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All TopicsForum: DCIS (Ductal Carcinoma In Situ) → Topic: Mom's Margins Are Not Clean

Topic: Mom's Margins Are Not Clean

Forum: DCIS (Ductal Carcinoma In Situ) — Just diagnosed, in treatment, or finished treatment for DCIS.

Posted on: Jul 16, 2008 09:48PM

JaniceC wrote:

My mother was diagnosed with DCIS and had a lumpectomy last week.  She met with her breast surgeon today who told her that her margins were not clean on one side (the top).  She has a re-excision procedure scheduled in two weeks.  My mother, unfortunately, isn't dealing with this so I need to be the one getting all the info.  Here are some questions:  What % of lumpectomies do NOT come back with clean margins?  How common is re-excision?  How many more times will we have to go through this before mastectomy becomes a consideration? 

This is the first time I have had to deal with breast cancer and I feel overwhelmed, upset and tired.  Any advice would be greatly appreciated.

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Jul 16, 2008 10:44PM Beesie wrote:

Janice, I don't know what percentage of lumpectomies do not come back with clean margins, but I do know that the percentage is probably surprisingly high.  Re-excisions are pretty common stuff, and fortunately don't change the prognosis.

With any breast cancer that isn't a clearly defined lump, it can be difficult for the surgeon to achieve clean margins.  This is often the case with DCIS, which frequently is found in the form of calcifications.  Calcifications are microscopic - completely invisible to the naked eye.  This means the surgeon is operating blind.  Usually a wire localization will be done before surgery so that the area of breast tissue that needs to be removed is marked for the surgeon, and some surgeons have MRIs done in addition to mammograms and ultrasounds so that they have the clearest possible idea of how large the affected area is and where it is located.  But in the end, they are still operating blind.  The other issue with a lumpectomy is that while the surgeon wants to remove all the cancer plus a reasonable margin, he/she also doesn't want to remove too much extra breast tissue, since this could affect the appearance of the breast.  So the surgeon is walking (or cutting) a fine line.  This is why re-excisions are so common, and why it has nothing to do with the quality or experience of the surgeon.

As for how many times you mother will have to go through this, no one can say.  Hopefully the margins will be clear and sufficiently wide after the first re-excision.  Usually, that's the case.  That was my mother's situation.  But there are some cases where the margins aren't clean even after the re-excision and more surgery is necessary.  And the question of mastectomy instead of a re-excision is always on the table.  I had a mastectomy after my first surgery without clear margins.  In my case, a lot of breast tissue had already been removed in the first surgery, an MRI showed a fairly large suspicious area still in my breast (which may or may not have been BC - we wouldn't know until the pathology was in) and I'm small breasted.  Because of that, I knew that the cosmetic results of a re-excision wouldn't have been good and the likelihood of clear margins was low.  So that made a mastectomy an easy choice (though not one that I wanted to make).  Other women, particularly those who with larger breasts, are able to have two or even three re-excisions without requiring a mastectomy. 

I hope that helps.  And good luck to your mother.  Here's hoping for nice wide clear margins after the next surgery!

Dx 9/15/05, DCIS-MI, 6cm+ Gr3 DCIS w/IDC microinvasion, Stage I, 0/3 nodes, ER+/PR- “No power so effectually robs the mind of all its powers of acting and reasoning as fear.” Edmund Burke

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Jul 17, 2008 06:00AM JaniceC wrote:

Thank you Beesie.  After a night without sleep, your response brought me some peace of mind.  All the best to you and your mom.

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Jul 17, 2008 08:29AM Beth1128 wrote:

I just had a lumpectomy June 17th and i had a 2nd opinion which came back that I didnt have clean margins either..so Im going back for a re-excision too...I feel that I was fortunate to have a 2nd opinion considering the first time they said I had clean margins so it wouldnt have been found if it didnt go out for a 2nd opinion ...they sent it out because they couldnt agree on DCIS or ADH...still in the dark on that outcome ..picking up path report soon ( i keep saying that but keep doing other things...) but it will give me peace of mind to have the re-excision and look at it that way ..that at least they are going back to get it all out..{{hugs}}  Beth

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Jul 17, 2008 08:47AM snowyday wrote:

I never got clean margins but ended up doing radiation to try and get any leftover cancer cells.  So that may be an option for your mother if they still aren't sure about her margins.  Good luck

PN

Dx 5/24/2007, ILC, 5cm, Stage IV, Grade 3, 0/2 nodes, ER-/PR-, HER2+
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Jul 17, 2008 12:50PM roseg wrote:

I have heard people say that 2 re-excisions is a limit many surgeons go with.

