Lumpectomy for DCIS but surgeon declined my MRI request

I have "extremely" dense breasts (there are different categories of density). My surgeon agreed to a pre-surgery MRI because my mammogram and ultrasound images weren't that clear even though the tumour wasn't tiny: 2.5 cm (I found it -- it had been missed by previous diagnostic mammograms). The MRI found a second tumour about the same size, in the same quadrant of my breast.

Do you know how dense your breasts are? Your mammogram report may indicate that. Did you have an ultrasound as well? Don't hesitate to talk to your surgeon again about your concerns and ask how clear your imaging was. Take good care of yourself.

I never had a MRI, but I don’t have unusually dense breasts, either. I think it depends (at least here) on each doctor what is standard practice for them. Don’t know where you are located, but would a second opinion be a possibility? In your case I think I would be more comfortable with a MRI before proceeding.

Agree with Cowgirl. If you’re willing to pay (even better, if your insurance will cover it), you should have some kind of imaging that is more reliable on dense breasts than just mammography, direct to core biopsy. Your center’s imaging may be “among the best,” but mammography has its limits and dense breasts are just one (uh, two) of them. You don’t want to proceed with lumpectomy & rads and then find more tumors in that breast--necessitating mastectomy because the same breast can’t be radiated twice. Better you should definitively rule out the medical necessity for mastectomy before proceeding with breast-conserving surgery. (I didn’t, because my breasts are fatty and stuff in them shows up well on mammograms). At the very least, they should be willing to do an ultrasound (non-invasive, and far cheaper and easier on the patient than MRI).

Oh Olive. I'm sorry that you don't feel like you have options. My worry for you is that you have your lumpectomy and then don't get clean margins and that the surgeon will have to operate again. Ugh. Maybe you can meet with another surgeon at the same facility and confidently insist on further scanning before the operation? I had a chemo board sister from Montreal who had a lumpectomy that didn't do the trick and she ended up with a bilateral mastectomy later (which didn't do the trick because now she's had a recurrence). How did your surgeon feel about a mastectomy?

My surgeon also didn't do the MRI before the first lumpectomy for high-grade DCIS. He ordered it after the second, though, and only because my husband strongly advocated for it .  Reading all literature and posts here I would say that MRI may add some more information to the case, but at the end of the day only the post-surgery pathology  will be definitive when it comes to the final diagnosis.  What they see on MRI is some background  enhancement and some areas with more prominent enhancement. This needs to be compared to some baseline MRI.  My MRI showed some residual disease around the lumpectomy cavity, but they already knew I had DCIS, thus not a clean experiment.  The exact words used in my case " Residual disease cannot be excluded. 2 small enhancing nodule medial to cavity. Satellite lesions cannot be excluded". As you see, not very definitive. In the perfect world docs would prescribe baseline MRIs when the breasts are healthy, and then monitor breasts with more MRIs. I believe they are reluctant to prescribe MRI because of the difficulty interpreting what they actually see , and the cost, of course. I hope this helps.

My BS was not inclined to approve an MRI, but I brought him a medical literature review that shows that MRI is indeed more effective in detecting the extent of high-grade DCIS than mammograms are. We certainly want our surgeons to know the extent of the DCIS before lumpectomy so that there is a chance of getting it all the first time and having wide clear margins. My BS approved my MRI which indicated that the DCIS was more extensive than the mammo indicated. I just printed the abstracts of each paper to give to the BS so that he could find the papers if he wanted.

http://jncimono.oxfordjournals.org/content/2010/41...

https://www.researchgate.net/profile/Eva_Wardelman...

http://synapse.koreamed.org/DOIx.php?id=10.3348/kjr.2007.8.1.32&vmode=FULL

http://www.ejradiology.com/article/S0720-048X(09)00522-1/abstract?cc=y=

And there are more!

I'm in Canada as well. Go back to your GP who originally ordered your mammogram and ask them to write the order for an MRI. THe wait time is extremely long however, so maybe consider private (not sure what province you are in- but in Alberta paying private is common). Worse case ask for an order for ultrasound from your GP. Your BS is only one member of your team... Use them all! And voice your concern about your BS to your GP too!

I did have an MRI done prior to surgery-both BSs I consulted wanted it done. I happen to have dense breasts, but a pre-surgery MRI seemed to be standard practice. The MRI was read at two different breast centers (done at Vanderbilt) and doctors at both agreed the MRI showed I had DCIS around a small invasive tumor (IDC was diagnosed per needle biopsy prior to the MRI). Because of this, a fairly large portion of my breast was removed. Final pathology showed I had a small tumor only, no DCIS.

