She was 25 years old when she was first diagnosed with breast cancer. She was tested and has the BRCA1 mutation. Following chemotherapy, radiation, and tamoxifen, she continued to live life to the fullest. Today, 13 years later, she is facing an unusual presentation of breast cancer recurrence in her reconstructed breast. She was the main topic of our tumor board discussion last week.
The patient had presented to her plastic surgeon after noticing a change in her breast implant contour. As she previously had had skin sparing total mastectomies, there was no preoperative mammogram. During the surgery to replace the implants, the plastic surgeon noted two firm masses and both were removed for tissue evaluation. Everyone on her breast care team was surprised to learn that both lesions were malignant and large at 4.3 cm in greatest dimension. This was most unusual and particularly since it has been 12 years since her original diagnosis. Local recurrence of cancer after mastectomy and immediate breast reconstruction is generally regarded as a poor prognostic indicator.1
What is interesting about this patient is that she also has a history of ulcerative colitis and had been placed on adalimumab (Humira). This may have been quite useful for her ulcerative colitis, but may be complicit in causing immunosuppression, allowing for the perfect environment for a second cancer to thrive.
What we know from the literature is that not all local recurrences will be the same and time intervals will vary greatly. Also, immediate breast reconstruction while it can conceal a chest wall recurrence, does not seem to delay detection and intervention—but a chest wall recurrence is highly associated with metastatic disease, and the survival rates are not favorable (ranging from 45% to 61% over 5 years).2
The breast care team has decided that the best course of action at this point is to return to surgery, remove both implants, retain the skin, but remove the pectoralis muscle. Perhaps a course of radiation to the side with the original masses may help local control. The patient must again face more surgery and some difficult decision making about her future. As the nurse navigator, I will be walking beside her along the path of this new journey.
Langstein HN, Cheng MH, Singletary SE, et al. Breast cancer recurrence after immediate reconstruction: patterns and significance. Plast Reconstr Surg, 2003 Feb;111(2):712-20; discussion 721-2.
Yang X, Zhu C, Gu Y. The prognosis of breast cancer patients after mastectomy and immediate breast reconstruction: a meta-analysis. PLoS One, 2015 May 29;10(5):e0125655.
Male breast cancer accounts for about 1% of all breast cancer cases in the United States, therefore it can be a shocking diagnosis. During my career as a nurse practitioner in the field of breast oncology, I have been involved in the care of only five male breast cancer cases over the last 25 years.
FDA Approves Onivyde for Advanced Pancreatic Cancer Marijke Vroomen Durning, RN, 10/27/2015 3 On October 22, 2015, the US Food and Drug Administration (FDA) approved Onivyde (irinotecan liposome injection, Merrimack Pharmaceuticals, Inc.), in combination with fluorouracil ...