second opionion

Hi beth, it definitely sounds like a second opinion is in order.  What were the changes that were seen in the lump, that they feel they must remove it?  Were there atypical cells (atypical ductal or lobular hyperplasia or lobular carcinoma in situ) found?  The area with the DCIS, itself, appears to be very, very small, so if that alone were removed, you shouldn't have cosmetic changes.  Even with a larger area, such as removing the lump, it can take a lot to get cosmetic changes, unless the area is near the nipple, as you said, or you have very small breasts.  I would definitely get a second opinion as to whether the lump needs to be removed and mastectomy is required.  If you really want a mastectomy, no matter what, that's another matter.

About second opinions, it varies depending upon where you go.  When I went to another breast surgeon, he just looked at the imaging and rendered his decision.  When I ultimately went to a National Cancer Institute (NCI) designated breast cancer treatment center, they examined the actual pathology slides (from both the core biopsy and the first lumpectomy, done elsewhere) and they reviewed all of the imaging. So, a breast surgeon, a pathologist, and a radiologist were involved. They recommended a repeat of the MRI done at the first facility on the other breast, and then decided biopsy wasn't necessary (it had been coded as a BI-RADS4 and they downgraded it to BIRADS3). I also had a meeting with a plastic surgeon.  I had already had 4cm of tissue taken out with the first lumpectomy at the first facility, and then went on to two more re-excision lumpectomies at the NCI-designated breast cancer facility, in order to get clean margins.  I didn't really have cosmetic changes until after the third surgery (and it was actually the sixth surgery on that breast due to three prior surgeries).  So, it took a long time to get to the cosmetic changes (including the downward going nipple).  In the end, after radiation, and then a year of recovery post rads, the breast doesn't really look so bad.  Smaller, but I can live with it.  About the idea of a core biopsy messing things up, yeah all those surgeries and biopsies mess things up. With DCIS; however, the "messing up" doesn't cause cancer.  It does make imaging difficult due to architectural distortion. I would be surprised if your second opinion surgeon decided to re-biopsy the same area, unless imaging suggested that there were additional areas or other suspicious things seen on imaging that hadn't already been investigated.  Maybe they would re-biopsy the lump.  They should definitely have someone look at the path slides, if possible.

Hi Bethq, I understand your indecision.  I too am a small breasted woman (AA) and have DCIS, grade 2-3 with comedo necrosis and am ER/PR +.  My BS recommended Lumpectomy and Radiation followed by Tamoxifen.  I asked about mastectomy and reconstruction for my left breast.  She said that she didn't feel it was necessary but understood if I wanted to choose that option.  She mentioned apprx. half her patients in my shoes choose to do so.  So my main concerns were; long term result of radiation (BC on left breast next to heart & I have asthma), coupled with my age (43 years old), and my tiny size.  If I have radiation at 43 yrs and something comes back down the line, I will still be at an age where I want reconstruction.  And I heard reconstruction on a radiated breast is a bit more challenging. I just had my lumpectomy yesterday and will know my final pathology next week.  At that point I can decide for sure what I want to do.  My BS and I have already agreed that if they didn't get clear margins a mastectomy would be best because I am so tiny that going back again would leave me deficiant. If they did get clear margins and pathology doesn't show anything new, the choice is mine.  And honestly, its still very confusing, and it is my choice to make.  In the back of my mind I think I know that  I would prefer the mastectomy over radiation, but believe me the surgery part totally scares me.  We all understand your difficult decision, there's no getting out of that. But we will be better in the end, whichever choice we make.  I feel for you.  My thoughts are with you.  You will prevail :-)

Bethq - my MRI/mammogram showed that my DCIS went from 10oclock down into my chest wall.   The radiologist who did my MRI said she did not think I would have good results from a lumpectomy (I am pretty small 34A/B depending on the bra).  My BS thought that he could do a good job, and at the end of the day I trusted him.  I felt that a mastectomy would always be an option if things went badly.  I am a runner and did not want the down time from running than a mtx would entail, and, I am sort of mtx adverse because many women in my family had mtx's in the "old days" when they were much more invasive, and the only option.

At the end of the day - I am very very happy with my decision.  The indentation is hardly noticable in a bra.  Even after radiation.  I always wear padding now, have changed up the type of bra I wear, but am very happy with my decision.  It is different for everyone -- but I thought I need to share a good experience with you.  

Best of luck to you as you make the decision that is right for you.