Positive margins after mastectomy

bc226 · August 2013

Hi!I am not sure if I'm posting this in the correct board. My question is: Does anybody else have positive margins after mastectomy? did you have another surgery?

I underwent bilateral skin sparing mastectomy, with placement of tissue expanders on July 24. I had neoadjuvant chemotherapy prior. my path report shows: presence of invasive component at the inferior margin, less than 1mm distance to posterior margin. My surgeon says she is not concern about this since she removed the muscle fascia. She even thinks I do not need radiation (although I had met with rad onc prior to surgery and planned for rads). When I saw my medical oncologist last week, she was very concern and very upset about the positive margins. She thinks that I will need another surgery and should consider another surgical opinion ( making things complicated since the surgeon is the department head and I imagine I would need to go to another hospital). When I saw my RO, she said that repeat surgery after mastectomy is not common and radiation should be enough. I am so confused with the conflict in recommendations.

Anybody else with similar findings? I would appreciate it if you could share your experience.

Thanks!

KSil · August 2013

Hi BC226,

I had a mastectomy without clear margins. I am currently doing chemo (ACT) and I just started My first Taxol today. Doing well so far, just tired. Anyway, my breast surgeon is going to do re-excision upon placement of my tissue expanders after chemo and rads. It is confusing, and unsettling knowing there are cells lurking around the primary tumor area. Ugh! Anyway, she is an incredible surgeon and doesn't seem too concerned about waiting to do the re-excision.

TectonicShift · August 2013

.

meghar · August 2013

http://www.ncbi.nlm.nih.gov/pubmed/9635708

http://www.lifemath.net/quantmed/pdf/Jagsi%20LocaRegional%20Recurrence.pdf

Some articles of interest.

Conclusion: Postmastectomy radiation therapy has not been recommended for node-negative patients becausethe LRR rate is low in that population overall. This study suggests, however, that node-negative patients with multiple risk factors, including close margins, T2 or larger tumors, premenopausal status, and LVI, are at higher risk for LRR and might beneﬁt from PMRT. Because the chest wall is the most common site of failure, treating

the chest wall alone in these patients to minimize toxicity is reasonable. ©

SpunkyGirl · August 2013

I also had a posterior positive margin, and my surgeon said the same thing yours did. We took everything we could and rads will get the rest. Almost seven years later, and I haven't had any issues ( knock on wood)..,

Hugs

Bobbie

karen1956 · August 2013

I don't remember being told about margins, but I had modified radical mastectomy with axillary dissection on BC side and simple mastectomy on prophy side....chemo and rads followed bilat......

InspiredbyDolce · August 2013

I'm confused about the wording of less than 1mm ... is your margin 1mm and they are calling that a positive margin, or does your margin contain cancerous cells, and the nearest of those cancerous cells are at 1mm distance to the other side? If the margin is narrow but negative for neoplasm, then I wouldn't be as concerned, but if the margin is positive for neoplasm, then I woud explore that further. I would suggest going in front of a 2nd tumor board. I have heard excellent things about Dana Farber and Mass General. Definitely get a 2nd opinion on this. I had a narrow margin after my mastectomy, but it was a clear margin, and a 2nd lab found that the tumor had a rim of fat around it, which added to the margin, and the final operating report (not path report, but the step by step surgical report) showed that a sliver of muscle was removed, adding to the margin. So with a sliver of muscle and a rim of fat, they considered my margin larger than the original assessment. It was very comforting to get a 2nd opinion. I highly recommend it. Your team probably expects you to do that as well. Don't feel like you will upset anyone, they will understand.

In addition to what Meghar posted, I do remember reading a study, where it said if you had a specific number of risk factors, it might be beneficial. So it gave the various components, and depending on how many of those risk factors one had, it said that would be taken into consideration to treatment suggestions.

You can also look up the standard of care found within the NCCN Guidelines for Physician's Manual. You have to google for it, and you'll know when you get the right manual, as it's about 350 pages and very techical, but you follow the schematic and it gives treatment recommendations based on receptor status, node involvement, margin status, stage, etc.

InspiredbyDolce · August 2013

Here is an article that I had saved as well:

www.acr.org/~/media/40E521E42778421DBD4D414D09BB1070.pdf

You have to cut and paste into the browser because it takes you to a pdf not a website, I guess.

It seems to contradict one of the other links that was posted. In this article, it references the thinking of earlier articles, and then does say that tumor size, number of nodes affected, etc affect the LRR ..... it is very informative.

I would get clarity on if any cells have remained, because for me it's hard to understand. Were there positive margins, but they were located at the muscle, so when she removed the muscle the cells were also removed? The Radiation Onc, told me that sometimes muscle falls away from the tumor and doesn't arrive at the lab, and therefore with absence of the muscle, they assess only what arrived. So maybe you don't have a dirty margin, which maybe that is why she is not concerned?

Let us know what you find out. Also, what is your receptor status? Wishing you all the best.

You can also post a question online in the Breast Center Ask an Expert at John Hopkins University - google and you'll find the forum. The Experts there answer very fast, and I've posted there before. I've always received information back within 24 hours, sometimes within only a few hours.

Elizabeth1959 · August 2013

For me personally, I follow the advice of my oncologist. His emphasis has consistently been what is in my best interest long term I.e. staying alive. I would discuss this further with your oncologist. She might value a second opinion as well. Since many people with large tumors have neoadjunctive chemo, I doubt the positive margins will affect your long term survival.

Please let us know what you decide to do.

lkc · August 2013

I had a small bit of dirty margins after my mastectomy. I then did chemo , then 5 fields; 30 Rad Tx with 5 Rad boosts. That was 8 + yrs ago.

bc226 · August 2013

Thank you all for sharing your thoughts and personal cases. It has been a week of me stressing about this, making numerous phone calls to doctor's offices and doing my own research as well. I tried to get an appointment with a surgeon at Sloane Kettering but appointment availability was an issue. Fortunately, the surgeon in MSK suggested that my oncologist talk to her on phone and they did. And the surgeon, did not think that another surgery was necessary. And a physician friend of mine was also able to ask oncologists at Dana Farber and they agreed. I will proceed with radiation, with additional 5 boosts.

It would have been ideal to have clean margins, but I guess we don't live in an ideal world. ..

Positive margins after mastectomy

Comments

Categories