DCIS- getting clean margins

Hi Denverbarb,

My understanding is that about 20% of all lumpectomies for DCIS have come back with a small amount of IDC in the lesion so getting clean margins is imperative for this reason as well as finding more DCIS than originally thought was there by the biopsy. It is not that uncommon an occurence as a biopsy just samples parts of the microcalcs and therefore can't actually predict size. The pathology after lumpectomy is where they determine most of the pathology of the BC. Clean margins are one of the single most important factors for recurrance so it is uber important that this is achieved. Depending on the size of your breasts, sometimes a third surgery may have to be done to achieve this. After that, I am pretty sure they would recommend a mastectomy.

It is common to have to do a re-excision anywhere from 20-40% of the time by what I have read. I am waiting for my path results and will get them this Tues the 5th at my post op appt. I had my lumpectomy on 2/21.

As to #2, you would just have to keep getting regular mammos or diagnostic mammos on the other breast as that is how DCIS is generally discovered. DCIS by nature is in-situ and does not spread to your other breast. Even IDC does not spread to your other breast (or rarely if ever does) so it would be a new primary if found in the opposite breast.

Wishing you the best and hoping you get the all clear after your re-excision! Hope my post helped a little. You also might want to read Beesies post on DCIS in this section. It explains a whole lot about what we have!

Hi Denverbarb,

About whether they find more DCIS than what is found on mammo and MRI, as you said, they can't really diagnose DCIS from Mammo/MRI, only from a biopsy and then review by a pathologist.  After a core biopsy, they still can't assess the amount. I presume they estimate it from the mammo/MRI, and then determine the extent from the surgical biopsy.  My DCIS wasn't even found, at all, at the time of the stereotaxic biopsy.  ADH was diagnosed from the samples taken at the stereotaxic biopsy. The DCIS was diagnosed with the first large lumpectomy (which was really an excisional biopsy--since there had been no diagnosis of DCIS).  Mine was found to be multifocal and positive to all margins.  I needed two subsequent surgeries to get it all.  I have even communicated with someone on this board who had four lumpectomies done to achieve clean margins (and knew of one other case through a breast surgeon who is a friend of the family).  I guess when you get into the third and fourth surgeries, you start to deal with the cosmetic defect issues resulting from multiple surgeries to smaller breasts, as well as concerns that you might not get clean margins even after the third or fourth surgery.  I gambled (avoiding the mx), and had clean margins by the third surgery, but a not too pretty breast (and significant assymetry).  Somehow, radiation has improved its looks, crazy as that may seem.  To me it was worth the gamble.

I had 2 lumpies and the surgeon said go to rads

RO pulled another mamo and found more DCIS about 2 " from the earlier.  Since it was still in the same quadrant and I am a DD, the surgeon did a third lumpie

did my rads, am finishing up now on my 5 years of aromasin and looking forward to Dec 31 and ending the meds~

Hi Denver,

My path slides from the first lumpectomy were re-read by the second facility which did the two subsequent lumpectomies.  Confirmed to be pure DCIS.  The next two path results were not re-read by anyone, but I went with it (Memorial Sloan-Kettering).  Anway, it's all radiated now (and hopefully gone).

Margins are one of the most complicated issues in the whole DCIS discussion.  (You can search and find lots of comments.)  Part of the issue is that there doesn't seem to be a standard way of treating and evaluating specimen tissue.  Also a lot of the research doesn't differentiate between close margins and wide margins.  I really tried to understand my margin issues, and I suggest you do too.  But in the end, I had unanimity of opinion among my doctors that my margins were okay, even though the margins seemed really narrow to me.  I actually wanted the second lumpectomy but I was eventually had to come to terms with the fact that no one (besides me) seemed to think I needed one.  I am now about over three years out and have had clean mammograms and breast exams since.  Good luck to you.  Going through all this decision-making is the worst part.   

Just back with an update. My path report came back with pure DCIS which was great news. But, I have to have re-excision surgery on Monday due to ONE margin being <1 mm! Ugh...anyway, all other margins were quite large, the smallest being 6mm and the largest 3.2 cm! The posterior margin was the pesky one.

Just thrilled the path report gave me no other hidden stuff...just the DCIS, Grade 2, cribriform and papillary that it said on initial biopsy.

While re-excision is not the ideal, I think it is a small price to pay for peace of mind and of course the rads are supposed to take care of any cells it might have missed!

Best to all!

Windycity, that was a great explanation for Barb! Mine was not diffuse, it was a small area (5mm) concentrated in one area of my breast. I did get totally clean margins all around, but one of them is too small (<1mm) so I chose to go back in and shave more off. I could have just gone straight to rads according to the BS but HER recommendation is that I get that margin wider and I agree. Also, the RO wants nice big margins. Most of mine are more than a cm with one of them 6 mm except that one that is being made wider on Monday. I told the BS to make ALL of my margins bigger cause my bikini days are over since I am 57...lol She said she would make sure to give me a wide area. She did already in most of them as the largest was 3+ cms!

Clearing those margins has to happen in about 20-40% of the cases cause as WindyCity said, these DCIS cells are microscopic. So tiny that it takes several years to show up on mammos or US's! They are like grains of salt my BS told me. My less than one mm margin is like a grain of rice in size so she wants to make it larger to be sure! I am all for it after the initial disappointment of having to go back in for more surgery but it is what it is.

I hope that you ONLY have to have one re-excision! Hugs!

Hi Denverbarb1,

I had the same results. Re-excision showed more than the original. I actually had a lump removed the first time so they focused on that but the margins weren't clean. This time she took s large amount of tissue and mire than half was DCIS, cribiform and papillary, grade 2. So mastectomy it is! I see plastics on Wednesday, clueless as to options at this point. BS said she feels I will need tissue expanders but that's all I know. Please keep me in the loop if you have any tips.



Thanks,

Angie

So sorry Angielee and Denverbarb...sigh. I get my results this Tues from my re-excision. Hoping the news is good but preparing for if they aren't. Hugs!