multifocal cancer

Hi

 I had 3 areas of the breast involved - one was a lymph node and one was 3 cm. (they never talked about the other one so i guess it wasn't much.) I was stage llB. I had chemo first (4 A/C) then a mastectomy, then 2 more chemo (A/C - allergic to Taxotere) then rads. That was 6 years ago and so far, so good!

Good luck with your treatments.

Barb

Hi, Jess ~ I had multicentric bc.  Originally, they though I only had 1 lesion, but when the pathology from my lumpectomy and SNB said that the bc found in my positive node didn't totally match the tumor cells, I went for a second opinion, and a new (better) MRI came up with 2 additional lesions.  I was told the standard of care for multicentric bc is a mastectomy, and thank God that's what I did (with immediate Diep recon), because the path from that surgery found a 4th microscopic spot.  Mine was also a combination of ductal & lobular.

I did 4 rounds of TC and I also did RT, which was recommended based on a 1mm unoriented margin on that tiny 4th spec they didn't know was there, as well as extracapsular extension in the lymph node.  I also learned in questioning the recommendation for rads, that RT w/a mast is the newer, more aggressive approach that some institutions are now starting to follow, especially if there are any issues like positive nodes or minimal margins.

Hope this info' helps you with whatever you're trying to figure out ~  Deanna

Dear Jess,

To answer your question, I had delayed reconstruction with TE/cohesive gel implant five years after my treatments. While one PS advised against TE/I, another university center PS agreed to try, as my skin showed few signs of radiation damage. I am now 3 years out without problem.

Please realize the issue of PMRT (post mastectomy radiation therapy) in women with 1-3 nodes is widely debated as no definitive prospective study has ever been completed or had enough participants to bring a reasoned answer forward. Thus as a patient, you will hear strong opinions one way or the other depending on the specialist's view. This may even apply to why your own doctor does or does not suggest PMRT.

The main referenced association guidelines on PMRT are available at the National Comprehensive Cancer Network (NCCN), the American College of Radiation Oncology and American Society of Radiation Oncology, amoungst others. Beyond these guidelines are valuable retrospective reviews, meta-analysis, and individual large institutional reports from which much insight may be gleaned to grasp the depth of the question: does post mastectomy radiation truly aid in reduction of local recurrence (best evidence points resoundingly to "yes") and does it increase absolute (individual) survival (best evidence, in my view, points to yes for those with fewer nodes surprisingly). This is an incredibly individual decision with your doctor. Here is one well-respected radiation oncologist's recent writings on this matter:

Department of Radiation Oncology, Duke University Medical Center, Durham, NC

http://jco.ascopubs.org/cgi/content/full/26/13/2075

Lastly, you ask about feasibility with tissue expander in place, so I offer you Monica Morrow and colleagues recent abstract from Fox Chase Cancer Center, Philadelphia for review should you elect PMRT:

PURPOSE: The purpose of this study was to evaluate the likelihood of complications and cosmetic results among breast cancer patients who underwent modified radical mastectomy (MRM) and breast reconstruction followed by radiation therapy (RT) to either a temporary tissue expander (TTE) or permanent breast implant (PI). METHODS AND MATERIALS: Records were reviewed of 74 patients with breast cancer who underwent MRM followed by breast reconstruction and RT. Reconstruction consisted of a TTE usually followed by exchange to a PI. RT was delivered to the TTE in 62 patients and to the PI in 12 patients. Dose to the reconstructed chest wall was 50 Gy. Median follow-up was 48 months. The primary end point was the incidence of complications involving the reconstruction. RESULTS: There was no significant difference in the rate of major complications in the PI group (0%) vs. 4.8% in the TTE group. No patients lost the reconstruction in the PI group. Three patients lost the reconstruction in the TTE group. There were excellent/good cosmetic scores in 90% of the TTE group and 80% of the PI group (p = 0.22). On multivariate regression models, the type of reconstruction irradiated had no statistically significant impact on complication rates. CONCLUSIONS: Patients treated with breast reconstruction and RT can experience low rates of major complications. We demonstrate no significant difference in the overall rate of major or minor complications between the TTE and PI groups. Postmastectomy RT to either the TTE or the PI should be considered as acceptable treatment options in all eligible patients. 

