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Medical Forum / Diseases and Disorders / Breast Cancer / December 2003Quick recurrence
Hello, I'm a new poster with a question. On 8/29/2003, my mom, 49, had a lumpectomy for what turned out to be stage I ductal breast cancer. The sentinel node(s) they checked were clean, as was the perimeter of the removed mass. On 10/15/2003, she had her first round of chemo, after the initial cat scan, bone scan, etc, etc, to check for other cancer. These were negative. On 10/30/2003, she began to notice a sore lump in her throat, along with a fever. The fever had prevented her from taking a second round of chemo, and about a week later the doctor later took a biopsy, which turned out to be thyroid cancer. He didn't think it was a metastacized cancer, but a separate cancer. Now recently, around Thanksgiving, she developed a large and painful lump (approx 1 inch) at the very site of the lumpectomy. It was thought to be a seroma, but a biopsy revealed it to be a cancer recurrance. Needless to say our whole family is just utterly devastated by this constant string of bad news. This is the third time now in four months we've had to call up friends and family and spill the bad cancer news. Has anyone seen this before? What would be a possible explanation for how a cancer could grow so incredibly rapidly in 12 weeks, during at least one round of chemo at the same time, where a surgeon had removed cancer previously, to 'clean' results? Thanks, Marshal Funk One of the down sides of lumpectomy is a recurrences.....considering she hadn't completed the inital therapy and perhaps the margins weren't as clean as they would have liked and the radiation would have contained the growth. I would just assume that the cancer was fast growing . The good news it should not effect her overall survioral. Although this is rough time It sounds like the cancer was still in the early stages and prognosis is good. > Hello, > [quoted text clipped - 32 lines] > > Marshal Funk > Hello, > [quoted text clipped - 28 lines] > least one round of chemo at the same time, where a surgeon had removed > cancer previously, to 'clean' results? What terrible bad luck. I don't know anything about thyroid cancer, but getting bc, then that, then more bc, well I suppose they say these things come in threes! It is possible, even likely, that there was already a second undetected cancer growing close by in the breast at the time of surgery. Pain symptoms tend to be associated with fast growing cancers. It is not particularly uncommon for breast cancers to be multi-focal, that is to say that several cells over a small area become cancerous at about the same time. After all they are the same tissue, same genes, same environment, so perhaps what is surprising that they don't happen more. It is unlucky that it was not detectable. Chemo will not stop large fast-growing tumours, partly because it cannot get at some parts of the tumour. It works best on destroying very small tumours or single cells which have a lot of surface area in proportion to their volume. It is also good at shrinking slow-growing tumours, think of it as peeling layers off an onion. This doesn't help in her situation, but fortunately the problem should be treatable by further surgery. I would imagine a modified radical mastectomy would be the next choice. This sort of thing is, as Alex says, one of the risks of lumpectomy. It is not considered a serious drawback because it does not happen often and rarely affects the ultimate outcome. The prognosis after a second surgery is pretty much the same as after the first. Tim Jackson > What terrible bad luck. > [quoted text clipped - 17 lines] > fortunately the problem should be treatable by further surgery. I would > imagine a modified radical mastectomy would be the next choice. Hello Tim, To add to the above, we've got 3 ladies with papillary thyroid cancer on 2 newsgroups, one has a second cancer in her throat area (and has had to have 3 IIRC surgeries so far). There's 4 types of thyroid cancer (and/or sometimes mixed types) http://www.endocrineweb.com/thyroidca.html The good news is sometimes it's a nodule (or lobe) that can be removed surgically and continue to monitor and/or RAI. The good news is I don't think any of them respond to chemo. One of the types mentions mets to the skin. I've never seen nor heard of BC metastasizing to the thyroid...however, I have heard of thyroid tissue being found "anywhere in the chest area" (in animals specifically, and the vets I've discussed this with did not consider it "too far out" to think that perhaps this can also happen in humans) although none of us have specific info to confirm that's ever happened. Probably near (or of) the thymus which is part of the endocrine system.