alli

Kartessa,

I don't believe there's any way I could find a lump in my previously radiated breast-very firm and nothing but lumpy.

Wishing you B-9 results!

kkuziel.

Going through this through the holidays is a real bummer! Did the same 10 years ago during the holidays. Only good part was being out of work which allowed me to spend the holiday with my family

Hoping no lumps of coal or cancer for you!

Alli

percy4

You know, I think about this. I had DCIS, no necrosis, grade 1 with non-aggressive microinvasion Nov. 2013. About to have my 3-year-since-diagnosed mammo. This is two months "late" and my HMO is nagging me like it's the end of the World, which it isn't. I simply wish to re-set my mammo date to early Jan., instead of late November, which is right before the Holidays and my birthday, which happens to be Christmas Eve. Anyway; back to point. I am turning 60 on this next birthday in 9 days (56 at diagnosis), my kids are grown, etc. Everyone in my family lives to be 98, so 60 should leave me a lot of time. Still. I have thought about what I would do if there was a recurrence. I never think about BC, except at screening time, when, for a week, I turn into a little puddle of mud. I refused hormone blockers. My recurrence chance was too low for me to live with the side effects. May have made a different decision if I had small children. I think if I have a recurrence of DCIS I would probably go with lumpectomy without rads. In my particular situation. I don't want to be chopped up like a turkey and I don't want the drugs. I would get the cancer out of me and move on. Happy Holidays and Life - P. xx

kkuziel

Nurse navigator called, all good B9. It's amazing to me how a call back or a biopsy just throws you right back into the panic zone. Guess we're never going to be prepared for the possibility of this crap returning. Thanks for the support. It's really the only place people really get it. My friends try, but even they admit they have no idea what I go through, what any of us go through. Very thankful there is a place we can be understood.

Alli

Kkuziel

Congratulations on you B9 result!!

danix5

How are you doing? Our stories are similar but I had bi lateral mx in 2008, total hysterectomy and ovaries removed, I found a lump Dec 2016, and here I sit recovering from biopsy to tell me hopefully by Monday if I have breast cancer again...

MWGal

I too am going through a similar situation. I was treated the end of 2014/the beginning half of 2015 for stage 2 bc with chemo, lumpectomy, then rads. Everything had been good until I pushed for a breast MRI after my mammo this past spring due to extremely dense breast tissue. They found dcis with micro-invasion. At this point, I was just like, get these things off of me and had a double mastectomy with expanders placed. No rads since I can't have that again. I have my exchange surgery in a couple of weeks. I am her2+, and was very disappointed I didn't even make it a full year after completing Herceptin before I had a recurrence. I am hormone negative so I don't have the option of taking estrogen blockers. I had always hoped I felt it came back it would be ER+.

Alli

Danix5,

Have you heard from your biopsy results yet? Where is your lump located? Hoping you get good news!

MWGal

So sorry you had to deal with a recurrence so soon after aggressive treatment. Hope you are healing well and this will soon be behind you.

I had my BMX on Friday and feel like I am doing reasonably well. I had nipple sparing and both nipples are dark purple but today the surrounding area of the left side (previously radiated side) is looking kind of red. I hope it's just bruising but I feel like there may be healing issues. Will get final pathology results on Thursday.

aquilegia

DCISCarol I'm in the same situation as you. Two earlier lumpectomies found DCIS 16 and 18 years ago, radiation and tamoxifen after the second one. Now DCIS (< 1 cm) found via mammogram in about the same location and confirmed with steriotactic core biopsy.

It's interesting that your surgeon is open to doing another lumpectomy -- mine is adamantly opposed to it. He feels it's too big a risk since I can't have a second radiation treatment. I told him I would be OK with a lumpectomy and then a mastectomy if they find any invasive cancer. His worry is that the next time it will be invasive and could have already metastasized by the time it's identified. I'm really torn - the fact that DCIS has come back 3 times tells me it's not a happy breast, but if the lumpectomy comes out clean I'm spared a disfiguring and painful operation (at least until next time).

Can you give me any insight into your decision process?

danix5

I feel you would be better off having the bilateral mastectomy. I am 9 years out from that surgery and just diagnosed again with BC. Had I not done the mastectomies my situation would be way worse. It is now IDC AND ILC still caught early when I went through it the first time,I thought I was being over treated. But now I know,if I hadn't done mastectomy hysterectomy and oopherectomy,my future would be much worse. Tiny tumor but 80% ER positive and HER2 positive.

I really didn't want a mastectomy, but did it and moved on now I face the beast again but with far less chance of cancer winning since I made the choices I made 9 years ago.

It was however one of the hardest decsicions I have ever made in my life. The left side continues to be the good boob no cancer there ever but I cut that one off too.

