Recurrence at core needle biopsy site
I had a double mastectomy 2 years ago. No chemo or radiation.
I recently felt a small lump right under the site where I had my original biopsy. My oncologist thought it was scar tissue, but a second biopsy shows it's a recurrence.
The cancer is small (5 mm) and well differentiated, however it's present in the dermis. It's looking like I am one of the very rare cases where recurrence is due to tumor cells seeding the needle tract during biopsy.
Anyone else ever had this happen? I'm wondering if the treatment approach is different since it is not a typical local recurrence.
Also, I know that when cancer has spread to the breast skin, that is considered Stage 3b, but again, I'm wondering if this is different in a case like this, where it didn't spread on its own, but was seeded to the skin.
Comments
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I had skin mets develop shortly after a biopsy as well. Staging is a weird with skin mets. For me it didn’t matter being stage 4 already (even though I had just one tumor outside of the breast at the time). I can’t say it was seeding that caused it but the timing is spot on.As for treatment they can remove the tumor and do a skin graft if necessary, they can do radiation (if the area hasn’t been heavily radiated already), or what’s called electrochemotherapy. I think there may also be a topical chemo lotion like thing, but I’m checking with my MO on this. Plus there is also regular ole systemic treatments. Mine is very aggressive and has spread over my entire right breast. It’s miserable. If I was in your shoes I would get the one tumor removed before it has a chance to do anything else.
What I worry about is having my chest port. If it’s accessed and their is skin cancer in my chest...could cancer cells be transferred to my heart via the port? Million dollar question...
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Thanks, Sierra! I hadn't heard of the chemo lotion. That's interesting. I'll bring it up with my MO.
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I read about it while search for info about skin mets so I’m not sure if it applies to BC. If you find anything else out please share
it seems like the skin mets world is small making it hard to find information.
Good luck!
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Why didn't you have chem
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I didn't have chemo because my Mammaprint was low risk (low risk of metastasis + low efficacy of chemo for my type of cancer)
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When I had my recurrence, I had one tumor at the original site and a second right where the needle went in for the core biopsy. They did not say that was the reason, but since no breast tissue was found, and it was growing in the soft tissue, a safe assumption is that it was seeded from the original biopsy. I would encourage you to do the oncotype or mammaprint. The first time, my oncotype was 16. The second time it was 40. Don't let them assume it will be low risk again. It took me asking 2 different oncologists; the first, at a well known major medical center told me it was unnecessary because it was an isolated low risk recurrence, and he was "sure" it would be low again. He changed his tune on chemo when he heard the resutls.
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I think any seasoned and knowledgeable MO would want to retest across the board with a recurrence no matter the location. BC can change and go from ER+ to ER & PR + or be negative across the board on top of the oncotype. I don’t think this happens often, but it does happen and you don’t want to fall through the cracks of assumption.
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Thanks, KBeee. That is alarming! I will definitely insist on Oncotype/Mammaprint testing.
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Mine went from PR+ to PR-. Testing that was no issue. The doc at the well known medical center was sure that my local docs must have just missed some of the cancer. He would not even order the oncotype if I offered to pay (my insurance did cover it). He was "certain" that radiation and then an AI would be good enough. It is frustrating to have to advocate for yourself, and hopefully your docs will order the test without you having to fight for it, and not give you the "but it is just a small recurrence" garbage. Sorry you are facing this again, but glad that you caught it. Hoping you have a plan in place soon. If my oncotype was low, the plan would have been radiation, then oophorectomy (or ovarian supression) plus an AI. Since it was high, it was chemo then radiation then AI. I did have my ovaries removed in there too.
Hoping you meet with the surgeon and MO soon to get a plan of action. Once my plan was in place, it was easier that being in limbo land.
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Why the oopherectomy? Because your tumor was strongly ER+?
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Yes; I needed either ovarian suppression for 10 years or oophorectomy, so I chose to have my ovaries and tubes out. This way I do not need to worry about ovarian cancer. I am not BRCA postive, but do have VUS in CHEK2 and a horrible family history.
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I am a firm believer in biopsies seed/spread cancer. It only takes 1 cell to be viable and lead to metastasis. That was the reason I wanted an excisional biopsy but all the surgeons I saw, claim biopsies do not seed or spread cancer. I disagree,.I had bilateral IDC with 2 needle core biopsies.
Prior to the biopsies, there was no lymph involvement. (according to the ultrasounds and palpation exam) After the biopsies, my cancer spread to my lymph nodes (palpable as well as ultrasound visibility) Because of the lymph involvement I was not able to have immediate reconstruction this cancer spread to my lymph nodes and grew to 2.6 cm in 9 days, then burst. They called it extranodal. This required me to have the axilliary disection and remove all my level 1 and 2 lymph node, radiation, and chemo after my bilateral mastectomy. I probably would not have had chemo or radiation and would have completed my treatment with in months... Now I am still dealing with treatments and surgeries for reconstruction and lots of damage from radiation and neuropathy from the chemo, and a very high risk of lymphedema, but I am alive.