(a theory of mine I've not had a chance to discuss with the vets nor an endocrinologist). (Actually the vet I discussed this with the most, left her practice years ago to work in the laboratory for the local human cancer centre). So the pathology report(s) on the three sites (first lump, second lump and thyroid lump) would be very interesting and/or these are issues to be discussed with both the oncologist and the endocrinologist as to sites to watch for mets. There's an ACOR list serve for thyroid cancer http://listserv.acor.org/archives/thyroid-onc.html I'm hoping this poster's mother's thyroid cancer is the least aggressive and uncomplicated. I guess the poster will have to have a look through the above website and match what he knows about his mother's thyroid cancer and surgery to what is said there about treatments and followup etc. I'm sorry if I'm complicating things, but forewarned IMO is forearmed. J - not an expert First, thanks to everyone for your responses. > > It is possible, even likely, that there was already a second undetected > > cancer growing close by in the breast at the time of surgery. This is what the surgeon thought, as well. However, with a mammogram the day of the first surgery, and a thorough scan a few days before her first chemo treatment, I find it very disconcerting that neither found any sign of *either* of the next two cancers discovered. > > Pain symptoms > > tend to be associated with fast growing cancers. Her mammogram in April was clear, and yet by July she was already noticing a lump. Sounds fairly fast to me. Is it the speed of growth, or the time that the cancer is in the body that increases the risk of metastasizing? Maybe both? I.e., this latest tumor seems fairly large already... but I don't think has been around for a particularly long time. Would the one chemo treatment have also helped prevent any metastasizing? I guess I'm grasping at straws here for some reassurance. > > Chemo will not stop large fast-growing tumours, partly because it cannot get > > at some parts of the tumour. This makes sense, thanks. > There's 4 types of thyroid cancer (and/or sometimes mixed types) > http://www.endocrineweb.com/thyroidca.html > The good news is sometimes it's a nodule (or lobe) that can be removed > surgically and continue to monitor and/or RAI. > The good news is I don't think any of them respond to chemo. I assume you meant 'bad' news on the last part. It's a papillary tumor, which is the most common, I guess. Despite the lack of chemo, it can be treated fairly successfully with radioactive iodine, no? Thursday morning is her surgery in which they'll remove both the breast and thyroid cancer. I think they plan on just removing the whole thyroid. > I've never seen nor heard of BC metastasizing to the thyroid... Her doctors don't believe this to be a metastasized tumor, but seperate. Pretty amazing. The first two were caught fairly early. I'm not so sure about this latest one, which was apparently allowed to grow rapidly since July, assuming that's what happened. Thanks again, Marshal Marshall, I think the chemo would help prevent any metastazing but having it surgically removed will be the best help. Think positive your mom may do very well.Alex > First, thanks to everyone for your responses. > [quoted text clipped - 11 lines] > Her mammogram in April was clear, and yet by July she was already > noticing a lump. Sounds fairly fast to me. You can't measure growth rate by the transistion frem 'undetectable' to 'detectable' because you don't know how big 'undetectable' is, it depends on depth, form and breast size and density. You might be able to estimate it by rate of change of a visible lump. A clear mammogram does NOT mean no cancer, it just means that there is nothing visible to x-rays. A minority of cancers do not show up, or are not recognisable as such, on the x-ray image. I assume that this was one of those. As you observe, it seems pretty unlikely that it wasn't actually there at the time of the first surgery. As a rather long guess, I would suspect that cancers invisible to x-ray were less likely to metastatise. I'm not going in to why I should think that right now, it's more of a gut feeling really. > Is it the speed of > growth, or the time that the cancer is in the body that increases the > risk of metastasizing? Maybe both? I.e., this latest tumor seems > fairly large already... but I don't think has been around for a > particularly long time. Both, and other factors. Rate of metastasis has a strong correlation with tumour size, but tumour size