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All TopicsForum: DCIS (Ductal Carcinoma In Situ) → Topic: Re-excision or radiation

Topic: Re-excision or radiation

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

Posted on: Feb 19, 2011 12:18AM

NorthSalem wrote:

I was diagnosed with DCIS, small but high grade on Feb. 1.  Feb. 9 I had a lumpectomy, Unfortunately the margins were not clear in one small area.

I was all prepared for a re-excision, but my surgeon is having me see a radiation oncologist to see if radiation alone would be enough.

I have not been able to find anything about this.  I handle surgery well and there is no reason not to have it if it is necessary. 

I am thinking I would not consider the radiation only unless I had an MRI that looked clear.

Has anyone else had their doctor suggest skipping the re-excision and going directly to radiation?

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Feb 19, 2011 07:59AM Jelson wrote:

NorthSalem-

I had a similar situation - high grade with the smallest margin 1.5mm margin on the skin side - at the areole. The surgeon was looking for a 2mm margin. If I had a re-excision, I would have lost part of the areole/nipple. Instead, my radiation plan - included boosts to the area of the incision.  Talk with the Radiation Oncologist - who may or may not be comfortable with radiation without the re-excision. I had an MRI after surgery but before radiation - mainly to check the othe breast. I had the impression that the area around the incision was difficult to read due to the scarring/healing going on, but others might chime in on that - I am not sure it would tell you definitively what you want to know. I would go with your gut feeling, what you would feel most comfortable with. It sounds like your surgeon wants to spare you the re-excision, but the decision should be yours.  

Take care 

Julie E

Dx 4/17/2009, DCIS, <1cm, Stage 0, Grade 3, 0/0 nodes, ER+/PR+
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Feb 19, 2011 08:46AM, edited Feb 19, 2011 09:49AM by redsox

The question of what is an adequate margin for DCIS is not as clearcut as simple guidelines might lead you to believe.  DCIS may taper off, it may jump over a gap, or there may be some outlying cells that are not caught in the surgery.  Deciding what is a good enough margin is not straightforward.  As Julie showed sometimes where the margin in question is located is an issue.  Even a small DCIS tumor has millions of cancer cells and they are not likely to get every one of them in surgery.  The goal of radiation is to kill off any remaining cells, so it is reasonable to consult the radiation oncologist for an opinion.  Edited to add: the question is whether the tumor burden has been reduced enough for radiation, i.e. have they gotten the vast bulk of the tumor out and only need to deal with stray cells?

What I would find best would be for the doctor to take the case to the multi-disciplinary tumor board where doctors from all specialties review the case.  Most cancer centers have weekly tumor board meetings.  If they come to a consensus either way and the explanation makes sense to you, I think that is the best route.  

Dx 2009, DCIS, Stage 0, ER+/PR+, HER2-
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Feb 19, 2011 03:57PM dsj wrote:

Hi, I had what may have been a similar situation.  My closest margin was .5mm and I was sure from reading that I would have to have a re-excision.  But when I saw the BS he said I didn't need it.  I was so surprised that I didn't take in everything he said.  But a few days later I had an appointment with the medical oncologist and he said the same thing: that I did not need a re-excision. At this point, I had myself together enough to ask why and  he said it all had to do with how the specimen was handled.  I had shaved margins (which I never really understood) which makes it even harder to understand.  He was completely adamant that I didn't need a re-excision.  He said it was likely I had scattered DCIS cells elsewhere in my breast, and then I asked  him if I should have a mastectomy and he said no, same statistics.  He said that's what radiation is meant for.  He said the person with the last word, though, would be the radiation oncologist, whom I saw a few days later.  The rad onc said that she didn't think I needed a re-excision, but that she had taken my case to the tumor board of the multidisciplinary cancer center at the med school (she used to chair of the radiaition oncology department) and they agreed that I did not need a re-excision. She said I didn't have extensive DCIS and that the close margins were away from the clusters of calcifications (which is what had started the whole thing).  As close as I can understand it, it is not unusual for women to have residual DCIS.  What they worry about, though, is that original tumor is out.  She said with radiation but without a boost my (personal) risk of recurrence was about 6% and with a boost about 4% (I had a small area of intermediate grade DCIS). 

 Your situation is not the same as mine, so your doctors might recommend other strategies.  But as much as I actually wanted the re-excision, in the end I just couldn't push it any further:  3 highly trained specialists and a tumor board had to know more than I did.

 I did a lot of reading about margins.  I am not a scientist but I can make my way through a research article.  In the end I decided I couldn't really understand the intricacies of the literature.  And there are so many variables in the research.  There's no consistency in how the pathology is handled or what counts as "close" margin.  I think you should try to understand as much as you can and ask your doctors as many questions as possible.  But in the end, I think one should understand that this is all very complicated and that general guidelines don't work in every case.

For me, negotiating the margin stuff was the most stressful part of the whole experience.  PM if you want to talk more.

dsj

Dx 1/20/2010, DCIS, <1cm, Stage 0, Grade 2
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Feb 19, 2011 04:46PM MarieKelly wrote:

Regarding specimen handling - sometimes what appears to be a positive margin really isn't because  the way the specimen was prepared. Compression of the specimen can distort it. It's called "the pancake phenomenon" or "pancaking effect". You can read about it in the following liink and see a diagram example of what happens on page 22...

http://www.senobox.com/uploads/BCT_Technical_Presentation.pdf

Ki-67 5%. Wide margin lumpectomy and biopsy track removal. Refused radiation and hormonal therapy.

Dx 2/22/2004, IDC, <1cm, Stage Ia, Grade 1, 0/1 nodes, ER+/PR+, HER2-
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Feb 19, 2011 04:58PM JBinOK wrote:

If it were me, I would insist on a re-excision, especially because your DCIS is high-grade.  That's just what I would do.

I was diagnosed with high-grade DCIS twice within a 12 month period.  First time, lumpectomy with  very wide, clear margins, followed by radiation.  Turns out, it didn't matter.  Exactly 1 year later I had a high-grade DCIS recurrence in the same breast.  Had a bilateral mastectomy (no reconstruction) last month.

DCIS is tricky enough, again, especially if it is high grade.  I would have the re-excision.  Just my opinion.  Good luck to you.

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Feb 21, 2011 02:28PM NorthSalem wrote:

I went to the RO today.  I'm not sure why my surgeon sent me, because the RO was certain that I needed more surgery.   My tumor was much larger than originally thought 3.8 cm and the margin was  2/10 mm.  So we'll try again for clean margins.  If not, it looks like a mastectomy is a realy possibility and I'm having a lot of trouble dealing with that.

 Thanks so much for your helpful comments.

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Feb 21, 2011 03:22PM Beesie wrote:

Fingers (and various other appendages) crossed that you get good clean margins this time!

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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Feb 21, 2011 03:25PM JBinOK wrote:

NorthSalem,

If you have not had one already, I highly encourage you to ask for a breast MRI before the re-excision.  It will give your surgeon additional information, such as a better idea of the size and area of concern; it may also show additional areas of suspicion, if any.