I know there are no guarantees in this business, but this really bothers me that I was unable to get an excisional biopsy and for you guys to have to deal with these recurrences, most likely because of the biopsy. I know that an excisional biopsy poses other problems, but in my case, it would have been in my best interest not to have radiation, chemo, and lymph node dissection.
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I'm so sorry for what you went through (and are still going through). I had an ALND the first time round and it was the roughest part of my surgery/recovery.
I know that doctors tend to downplay the risks of tumor seeding via biopsy, but the medical literature shows it happens. Maybe it's relatively rare, but there are case studies out there and the medical community has always understood it to be at least a theoretical risk. My dad, who is a retired breast surgeon, knew it to be a possibility, although he's never seen it before.
What bothers me is that the literature on this suggests that the biopsy site/needle tract should be excised, but this is not standard of care. If the skin there had been excised, I wouldn't be dealing with this! It's upsetting, to say the least.
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If they do not excise it and there is no radiation, then there is not much to stop the spread. I think with the current "less is more" approach, that we may see more of it in the future. It's hard to say though where to draw the line as far as treatments. Frustrating to say the least.
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I too had a recurrence at the biopsy site. I had my DMX in March 2018. August of 2018 I went in for exchange surgery and mentioned to the surgeon a worm like growth from the biopsy scar. It was cancer which had also spread to the chest muscle. Surgeon was not able to get clear margins. In October 2018 I went in for an additional surgery with my breast surgeon and plastic surgeon to get clear margins. Additional skin and slices of my muscle were taken. I was told it looked like normal tissue. Pathologist comes back with margins not clear cancer is everywhere microscopically and is now in the lympho vascular system. Originaly my onco score was 15 so no chemo and no radiation with negative lymph nodes. But now with recurrence and lympho vascular invasion I am doing chemo then another surgery and then 33 rounds of radiation. I have gotten a second and third opinion from completely different hospitals and was told recurrence from biopsy or at biopsy site is rare less than 1%. One surgeon told me that a breast surgeon will only see one case in their entire career. Other opinions agreed with treatment I am receiving.
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why didn't you receive radiation the first time around, if I may pry?
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No lymph node involvement and I received a double mastectomy so I did not need radiation.
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Sorry for what you're going through SewBze! I'm meeting with my oncologist and surgeon this week. And my case is also being presented at a tumor board at UC Irvine, so I'm waiting to see what they'll recommend. I am anticipating radiation. Not sure about chemo. Will probably depend on my Oncotype. Everyone keeps saying how rare this is, but I've already connected with multiple women this happened to. I wonder if we'll see more of this now that mastectomy without radiation is more common.
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mellee, I just saw this thread. Any updates on your treatment plan?
I had my BC spread into the skin at the needle biopsy site too. I had a chest wall resection with a skin graft this year, and had to have a second course of radiation and more chemo. I also started ovarian suppression and will start an AI because I recurred while on tamoxifen. My cancer was high grade and high oncotype though - so they really had to hit it hard. At this point I'm only locally/regionally recurrent (PET scans are clear), so they also hit it hard in hopes of still "curing" me.
Anyway, I just wanted to offer some support and encouragement to you. It seems that although it's rare, this unfortunately DOES happen too often! Please let us know how things are going.
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I also want to chime in and say I do believe that there is such a thing as seeding from needle track in biopsies. While I have not been diagnosed with a recurrence, the two tiny IDC spots in my mx report where found exactly where the two biopsy needles went in. The rest was extensive DCIS. My surgeon insisted on radiation after mx and I suspect this was also one of the reasons, besides the extensive DCIS.
Another seeding site according to my RO is the area where the drainage tubes come out after surgery.
Can I relax a little knowing I had radiation? I'm afraid to...
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I've posted this elsewhere, but MD Anderson did a small study on this recently. Here is the abstract and link:
https://link.springer.com/article/10.1007%2Fs10549-017-4401-7
Abstract:
Purpose
To identify clinicopathologic, technical, and imaging features associated with neoplastic seeding (NS) following image-guided needle breast biopsy.
Methods
We performed an institutional review board-approved retrospective review of patients presenting with a new diagnosis of breast cancer or suspicious breast findings requiring biopsy with subsequent diagnosis of NS. The time from biopsy to NS diagnosis was calculated. Histology, grade, estrogen receptor (ER) status, progesterone receptor (PR) status, HER2 status, T category, and N category were recorded. Biopsy guidance method, needle gauge, and number of passes were reviewed in addition to the mammographic and sonographic features of the primary tumors and the NS.
Results
Eight cases of NS were identified in 4010 patients. The mean time from biopsy to NS diagnosis was 60.8 days. The most frequent histology was invasive ductal carcinoma (7/8). Six cases were grade 3 (75.0%). Five primary breast cancers were ER, PR, and HER2 negative (62.5%). Seven patients underwent biopsy with ultrasound guidance. Multiple-insertion, non-coaxial ultrasound-guided core-needle biopsy was done in 6 cases. Mammographic presentation of NS was focal asymmetry (3/7 cases), mass (1/7), calcifications only (1/7), or occult (2/7). Sonographic presentation of NS was most often a mass (7/8) with irregular shape (5/7) and without circumscribed margins (6/7) and was occult in 1 case (1/8). NS distribution was subdermal and intradermal.
