re-excision/clearing margins

i know how upsetting this is.  i do not think your situation is unusual.  i had a chest wall tumor of 1.2cm that was 1mm from the chest wall.  my surgeon got 1mm margin and considered that a clear margin. however, the pathologists on the tumor board and my medical oncologist at UCSF said that they consider clear margins to begin at 2mm, especially for chest wall tumors. i had the choice of additional surgery or radiation (i already knew i was having chemo). i chose radiation because i wanted to feel like i had done everything possible to eradicate every cancer cell at the tumor area and also any that had spread in the chest area. if my case had not gone to the tumor board and if i had not gotten a second opinion at UCSF, i would never have known that 1mm is not considered clear margin for chest wall tumor, and i would not have had the option of additional surgery or radiation. i am very grateful that i found this out.

Thanks for the information about the re-excisions.  I have to have one because I showed calcs on the mammogram after my first lumpectomy.  It is helpful to know that they aren't that unusual.  Not looking forward to the needle localization again though but I will get through this and keep positive thoughts that my mammo will not show any calcs so I can start radiation.

I experienced similar confusion, at least in my mind, as to what constituted an adequate margin.  My first "lumpectomy" (perhaps more correctly partial mastectomy since there was no lump) yielded a .1 mm margin.  The surgeon felt that was a clear margin but probably too small to be conclusive.  He tried again -- this time 1 mm. He was prepared to go ahead and send me on for radiation and possibly tamoxifen but I wasn't satisfied. (He assumed from the start that I wanted him to minimize the amount removed presumably for cosmetic reasons but that was the farthest thing from my mind), I  went for a second opinion at a major center and quite frankly although they reassured me in the sense that the local team was on target, it was clear that even to them there was no single right answer -- go for larger margin (the literature suggests at least 2 mm as noted above) or let radiation take care of things.  I was set to try for a larger margin and then we realized (my husband and I discussed things all along) that I wasn't going to be satisified no matter what since I wanted to get rid of it all if possible and avoid radiation etc and the possibility of DCIS skipping around -- so I opted for a single MX. I also cancelled out meeting with a plastic surgeon -- I wanted to do as little as possible to remove as much cancer as possible -- two goals in partial conflict. So far so good -- that was January and all tests on both sides indicate no further problems -- the MX showed completely clear margins but with lots of precancerous stuff -- glad to be rid of it -- and MRI of the other breast shows no indications of problems at this time. I didn't have to go through any radition and am sticking to surveillance to avoid tamoxifen.  But I have to live with the consequences of the MX and having only one breast. I'm thinking of recontruction or prosthesis and/or breast reduction on the other side but also thinking I like to stay out of hospitals as much as possible so I may cancel my scheduled plastic surgery since I seem to be adjusting more and more to the missing breast and scaring (the initial bumping seems to be reducing -- as time goes by.  Good luck and as much as it doesn't seem that way we are lucky they found it when it was still DCIS. (But I agree with the books that say always get another opinion!)

Sorry ookie have now read down to the bottom and realised you posted an update in August!  Doh........Glad to hear you had a positive outcome - am off now to do more research (but will make sure I read all the way down......).

I wish I could remember the source, but as I understand it, 30% of DCIS lumpectomies do not achieve clean margins (for reasons which were described above in the thread).  So having a re-excision is not at all uncommon and does not really reflect on the surgeon's skill.  

Ookie, are you sure you meant to write that Tamoxifen increases the risk of contralateral cancer 440%?  I think that's a typo.    I can't imagine that it increases it at all, or it wouldn't be used as a preventative (barring some unholy Big Pharma conspiracy theory which turned out to be true), but even so...440%????

Carol - ummm....I don't know.  At first I thought you must be reading your path report wrong...but MAYBE they did a frozen section while you were still in surgery, found out the margins weren't clear and then the surgeon took some more?  As far as I know that's not how it's usually done and that pathology normally take a few days to get results back, but I can't think of any other explanation.  You should ask your BS if you're curious.

Carol,  yes, it is possible to do the re-excision during the initial surgery, if frozen sections are taken. This isn't usually done, however, since the analysis of the frozen section done during surgery usually isn't the final analysis - it's just a quick look and it's possible to miss something.  A frozen section often is taken during surgery when a sentinel node biopsy is done; this is so that if it's discovered that the node isn't clean, more nodes can be taken during the surgery.  But women are warned that if they get the "all clear" after surgery about their SNB, they should be aware that it's not the final word since the more detailed pathology review done after surgery might still find something.  With margins, since there is so much more breast tissue to analyse and since the analysis has to be done at such a fine level, I think most surgeons feel that they wouldn't get enough information from a quickly analysed frozen section during surgery to know for sure if margins are really clear.  So most surgeons don't bother.  But it sounds as though yours did, and it worked out to your benefit.

ookie, where did you hear that Tamoxifen "causes a 440% chance of getting cancer in the healthy breast."?  I did a lot of research on Tamoxifen when I was deciding whether or not to take it, and what you've said is completely contrary to anything I've read.  Here are some of the results related to contralateral BC from Tamoxifen clinical trials:

• "The incidence of contralateral breast cancer is reduced in breast cancer patients (premenopausal and postmenopausal) receiving Tamoxifen compared to placebo. Data on contralateral breast cancer are available from 32,422 out of 36,689 patients in the 1995 overview analysis of the Early Breast Cancer Trialists Collaborative Group (EBCTCG). In clinical trials with Tamoxifen of 1 year or less, 2 years, and about 5 years duration, the proportional reductions in the incidence rate of contralateral breast cancer among women receiving Tamoxifen were 13% (NS), 26% (2p = 0.004) and 47% (2p < 0.00001), with a significant trend favoring longer Tamoxifen duration (2p = 0.008). The proportional reductions in the incidence of contralateral breast cancer were independent of age and ER status of the primary tumor. Treatment with about 5 years of Tamoxifen reduced the annual incidence rate of contralateral breast cancer from 7.6 per 1,000 patients in the control group compared with 3.9 per 1,000 patients in the Tamoxifen group."
• "In NSABP B-14, the annual rate of contralateral breast cancer was 8 per 1,000 patients in the placebo group compared with 5 per 1,000 patients in the Tamoxifen group, at 10 years after first randomization."
• In NSABP B-24, a clinical trial of women with DCIS, the annual rate of contralateral BC (combined DCIS and invasive) was 7.9 per 1000 patients for the placebo group compared to 4.36 per 1000 patients for the Tamoxifen group.

All these results can be found on the following website, which provides a good summary of many of the Tamoxifen studies: http://www.drugs.com/pro/tamoxifen.html

Thanks Beesie,  I guess having a frozen section worked to my benifit...phew!  and I didn't have to go back in for a re-excision...yea! 

P.S.  I did have an SNB.

Carol~