alone is not a particularly good predictor for metastasis. > Would the one chemo treatment have also > helped prevent any metastasizing? I guess I'm grasping at straws here > for some reassurance. Probably. Tim > This is what the surgeon thought, as well. However, with a mammogram > the day of the first surgery, and a thorough scan a few days before > her first chemo treatment, I find it very disconcerting that neither > found any sign of *either* of the next two cancers discovered. It's a different scan for thyroid (one that uptakes iodine), if that's what you mean. > Tim said:> > Chemo will not stop large fast-growing tumours, partly because it > cannot get [quoted text clipped - 7 lines] > > I assume you meant 'bad' news on the last part. No, I meant "good". Who'd want to choose between chemo (for breast) or RAI (for thyroid) (ie decide which to treat first). OR have both at the same time? Not me ! > It's a papillary > tumor, which is the most common, I guess. Despite the lack of chemo, > it can be treated fairly successfully with radioactive iodine, no? Yes, although non-response (to RAI) or recurrence (or mets) are possible. Now here's where it gets "murky" in my brain. If they accidentally leave any residual tissue (for instance behind the throat area), then iodine uptake on scans would find a recurrence. If no tissue left, they'd have to watch (I think), thyroid hormone levels (after being put on thyroid medication) and maybe monitor/sample lymph nodes nearby if the thyroid levels don't stabilize within a reasonable time after starting the med. It's the pituitary that "asks" for more thyroid hormones. Endocrinologists can tell by the bloodwork what's happening (or not). So if she'd had to do chemo for the breast first, there could *potentially* be a long period of where any tissue left could continue to produce thyroid cancer cells. So the potential to spread to the neck lymphs would be higher. But she could be on thyroid hormone sooner and her thyroid stabilized. But since they (hopefully) removed all the thyroid tissue, she's going to do RAI, then after that can be on thryoid hormone, so there's a long period of not being on thyroid hormone..pre and during RAI, then while her hormones stabilize on thyroid med. So for your info and hers, she'll probably be hypothyroid..weight gain, cold, depression, anxiety, sleep problems, are some of the symptoms. Then after the RAI, it takes about one month (sometimes more) before the thyroid hormones restabilize..is my understanding from what the rad onc said on the other newsgroup. So could you imagine her having these symptoms http://www.endocrineweb.com/hypo1.html and side effects of chemo? Hence good news she does not need chemo... > Thursday morning is her surgery in which they'll remove both the > breast and thyroid cancer. I think they plan on just removing the > whole thyroid. I decided to hold my reply until after the surgery to see if that's what they actually did. > The first two were caught fairly early. I'm not so sure about this > latest one, which was apparently allowed to grow rapidly since July, > assuming that's what happened. I would say they did not get clear margins, because (IIRC) I'm told by said rad onc that "seeding" is extremely rarely if Nil, and since the person already (in theory) has little cancer cells in their body, so one more cancer cell would not cause such. It's interesting what Kaye said about lobular and the endocrine system. As I said before the path results might be interesting. FWIW J-not an expert > > I assume you meant 'bad' news on the last part. > > No, I meant "good". > Who'd want to choose between chemo (for breast) or RAI (for thyroid) (ie decide > which to treat first). > OR have both at the same time? Not me ! OR have to take two different types of chemo (one for breast and one for thyroid) at the same time... So another good reason, why no chemo for thyroid. J << Has anyone seen this before? What would be a possible explanation for how a cancer could grow so incredibly rapidly in 12 weeks, during at least one round of chemo at the same time, where a surgeon had removed cancer previously, to 'clean' results? Marshal, it definately sounds from what you describe that what is going on with your mom is very aggressive. It definately isn't the norm. It's hard to say though whether she had had undetected breast cancer that became aggressive. That can happen. One type, invasive lobular is more likely to metastasize to the endocrine system. Although you said she had stage I ductal, lobular often doesn't show up on mammograms. Sometimes a person can have a mixed type with both ductal and lobular. I had invasive lobular (pleomorphic--a rare aggressive variant) as well as DCIS plus a rare presentation of inflammatory breast cancer. They determined that this was what was going on pathologically after a mastectomy. The biopsy had only indicated invasive lobular. Just an update... My mom was in surgery for 8 1/2 hours Thursday for a total thyroid removal and a masectomy of the right side (with wide margins). The thyroid portion took a little longer than expected because it turned out to be somewhat inflamed (thryoiditis). Anyway, afterward the nurses kept commenting that she was very strong... which she is. The surgeon kept calling the new breast cancer a 'local site recurrence', and I'm wondering... how does he know it's only 'local'? He didn't really take any more lymph nodes for testing (because I guess the lymph nodes that the site would have drained to were taken in the first surgery?). So is this just a best 'guess' that it hadn't spread, since there were no lymph nodes to spread to? Just wondering what you guys think. Thanks again! Hopefully this is the day everything turns around for her. Marshal Marshal wrote << The surgeon kept calling the new breast cancer a 'local site recurrence', and I'm wondering... how does he know it's only 'local'? >> The surgeon is referring to the part removed. In order to know if it is beyond local, more scans will be needed, I presume. I am glad that the surgery went well--or as well as can be expected for your mom. I do hope she has a comfortable recovery. Wishing her all the best...and she is fortunate to have a concerned and interested son. Oh yeah, another thing... I don't think I posted this in my previous message tonight, but can't tell for sure since it hasn't shown up on Google yet :) The surgeon had an idea this morning before surgery that might have explained what happened.... He thinks that since the recurrence occured at exactly the same spot as the first needle biopsy... that perhaps during the needle biopsy, some cancer cells were transplanted, and 'seeded' the recurrence... I'm not sure how much I buy this, but maybe someone else will chime in? It seems to me that the site of the needle biopsy is what would have been removed in the first lumpectomy. :) Am I right, or wrong? Marshal << He thinks that since the recurrence occured at exactly the same spot as the first needle biopsy... that perhaps during the needle biopsy, some cancer cells were transplanted, and 'seeded' the recurrence... I think I read something to that effect once, but I thought it would take longer before a recurrence was visible, although from what you describe, what was going on was very aggressive. I was concerned about tumor seeding after my biopsy-only after my cousin (a former veterinarian with strong background in medical sciences who invented and developed the first small video camera (size of a quarter) that made procedures such as oscopy (i.e. laparoscopy) surgical procedures possible. My only regret was not investing more in the company which gave us a return of eight times our investment in 5 years--oh well, if we all had hindsight, oops back to what I was saying--he brought that possibility--probably would never have occurred to me with as little as I knew about breast cancer, let alone any cancer, at that time. So, in addition to everything else, when I think about it I do become somewhat concerned about the potential for local recurrence. By the way, there is a slight risk of tumor seeding along the path of a laparoscope for some procedures--which is probably why he was aware of that possibility. Then again, my imagination is ripe for seeing lots of possible scenarios--including the thought of tumor seeding from the needle used for tatooing marks for radiation. In my case, the mark made first was closest to the tumor site and then went on from there--at least 5 places. I guess this would not be a concern for most--but again in my case I had dermal lymphatic )skin) involvement. So, in the case of tatooes, if sharing needles between patients increases risk for hepatitis, it seems very possible that risk for tumor seeding might be increased if the same needle was used for all the tatooes, and the first tatoo was first done at or near tumor site if there were skin involvement. I don't know if that is of concern, but logic suggests that it is a possibility. And no, I am not worried about it--just a thought that did occur. In fact, I have more concern about the risk of tumor seeding from core biopsy done in 5 different areas (with same instrument, I believe) of an aggressive tumor and then no intervemming treatment until surgery 23 days later... |
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