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Topic: do surgical margins need to be clear?

Forum: Surgery - Before, During, and After — Surgical options and helpful tips for recovery and side effects.

Posted on: Feb 27, 2013 07:46AM

sockarmom wrote:

Had lumpectomy, lymph nodes neg but surgeon called and said one edge of tumor didn't have clear margin so she wants me to go back in for re excision. I'm just now starting to feel good and my husband doesn't want me to go back in. Will radiation kill the cells if there are any or is it necessary to go back in for clear margins?

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Feb 27, 2013 08:11AM cheryl1946 wrote:

From what I know as a nurse, you do need clear margins. You may need radiation even after clear margins.

As a stage IV at the start person, I did not have surgery, radiation, or chemo.

DX 7/6/11 with stage IV at the start;mets to several bones No surgery,rads,or chemo letrozole failed after 17 mos. 2 other hormonals failed; now on to xeloda Dx 7/6/2011, IDC, 6cm+, Stage IV, Grade 2, mets, ER+/PR+, HER2-
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Feb 27, 2013 11:38AM itsjustme10 wrote:

If radiation were that effective when used in the manner you're suggesting, why wouldn't they have done it to begin with, instead of any surgery at all?

I don't know the answer that that question, I'm just asking it... hope someone does have the answer, because it seems like it would be important to know before you make a decision. :)

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Feb 27, 2013 11:50AM fd1 wrote:

I was in a similar situation as you.  I had a lumpectomy with positive margins and then a re-excision which had one spot 0.5mm (that is tiny) and that spot happened to be right on the margin.  My surgeon told me that they had an elderly woman with the same situation and the radiation department decided to let her proceed through.  Even if the radiation didn't kill it, it would likely take 5-10 years to develop into anything which would be longer than her life expectancy.  However, with few exceptions such as this, I have heard that you cannot have radiation if you have a positive margin.

Just to reassure you, I had two re-excisions in the end and they were very easy surgeries to recover from.  They only put you under a light anaesthetic and it is over in 20 minutes.  The sentinel node biospy is the part that is much more difficult, which you have already done!

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Feb 27, 2013 07:54PM Beesie wrote:

sockarmom, why is your husband suggesting that you not go back for the re-excision surgery?  Is your husband a breast cancer surgeon?  Wink  

Here's what it means when you don't have clear margins. The breast tissue that was removed from your breast was analysed under a microscope. In one area, the pathologist found cancer cells right at the edge of the tissue.  Logically, it's reasonable to assume that if there are cancer cells right at the edge of the tissue that was removed, there will also be cancer cells in the breast tissue on the other side of that edge, i.e. the side that's still in the breast. What nobody knows however is how many cancer cells are left on the other side of the cut line, or how large the remaining area of cancer might be. 

If the cut made into the breast tissue was right where the area of cancer ended, there might only be a few cancer cells left in the breast beyond that cut line, and in that case, radiation might be effective.  But what if the cancer continues in the breast beyond that edge for another 5mm, or a 1cm, or even more than that? Screening is not precise, so while the surgeon would have estimated the size of the area of cancer based on the imaging from the mammogram (and ultrasound and MRI, whichever you had), it's possible that the area of cancer was larger than what showed on the images. So without further surgery, there is no way to know how much cancer is still in the breast. The only thing you know from the 'dirty margin' is that in all likelihood there is still some cancer left in the breast.  

That's why a re-excision surgery is necessary when the margins aren't clean. 

Dx 9/15/2005 Right, 7cm+, DCIS-Mi, Stage IA, Gr 3, 0/3 nodes, ER+/PR- ** Dx 01/16/2019 Left, 8mm, IDC, Stage IA, Gr 2, 0/3 nodes, ER+/PR-, HER2- (FISH) ** Surgery 11/30/2005 MX Right, 03/06/2019 MX Left ** Hormonal Therapy 05/2019 Letrozole
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Feb 28, 2013 05:14AM - edited Mar 7, 2013 07:12AM by Lolalee

If all the cancer cells are not removed and sent to pathology you will not know the extent or type of cancer you have.  It could be that the area beyond the dirty margin could be a micro-invasion in which case your treatment plan becomes a whole lot different and radiotherapy may not be the only treatment.