My best to you in a tremendously individual based decision. 

Tender 

I had multifocal, multicentric IDC and DCIS in right breast, and multifocal DCIS in left breast, but thankfully I was node-neg. I had a bilat mastectomy, chemo and Herceptin. I'm now on Arimidex. If I had had one positive node, my breast surgeon and my onc. both said they would've recommended radiation.

I had multifocal, multicentric IDC and DCIS and LCIS in my left breast.  I had a bilat mastectomy due to family history concerns and my right breast was cancer free.  Thankfully they removed 2 sentinal nodes which were both neg.  I was able to have the oncotype test done (15) which showed a 10% reoccurance if I take Tamoxifen.  This meant that Chemo would not improve my chances of reoccurance so no Chemo.  I just went to my radiologist today and was expecting to need Rads but he said because my margins were clear, no nodes positive and I had a mastectomy that radiation wasn't needed either.  I will start Tamoxifen in a few days.  I hope this helps.  I could not have asked for a better treatment, I just hope it is enough to keep me cancer free.  I feel in my heart that this is the right treatment for me.  God Bless you and stay strong.

I had 6 masses and 5 were primary (multifocal).  I had to have a mastectomy in the affected breast and I chose to go ahead and have the unaffected removed as well (prophylactic).  I do have to have chemotherapy but do not have to have radiation because the margins are clear and my nodes are clear.  I do have to have chemo because it was multifocal, because I am young and because two of the masses were larger in size (2.0 x 1.0. 1.5 cm and 1. 0 x 1.0 x 1.5cm).  Paula

(hi Jess!)

I had a multifocal ILC and had first a lumpectomy of a 1.7 cm mass, then a mastectomy.  I chose to have the cancer free breast removed as well (prophylactic).   At least 10 other masses were found in the infected breast and all were quite small, except the largest which was about 1cm.  My Onc said the standard is not to add the masses of the two largest lumps when there is more than 1 surgery, but he said it is unknown if they were the same lump initially.  If they were, my major lesion size would be closer to 3 cm.  That might warrant rads, since 2 lymph nodes were involved as well. 

My margins were clear technically but I am not sure if it is known how wide they were.  My mastectomy path report does not seem to be as specific or detailed as the one formy lumpectomy, unless I am not understand the language or codes. 

My PS assures me that rads will destroy my implant surgery but I keep finding evidence to the contrary.  My fella thinks the PS is great but I have thought about shopping around for a while.  This could be the deal breaker with him for me.

There is a lot to think about.  I had surgries in Oct. & Dec. of '08 with lengthy recoveries, then chemo from Jan. 9 until this afternoon.  Rads would have to be done over the lunch hour or I would likely lose my job.  After all I have been through, I just don't think I can handle skipping lunch and going back to busy and demanding job everyday, while continuing to recovery from chemo, especially, if the rads will make me tired too.  I'll need time to visit various doctors too.  This really puts me in a logistical bind.  I am taking Scarlett O'Hara's lead and will think about it all tomorrow.  Tonight I just want to feel good about finishing chemo.

Nancy 

jrg- good to take your time.  You have to do what's right for you. 

I was originally diagnosed with Pleiomorphic  Lobular Invasive Carcinoma based on biopsy of 2 lesions seen on mammogram and biopsy. MRI showed 3 more lesions, so total of 5 lesions in one quadrant. My surgeon recommended mastectomy which is what I had done. I figured my remaining breast would be so deformed I'd be better off just taking it off.  Mastectomy path showed a total of 10 tumors scattered throughout--mostly DCIS. All the invasive disease turned out to be ductal. Thankfully, my 3 sentinel nodes were negative. My oncotype score was only 13 so I opted to not have chemo. I'm on tamoxifen now and don't feel any differently which is a relief. I'm struggling with whethor or not to have a prophylactic mastectomy of the other but probably will hold on to it, at least for now.