The patient with the NSM for breast cancer (immediate reconstruction with pedicled LD flaps) developed metastatic disease, which was ultimately fatal but without any local recurrence identified (left multifocal grade 3 invasive cancer no special type {NST}, N0 {0/4 sentinel lymph node biopsy}, estrogen receptor {ER} positive 8/8, and human epidermal growth factor receptor-2 {HER2} negative). The gene discussed is ESR1; the disease is breast cancer.