Beesie is absolutely correct and makes a very valid point.  I would not mess with this  very unpredictable disease. 

Dx February 12 Lumpectomy March 12 DCIS Stage 0 Grade 3 HR-/PR-
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Feb 28, 2013 03:20PM Beesie wrote:

Since sockarmom had an SNB done with her lumpectomy, I've assumed that her diagnosis probably is invasive cancer, not DCIS. I might be wrong about that, but usually an SNB isn't done with a lumpectomy for DCIS. The presence of a microinvasion on the other side of that dirty margin would only be relevant if the diagnosis up to this point is DCIS and not invasive cancer, but even at that, a microinvasion alone probably wouldn't change much about the treatment plan vs. pure DCIS. I had a microinvasion and it made no difference to my treatment, except for the requirement that I have the SNB (which sockarmom has already had).

sockarmom, have you made a decision about the re-excision?  And to the point that Lolalee raises, what is the pathology of your cancer and the pathology of what was found in the margin? 

Dx 9/15/2005 Right, 7cm+, DCIS-Mi, Stage IA, Gr 3, 0/3 nodes, ER+/PR- ** Dx 01/16/2019 Left, 8mm, IDC, Stage IA, Gr 2, 0/3 nodes, ER+/PR-, HER2- (FISH) ** Surgery 11/30/2005 MX Right, 03/06/2019 MX Left ** Hormonal Therapy 05/2019 Letrozole
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Mar 6, 2013 08:10AM jj52 wrote:

In early 2011 I had my first lumpectomy after a diagnosis of DCIS. The margins were not clear so I had it reexcised. The first pathologist said it was ok , but I went to another hospital for radiation and they asked to have their own lab look at the slides. The RO then told me that the margins were "not as clear as they would have liked", so they added on an extra week of radiation.

As it happens, 2 years later I had a recurrence in the same spot and have just had a mastectomy of that breast. I may be completely wrong on this, but I feel that maybe I should have had a 3rd lumpectomy back then and maybe they would have gotten it all, or I wish the surgeon had taken more tissue on his 2nd try.

All that to say, clear margins are important and if I were you I would not hesitate to have the 2nd surgery and tell the surgeon to make sure to take enough out to give you really clear margins this time!

Surgery 1/6/2011 Lumpectomy: Left Surgery 2/28/2013 Mastectomy: Left; Reconstruction (left): Tissue expander placement
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Mar 6, 2013 08:34AM weety wrote:

You need to have the clear margins.  Radiation is sometimes used even when the margins are clear, but close.  Mine were 1mm and 3mm from chest wall and skin, so even though they were technically "clear,"  I still had to do radiation.  I had mastectomy and just didn't have anything left for reexcision, so that's why they couldn't just go back in. 

Dx 7/17/2009, IDC, <1cm, Stage IB, Grade 3, 0/1 nodes, ER+/PR-, HER2+ Surgery 4/18/2010 Prophylactic ovary removal Surgery 4/9/2013 Prophylactic mastectomy: Right Hormonal Therapy Femara (letrozole) Targeted Therapy Herceptin (trastuzumab) Radiation Therapy Chemotherapy Carboplatin (Paraplatin), Taxotere (docetaxel) Surgery Mastectomy: Left
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Mar 6, 2013 10:32AM Beesie wrote:

jj52 & weety, it appears that sockarmom hasn't been on the site since she wrote her post.  

Dx 9/15/2005 Right, 7cm+, DCIS-Mi, Stage IA, Gr 3, 0/3 nodes, ER+/PR- ** Dx 01/16/2019 Left, 8mm, IDC, Stage IA, Gr 2, 0/3 nodes, ER+/PR-, HER2- (FISH) ** Surgery 11/30/2005 MX Right, 03/06/2019 MX Left ** Hormonal Therapy 05/2019 Letrozole
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Mar 6, 2013 10:36AM SelenaWolf wrote:

Clear margins are essential.

