Mom just diagnosed dcis 9 cm reoccurrence

Val91668

Hi. My mom is 72 and had dcis 2 years ago and had a lumpectomy and radiation. Last week they did an MRI and found a 9cm mass in her duct. Same side as first diagnosis. Her doctor said it's contained in the duct and can't schedule her mastectomy for 4 weeks!!! My mom told her she had some shoulder pain and breast pain over the past week or two and is worried it has spread. I think 4 weeks is a long time to wait for a mastectomy for a 9cm mass. They said they will test the nodes when she has he surgery to see if it has spread. Can anyone tell me their thoughts on this? I am wondering why they can't give her a pet scan to see if it has spread and then if it has they should do the surgery sooner. I am very worried. Any info would be appreciated. Thanks.

Valerie

marijen

Hi, so they did nothing in between from radiation until now? NO aromatse inhibitor? In four weeks you can take her somewhere else to get a second opinion? And/or a new doctor. Yes, they should see how far it's spread. Willthey take out some lymph nodes

MinusTwo

Valerie - what is her ER/PR status? Obviously she wouldn't an aromatise inhibitor if she's negative. No, I don't think 4 weeks too long to wait for a mastectomy. But I agree that a second opinion might be in order.

Artista928

It's hard to guess without knowing her ER/PR/Her2 statuses. Certainly get a second opinion. GL

BarredOwl

Hi Marijen:

Re your comment: "Hi, so they did nothing in between from radiation until now? NO aromatse inhibitor?"

Are you suggesting that her prior treatment plan was deficient because she did not receive an Aromatase Inhibitor ("AI", a type of "endocrine therapy") after radiation, and therefore she should not trust her doctors now? She may still choose to seek a second opinion if she wishes, but I see no basis here to conclude that there was a deficiency in the prior treatment plan.

Please note that a person who had pure DCIS in 2015, who received lumpectomy plus radiation, may not have received any endocrine therapy (Tamoxifen or an AI) for good reasons. Such a treatment plan would be within 2015 guidelines.

For example, endocrine therapy would not be indicated if the prior DCIS was hormone receptor-negative (ER- PR-). Those with hormone receptor-negative pure DCIS would not typically receive a recommendation for endocrine therapy (Tamoxifen or an AI) to reduce recurrence risk in either 2015 or 2017.

If the prior DCIS was hormone receptor-positive, a treatment plan of lumpectomy plus radiation with no endocrine therapy would have been within 2015 guidelines. This is because in 2015, NCCN guidelines (Version 3.2015) provided that patients "consider Tamoxifen" as an option, if ER+. The 2015 guidelines for pure DCIS did NOT include the option of an Aromatase Inhibitor, and included Tamoxifen only for all women regardless of menopausal status. (NOTE: Current 2017 NCCN guidelines (Version 2.2017) now do include the option of an Aromatase Inhibitor for post-menopausal women with pure DCIS, in light of recent clinical trial publications.)

Tamoxifen might have been contraindicated due to certain co-morbidities. If Tamoxifen was a suitable option, it still might not always be warranted or elected for DCIS following lumpectomy plus radiation. Because pure DCIS is non-invasive, the main rationale for and risk addressed by endocrine therapy for pure DCIS is local. The main benefits for pure DCIS are reducing the risk of new or recurrent same in-breast or new contralateral disease. Depending on their personal risk profile, for some patients, the size of the potential risk reduction benefit might not be seen to sufficiently outweigh the risks, in light of their personal risk tolerance.

BarredOwl

[Edit: Fixed formatting and punctuation]

BarredOwl

Hi Val91668:

RE: "Last week they did an MRI and found a 9cm mass in her duct . . Her doctor said it's contained in the duct."

Her current diagnosis is not entirely clear from the information. I recommend that she obtain complete copies of her pathology reports from all recent biopsies, and share them with you, so you can check if her current diagnosis is all DCIS or if there is any evidence of invasion.

Was the mass biopsied?

Do you mean 9 centimeters or 9 millimeters? Is this estimated extent of disease biopsy-proven, for example, by taking cores from different areas 9 cm apart?

IF the biopsy showed pure DCIS (which is confined to the inside of the ducts or "noninvasive") and no evidence of any invasion, then a four-week wait for mastectomy seems reasonable (even for an estimated 9 centimeters of DCIS). As noted by others, she may wish to seek a second opinion during this time.

The pathology report on biopsy for DCIS typically provides grade, ER and PR status, and describes the appearance or architecture of the cells in the duct (e.g., solid, cribiform, etc.). DCIS is not typically tested for HER2 status, because HER2 status does not affect treatment options for pure DCIS.

DCIS is "noninvasive" and so does not ordinarily pose a risk of distant spread. Because the chances of distant (metastatic) spread are so low, patients diagnosed with apparently pure DCIS and who have no symptoms of concern appropriately do not receive such scans under current guidelines.

Sentinel node biopsy ("SNB") is being recommended because mastectomy disrupts the lymph channels needed to perform and identify the sentinel node(s). Patients confirmed by surgical pathology to have pure DCIS are expected to be node-negative. However, per ASCO, among patients diagnosed with apparently pure DCIS by minimally-invasive biopsy, about 10-20% overall will be found to have some invasive breast cancer (about half of which are very tiny microinvasion). The lymph node status info will be used for staging and treatment decisions if invasive disease is found.

On the other hand, if the biopsy found any INVASIVE breast cancer (e.g., invasive ductal carcinoma ("IDC"), invasive lobular carcinoma ("ILC"), or other types), then you will need more information at this time, such as the size of the invasive tumor, and its ER, PR and HER2 status, to make informed decisions about work-up, treatment plan and timing. For example, with larger invasive tumors, particularly triple-negative (ER-PR-HER2-) or HER2-positive invasive tumors, patients should consult a Medical Oncologist prior to surgery to determine if they are a suitable candidate for neoadjuvant drug treatment administered PRIOR to surgery.

BarredOwl