But a lot depends. If your Mom has a lot of breast tissue then she's got more to work with. 

Rose

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Jul 17, 2008 06:00PM Jordymom wrote:

Janice,

I did 3 lumpectomies on one side, and 2 on the other to get clear margins.  I still had 'close' margins in the end and my surgeon was willing to do another attempt.  Ultimately, the radiologist was comfortable with the close margin, so I went forward with the radiation/Tamoxifen.

I think a surprising number of cases of 'dirty' margins occur and are particularly distressing and discouraging to the person going through it. To my knowledge there is no 'limit' on the number of times a lumpectomy can be performed, but at a certain point there may be so little breast left it may be essentially be a mastectomy.  I did research and found studies which showed no difference in outcomes for persons with one lumpectomy vs. multiple, so the fact one of the margins wasn't clear is not a prognosticator.

One surgeon I talked with did at least 5 attempts at clear margins on one woman and then said no more.

Good luck to your mother in her second surgery.

Dx DCIS right 9/07 (.5 cm), Dx DCIS left 11/07 (1.5 cm), ER+/PR+, Rads 4/1-5/16

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Jul 17, 2008 10:07PM nack35 wrote:

Hi, I had a lumectomy July 1sr. Margins not clear. Having second surgery next Wed.This time with blue dye and all that.When I first found out it was DCIS I felt pretty good. Now I am told it is invasive,but Dr. says it is so small 2 mil, he is pretty sure it will be ok. I am so scared it is in the nodes and will need drains and chemo. Keep your fingers crossed for me.

                                             Nancy

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Jul 18, 2008 07:33AM redheadace1 wrote:

According to my oncologist, margins come back clean about 90% of the time; I've read this elsewhere, also. 

Dx 6/08, DCIS stage 0, Grade 1, ER/PR+, 0/0 nodes, lumpectomy 7/24/08, finished rads 10/16, thinking about Tamoxifen

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Jul 18, 2008 04:24PM Beesie wrote:

The average may be 90% but I'd guess that it varies greatly depending on the type of BC. For example,  I suspect that the 90% isn't true for DCIS found as calcifications or in fact for any breast cancer that is not a defined lump.  Certainly DCIS, because it can only spread through the milk ducts, tends to spread out more within the breast (rather than grow in one place) and as a result, is more likely to be multi-focal and multi-centric.  Often the extent of the spread isn't discovered until surgery because the calcifications are simply too small to be visible even on a diagnostic mammogram. That was the situation in my case.  I also suspect that breast cancers that are defined lumps bring the average up - I'd guess that clean margins are achieved in close to 100% of cases where there is a well defined lump. 

Dx 9/15/05, DCIS-MI, 6cm+ Gr3 DCIS w/IDC microinvasion, Stage I, 0/3 nodes, ER+/PR- “No power so effectually robs the mind of all its powers of acting and reasoning as fear.” Edmund Burke

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Jul 19, 2008 02:34PM Beth1128 wrote:

Bessie...I had a very defined lump and Im scheduled to go back because the 2nd opinion came back that the margins werent clean but when I went the first time for my 1st results the bs said they were...glad i had the 2nd opinion...and it was initially to determine if it was dcis or adh ...they still havent given me that answer ..maybe after the 2nd re-excision they will ...

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Jul 20, 2008 06:06PM Gulfwater wrote:

And sometimes it happens -- my wonderful surgeon got clean margins first go!  One was very narrow, but it was clean.  Because of tumor size and the one narrow margin, I had rads.  Easy time with it.  I finished my five years of Tamoxifen last January.  I am fine today.

Mary D.

DCIS / stage 0 dx 11/18/02; lumpectomy 12/02/02; radiation 1-2/03; tamoxifen 1/13/03 - 1/12/08