"... good girls never made history ..."
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Mar 7, 2013 04:16AM 007-Lynn wrote:

I just had a lumpectomy and when I went to see my surgeon, post-op,she told me that I had the option to go back to make the margins clear.   I did it as quickly as I could because I want to give myself every "edge" that I can.   I may not need radiation as  result of my action, but that will depend upon my oncologist.

You should really trust your sugeon.   

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Mar 7, 2013 05:13AM april485 wrote:

Having surgery again on Monday to get a larger margin. One of them was <1 mm so back I go. Clear margins are essential to start rads. Mine were clear and most were over a centimeter but one of them was too close. A small price to pay imho.

"Fear has been a huge dictator in my life - so I am trying to stage a coup!" ~ a friend Dx 1/30/2013, DCIS, <1cm, Stage 0, Grade 2, ER+/PR+ Surgery 2/21/2013 Lumpectomy: Left Surgery 3/11/2013 Lumpectomy: Left Radiation Therapy 4/22/2013 3DCRT: Breast Hormonal Therapy 6/20/2013 Aromasin (exemestane) Hormonal Therapy 1/2/2016 Femara (letrozole)
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Mar 7, 2013 07:06AM Bluegem wrote:

My diagnosis was early stage invasive ductal carcinoma and I had a wide local excision with sentinal lymph node biopsy end Jan.  At my followup appointment the surgeon said it was good news - lymph nodes were clear and they 'got it all' or something like that.  I have been happy and optimistic and feeling that the 3 weeks of radiotherapy is just belts and braces to prevent a reoccurance.  I had my first appt. with the registrar oncologist yesterday and she said that I would need 4 weeks of rads due to the fact that cancer cells were right to the edge of the margin.  I am now really worried that there are more cancer cells floating about in my breast as if they are on the edge of the margin, they could also be further afield.  I wish I had asked the Oncologist more but as usual you only think of these things after.  Does cancer cells at the edge of the margin mean not a clear margin?? And if so should I press to have more surgery or just have faith in the team looking after me. 

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Mar 27, 2013 08:13AM ironmagnolia wrote:

I had BMX with DIEP on 3/4/13 for bilateral invasive ductal CA. I was just told that the upper margin near the tumor in the left breast showed a cluster of microscopic cancer cells near the edge. My BS says this has only happened to her 2 times previously, and that it is a fine line taking enough tissue to eradicate the cancer while leaving enough under the skin for the PS to get a good cosmetic result.

Also, I discussed with her that I had read that this can be a result of how the pathologist prepares the specimen, slides, etc and she agreed with that. But, stated that we cannot take a chance and just do nothing based on speculation that this report may not be accurate.

She says radiation is out due to the DIEP recon, and although she did not recommend it, one option is to just take the oral drug and watch this area. No thank you. We both feel that going back in to re-excise this area is essential, so back I go to surgery within the next two weeks.

It sucks, but clean margins are important to make sure I've done everything I can to prevent a recurrence.

Dx 1/30/2013, IDC, <1cm, Stage I, Grade 1, 0/2 nodes, ER+/PR+, HER2- Dx 2/11/2013, IDC, 1cm, Stage I, Grade 2, 0/1 nodes, ER+/PR+, HER2- Surgery 3/4/2013 Mastectomy: Left, Right; Reconstruction (left): DIEP flap; Reconstruction (right): DIEP flap Hormonal Therapy 4/23/2013 Arimidex (anastrozole) Surgery 9/23/2013 Reconstruction (left): Nipple reconstruction; Reconstruction (right): Nipple reconstruction
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Mar 29, 2013 07:42AM gramwe wrote:

Hi I'm a newbie, shaking in my shoes. DX with ILC 1/29/13. Bi-lateral mastectomy 3/12/13. JPs and 1/3 of my staples removed 3/19/13. Returned to surgeon 2 days ago, thinking all my staples would be out and I could go on to the next step of my journey, wrong! Margin wasn't clear, so another surgery will be done 4/2/13, to remove more tissue, a skin graft will be taken from my thigh to close this incision. Right now I feel like I'm the only person who's had to deal with this, Lol...Please someone tell me this happened to them too! I have no idea what treatment is next, I will see the oncologist for the first time on 4/9/13. Thanks for being here, I'm so glad I found this site.