Conclusion
High-grade, triple-negative breast cancers and multiple-insertion, non-coaxial biopsies may be risk factors for NS. NS should be suspected on the basis of the superficial and linear pattern of disease progression in these patients.
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This whole seeding topic makes me very uneasy. I also believe this happens and unfortunately, I had both needle and core biopsies the same day and they took several samples from each method. I believe that may be how the 2 tiny micromets made it into my first of eight sentinel node. My doctor said that the lymph system was just doing what it is supposed to do by possibly picking up the residue from the procedures that were done 3 weeks before my lumpectomy. Who knows...that may not be why I had micromets but I will always wonder. Glad I did have radiation.
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Agreed that this makes me wonder how much of the benefit of radiation is cleaning up after their own mess. Not that I'm not grateful for it. I'm glad I was able to have BCS. But I'm glad they're doing more research into it and hopefully can figure out ways to make biopsies even safer.
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buttonsmachine, thanks for your support! I haven't finalized my treatment plan (although surgery is a given, and hopefully will happen within the next 2 weeks). With the holidays and a switch in my insurance, everything has unfortunately been delayed. My surgeon thinks the surgery will be very simple (knock on wood). Most of the recurrence was already removed during the original excisional biopsy, but the margins weren't clear. So he's going to go in and do a wide excision. My oncologist wants me to strongly consider radiation. She doesn't anticipate that I'll need chemo, but we're still waiting on my Oncotype to come back. I'll update when I get the recommendations from UC Irvine's tumor board. I'm also going to get some second opinions from another MO and RO. I will keep you all posted. Thanks for all the feedback and support!
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So after a month of waiting, the lab finally came back with my hormone results. I am only weakly positive for ER/PR this time, with 10% for both with weak staining (My original tumor was ER 100% PR 98% with strong staining). The Her2 was indeterminate.
I had my surgery on the 10th, and there was enough cancer left to rerun pathology. They will also be running Oncotype.
The UCI tumor board believes this is a heterogenous tumor that doesn't respond to tamoxifen. They say I definitely need radiation and may also need chemo. They don't believe the Oncotype offers much guidance in my case. They also recommend I consider ovarian suppression plus Aromasin. I'll be meeting with an oncologist at UC Irvine, as well a top oncologist here in LA. We'll see what more they say. Honestly, I'm reeling a bit by the chemo possibility, and the ovarian suppression. I definitely wasn't expecting either one. Really worried about the ramifications of all these treatments.
I already have lymphedema in my upper arm. Scared it will get worse. The side effects of ovarian suppression also freak me out. Also, I'm doing relatively well on tamoxifen, so I'm not keen on the idea of switching to an AI.
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If you recurred on Tamoxifen, it did not work for you. When I asked how my hormone profile changed, I was told that the Tamoxifen worked on the strongly ER, PR positive cells, but it did not on the others, and they were aggressive and grew. In those cases, chemo tends to work very well to keep is from spreading and metastasizing. If ER and PR are such a low percentage, oncotype will recommend chemo. The cutoff for triple negative is 5%, so you are close to that. Second opinions are always useful thoguh.
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Yes, that's what they said about my recurrence. It's the cancer cells that didn't respond to tamoxifen. It's strange though because it wasn't an aggressive recurrence. It's Grade 1 and didn't get larger in the 9 months my oncologist was monitoring it. I'm very upset my MO dismissed it for so long, because now I'm wondering what happened in the time it was allowed to hang around in my body. But there wasn't any lymphovascular invasion or other bad signs. So hopefully we still caught it early enough.
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Thanks for sharing Mellee. Just wanted to chime in that ovarian suppression may not be a bad experience. Sounds like you tolerated Tamoxifen well so maybe the same experience with Ovarian Suppression. I'm on Zoladex and have tolerated it well so far, a shot every 3 months. Also on Tamoxifen and while it is early days, doing fine in terms of SEs.
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Mellee, I'm glad you're able to get multiple opinions. It seems like they are being thorough and taking good care of you.
I had a similar experience to Palesa in the sense that ovarian suppression has been okay for me. I've been on Zoladex for about seven months now. (I haven't started my AI yet because I've been on Xeloda, but I will soon.) So far my side effects are actually less than when I started Tamoxifen. I did well on Tamoxifen too, after an initial adjustment period. My oncology nurse practitioner once told me that often the effects of hormone medicine subside with time. I didn't believe her at first, but in retrospect that was my experience with both Tamoxifen and Zoladex.
Thanks for keeping us posted, and I'm wishing you the best.
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Also, did they give you any indication of what chemo drugs they might be considering? Just curious. I've heard that sometimes chemo isn't super effective on low grade cancers - but as KBeee pointed out, chemo tends to work well on low hormone receptor cancers. You do have a unique situation, it seems. In any case, it's great that they didn't find any lymphovascular invasion.
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