IMO MRIs are not all they are cracked up to be and mine showed DCIS where there was none. It also missed my positive node. In retrospect, I'm not sure I would even want one done again. It was not helpful in my case causing me to have more extensive surgery than was needed. While I understand wanting as much info as possible prior to surgery, it is the surgery itself that will tell the true story. No matter how much imaging we have, none of it is truly definitive.

In the "healthy" breast, I had IDC, DCIS and a positive node that were NOT seen by mammogram, but only on MRI.

I'll add that my sister had a clear mammogram, but an MRI showed IDC.

I would be more concerned about doing the SNB with the lumpectomy. As long as it is just a lumpectomy, I would want to skip that until/ unless they find invasive cancer. If they do, they can go back for the SNB.

I just had a bilateral mastectomy for extensive high grade dcis. I had two mammograms two years prior that showed nothing. I found a lump that was also negative on the Mamogram and ultrasound. I had the lump removed by my own persistence. The pathology showed high grade dcis with necrosis with positive margins on all sides. I really pushed for an MRI which showed extensive dcis 6.5 cm covering almost half the breast. This was all undetectable by Mamogram. I would really kick and scream to get an MRI Good luck and best wishes.

Olive4,

I am so sorry you are having to deal with a less than aggressive doctor. I really hope that all goes well with your surgery.

I was recently diagnosed with DCIS after having bleeding from my right nipple. After a negative mammo and a negative ultrasound the radiologist was ready to send me home. I am so glad I was my own advocate and demanded they do more. I was scheduled for a second ultrasound and a different radiologist found the mass and biopsied it. Next thing I know I have DCIS, Stage 0, High grade and am scheduled for an MRI. The initial plan is to do breast conservation surgery with radiation to follow. Of course that may change after the MRI.

The question I have is should I opt for lumpectomy with radiation and live with the chance that it will come back in 5 yrs or have a mastectomy to reduce my risk of recurrence? It is a decision I ponder all of the time. I am 56 and healthy and have no breast cancer in my family. So what do I do? Any ideas out there?

6/2/2016 DCIS, Right, Stage 0, High Grade, ER-/PR-

7/11/2016 Pending MRI and surgical consult

Pending lumpectomy and radiation

Average recurrence rates can be really misleading and in my opinion shouldn't be considered when making treatment decisions for DCIS. There can be such a wide range of differences between DCIS diagnoses and surgical outcomes - the grade, the size, the focality, the location in the breast, the hormone status, the surgical margins - that it's important to understand the specifics of your own diagnosis when assessing the surgical options and the likely resultant recurrence risks.

The recurrence rate after a lumpectomy + rads can range from a low of less than 4% to a high of over 30%, depending on the pathology of the DCIS and the size of the surgical margins.

Similarly, while the recurrence rate after a MX is usually in the range of 1% - 2%, for those who have DCIS at or close to the margins, some studies have shown that the rate can be as high as 10% - 15% (although those higher numbers can be cut by adding rads).

This is very old data, but it shows a huge variability in recurrence rates based on key pathology factors, and it shows how important margin size is in reducing recurrence risk: http://theoncologist.alphamedpress.org/content/3/2/94/T2.full

This is more recent, and again confirms the importance of margin size for those having a lumpectomy. Surgery for DCIS: If Inadequate, Recurrence Skyrockets Unfortunately in this study an "adequate" margin was defined as being >1mm and no investigation was done on how much recurrence rates can be further reduced by having margins that are larger. Back in my day (10 years ago) 'ideal' margins were considered to be 10mm or greater but more recent studies have shown that even slightly larger (than 1mm margins) margins will further reduce recurrence risk. For example, the following study shows that a single facility was able to reduce it's 58 month (almost 5 year) recurrence risk to zero, regardless of the pathology of the DCIS, by focusing more carefully on surgical margin size. They were targeting to have >2mm margins: Improved Outcomes of Breast-Conserving Therapy for Patients With Ductal Carcinoma in Situ

So a key question for anyone trying to decide between a lumpectomy vs. a mastectomy is whether the location and pathology of her DCIS, combined with the size of her breast (large enough to achieve good surgical margins without significantly compromising breast size & appearance), will allow for optimal recurrence risk results following a lumpectomy (+ rads). If the answer is yes, then there is little benefit, in terms of reducing recurrence risk, to a MX. If the answer is no, then a MX might provide a significantly lower recurrence risk, unless the location of the DCIS is right at the chest wall, in which case rads might be recommended even after a MX in order to achieve a lower recurrence risk.

Dear Ingerp,

I hope your recovery is still going well. I feel fortunate that my medical center recommended an MRI to find additional areas of concern and look at the left side as well.

And thank you for the link.

Best,

Lynda