I wish you strength and knowledge in this very hard choice you are facing

cookiegal

hey y'all, I am waiting for results on a possible DCIS on my radiated and reduced breast from 09.

I am very interested in non-mastectomy options.

This is a small and older study, but it was interesting.

There is another study a little newer, I think a few more complications were reported, but still also promising.

But basically the world did not seem to end without the mast.

**********************************

The feasibility of a second lumpectomy and breast brachytherapy for localized cancer in a breast previously treated with lumpectomy and radiation therapy for breast cancer.

Chadha M1, Feldman S, Boolbol S, Wang L, Harrison LB.

Author information

• 1Department of Surgery, Beth Israel Medical Center, New York, NY 10003, USA. mchadha@chpnet.org

Abstract

PURPOSE:

With accumulating evidence supporting partial-breast irradiation, we conducted a Phase I/II study to evaluate the role of a second conservative surgery and brachytherapy for patients presenting with a local recurrence/new primary in a breast who has previously undergone a lumpectomy and external radiation therapy for breast cancer.

METHODS AND MATERIALS:

Fifteen patients with a localized lesion in the breast have undergone a second lumpectomy and received low-dose-rate brachytherapy on protocol. The first 6 patients received a dose of 30Gy. With no unacceptable acute toxicity observed, the brachytherapy dose was increased to 45Gy. Three patients received adjuvant chemotherapy and 8 patients are on antiestrogen therapy.

RESULTS:

The median time interval between the primary breast cancer diagnosis and the second cancer event in the ipsilateral breast is 94 months (range, 28-211). With a median followup of 36 months after brachytherapy, the 3-year Kaplan-Meier overall survival, local disease-free survival and mastectomy-free survival are 100% and 89%, respectively. There was no Grade 3/4 fibrosis or necrosis observed. All patients had baseline asymmetry due to the breast volume deficit from the second lumpectomy. With breast asymmetry as a given, the cosmetic result observed in all patients has been good to excellent.

CONCLUSIONS:

Early results suggest low-complication rates, high rate of local control and freedom from mastectomy. Additional studies are needed to establish whether a second lumpectomy and breast brachytherapy are an acceptable alternative to mastectomy for patients presenting with a localized cancer in a previously irradiated breast.

Tunegrrl

Very encouraging, cookiegal. Thanks for sharing!

A 7mm DCIS went missing in my breast (no longer appearing in scans). It is a real concern to me what will happen if it ever resurfaces or becomes invasive. My RO believes there is a 70% chance rads will deactivate the DCIS, and a 15% chance i'll need a mastectomy at some point in the future. For now, i'm just relieved i don't need a mastectomy right away.

Hoping for some advances in second-lumpectomy research before i need to make any more hard decisions.

cookiegal

Tune girl that is an interesting case.

I am just straight up guessing here, but I bet it got gobbled up in the lift.

(I had bi-lat reduction with my lump.)

I mean personally if I have a small DCIS I am ok with the 50-50 ods of the second lump.

I have a guess my onc will have a ton of reasons the brachytherapy is not the standard of care, but even the other more recent study looked promising.

Good luck with your treatment!

MinusTwo

Cookie - my MO insisted on chemo & the whole ball of wax the 2nd time. I'm guessing it's because I was not HER2+ and because it had recurred in a lymph node under my collar bone. May you be lucky.

ChiSandy

My 1.3cm IDC was located at 10:00 on my R breast (which while even then was the smaller one but still huge). Because of my age (almost 65 at the time) and the tumor being Stage IA Luminal A, my RO said I was a candidate for partial-breast (just to the tumor cavity) short-protocol (16 tx) hypofractionated radiation: he’d just finished participating in a study that found in women my age with my kind of tumor, whole-breast std. protocol (33 tx) conferred neither a disease-free survival nor an overall (mortality from all causes) survival advantage. So for me, it was a big “duh.” But a couple of months ago, I learned from my nurse-navigator at our monthly support group that it (or brachytherapy or IORT) also makes a second lumpectomy + rads feasible in the event of an ipsilateral recurrence or new primary tumor in an area that hadn’t been part of the original field. (I’d always assumed that a second ipsilateral tumor meant an automatic mastectomy).

cookiegal

Chi Sandy, those are all the things I am thinking about. I really would like to avoid the mast if possible.

On the other hand, I developed lymphedema after rads, and some reconstruction is beneficial for lymphedema.

At the end of the day I just want the fewest complications and the easiest recovery.

JoniB

I'm someone who had a second lumpectomy 8 years after my first one. Full breast radiation the first time IORT the second time. My cancers were small both times 3 mm first time and 4 mm the second time. I was shocked when the surgeon recommended this treatment. I'm one year out from my last surgery.

Tunegrrl

Thanks, JoniB! That is encouraging to hear