Oncotype 16 Dx 1/29/2013, ILC, Stage II, Grade 1, 0/3 nodes, ER+/PR+, HER2- Dx 3/12/2013, DCIS Surgery 3/12/2013 Mastectomy: Right; Prophylactic mastectomy: Left Hormonal Therapy 5/28/2013 Femara (letrozole)
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Mar 29, 2013 10:16AM Lolalee wrote:

Hi granwe, I am so sorry to hear you will need further surgery.  This did not happen to me but I am sure that once they have removed further tissue they will have a better idea what they are dealing with.  

I would assume that radiotherapy will be recommended along with chemo.  Hopefully someone who has experienced this situation will reply to you soon, meanwhile know that I am thinking of you and send best wishes for a good outcome.

Hugs Lola.

Dx February 12 Lumpectomy March 12 DCIS Stage 0 Grade 3 HR-/PR-
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Feb 16, 2016 06:52PM V1Teach wrote:

I was diagnosed just before Christmas. I had surgery on my left side above my breast in the tissue between the muscle and skin The 1st surgery was on January 13, 2016. There was < 1mm clearance so back to surgery I went and this time they found more microscopic sprinkles of cancer and so now I am scheduled for the 3rd surgery on February 26, 2016. I hate that there has been 2-3 weeks between each surgery.

I was just crying and freaking out, but now seeing these posts has calmed me a bit. This is my first time on this site. Thank you!

Dx 12/21/2015, Left, 1cm, 0/3 nodes, ER+ Surgery 1/12/2016 Lumpectomy; Lymph node removal: Sentinel Surgery 2/26/2016 Lumpectomy: Left Hormonal Therapy Radiation Therapy
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Feb 16, 2016 08:03PM Hopeful82014 wrote:

V1Teach - just wanted to pop in and welcome you to the site. I am so sorry you are here but hope you will find support, camaraderie and a wealth of helpful info here. Good luck.
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Feb 16, 2016 11:20PM Moderators wrote:


Welcome to BCO! We know it can be scary and overwhelming, but you've come to the right place for support as you begin down this road. We wish you luck on your upcoming surgery and recovery!

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Feb 17, 2016 06:46PM Hopeful82014 wrote:

V1Teach - Let's hope that third time is a charm, right? You must be sick of the way this is dragging out.

In the meantime, you may find additional support on the lumpectomy thread ("Lumpectomy Lounge") and, if you know your stage, there is a group for each stage that you'll find very welcoming.

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Feb 4, 2018 09:18AM Paisley123 wrote:

All I am reading is bad news. What percentage of re-excision come back with good margins?

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Feb 4, 2018 10:59AM Lula73 wrote:

paisley-for every 1 re-excision that comes back without clear margins, there are about 10 that come back clear. However, when they come back not clear that second time, an mri is a very good idea. What’s likely happening is there is another area that mammo & ultrasound did not detect and it can’t be seen with the naked eye. MRI should pick it up and give the surgeon a better view of where they need to excise. You can also request mri after the first margin comes back not clear before going back in.

-Lula Dx 1/2017, DCIS/IDC, Right, 1cm, Stage IA, Grade 1, 0/2 nodes, ER+/PR+, HER2- Surgery 2/14/2017 Lymph node removal: Sentinel; Mastectomy: Left, Right; Prophylactic ovary removal; Reconstruction (left): DIEP flap; Reconstruction (right): DIEP flap Hormonal Therapy 3/3/2017 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 11/1/2017 Prophylactic ovary removal Hormonal Therapy 1/3/2018 Femara (letrozole)
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Feb 5, 2018 09:17AM - edited Feb 5, 2018 09:23AM by Ann27

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Feb 5, 2018 09:22AM Ann27 wrote:

I am scheduled to have a re-incision this upcoming week, as my margins were not clear with the first lumpectomy. Concerned about not having clear margins as well. It was recommended that I don't need chemo as my oncotype score was low. But this past weekend the opposite side of breast looked a bit red and sore. The incision site looks normal on the skin. It's been 7 weeks since the last surgery. Should I be concerned that it can be an infection this late in or something else?? Has anyone else experienced this not having clear margins before second surgery?

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