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All TopicsForum: LCIS (Lobular Carcinoma In Situ) → Topic: LCIS and excisional biopsy

Topic: LCIS and excisional biopsy

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

Posted on: Oct 10, 2017 12:46AM

Kerri_Oz wrote:

I was just wondering how common it is for an LCIS dx to lead to an excisional biopsy? If it does, what is taken? From what I've read, LCIS can't be seen on any of the screening tests, so how do they know what to excise? Mine was found in a core biopsy of an area of microcalcifications, so if I do need an excisional biopsy, would they take the entire area of microcalcifications? I have minimal breast tissue (surgeons words, not mine, tho they are pretty small), and if the 50mm area of calcs was taken, it would be a quarter of my breast. Also, are excisional biopsies normally done under local or general anaesthetic?

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Oct 10, 2017 03:19PM - edited Oct 10, 2017 03:42PM by leaf

When they did a core biopsy and found LCIS, there was some reason why they did that. Normally it was because there was something seen on a mammogram (such as microcalcifications), but they may have seen something on ultrasound or MRI or felt a lump.

As with almost everything else with LCIS, this too is controversial. But it seems like they've somewhat settled down to: they compare the imaging (or tactile feel of a lump) with the LCIS-revealing core biopsy. If there is ANY difference between the location found on imaging and the core biopsy location, they do an excision. Other people just recommend an excision in any event after they've found LCIS on a core biopsy.

What they do is they excise the area around the core biopsy. If the abnormality was seen on a mammogram, they often 'bracket' the lesion. They insert brackets (like fish hooks) into the breast to locate the lesion/core biopsy area. This is because obviously they can't do a mammogram while the surgeon is doing surgery. Then the surgeon excises the area between the brackets. I assume they would also do this if the lesion was found on MRI. (Since my lesion was seen on MRI in Aug 2017 showed ALH bordering on LCIS, I may be having a surgical excision in the next many months.)

I've never had an ultrasound excision, but I assume you could do that on the operating table (but I'm not sure).

On my initial LCIS diagnosis, my abnormal mammogram (due to microcalcifications) was done in late October, they tried to do an ultrasound biopsy in late November but couldn't see anything, they did a stereotactic mammogram core biopsy in early December, and I had the area excised in late January. If you look at studies, they differ with the study, but if the imaging and core biopsy locations do not match, about 20% of the time when they surgically excise the area they find DCIS or invasive cancer.

They took about 2 tablespoonfulls of tissue in my excision. (I have a B cup.) Its the decision of the breast surgeon how much to take. I did have a 'dent' for a few years, but it completely filled in over time, and by about 2 or 3 years, it was REALLY hard to see exactly where they did the excision. Your experience may differ; I've not seen any other women with breast excisions so I don't know what the 'average' dent or scar is like.

I had conscious sedation (midazolam (Versed) and propofol for my surgical excision, and once an anesthesiologist was involved (immediately before the surgical excision, after the brackets were inserted), it was totally fine (NO PAIN). This means that while sometimes I was conscious, I did NOT feel any pain. When I said 'Ohhhh', not in pain but more like asking what was going on, they gave me another slug of propofol, which put me out again.

However, before the excision, when they were inserting the brackets, I had a miserable time (pain 9/10 because I'm sure if they were pulling off my arm it would be more painful at 10/10), because they wouldn't let an RN be present so I couldn't have any opiate or anything by mouth because they were going to do surgery for the excision. Before they started the bracket insertion, they said I had to promise that I 'would not move a muscle' during the procedure. They did about 3 seconds with the equivalent of an ice cube, then inserted the bracket. It hurt so much, but I knew if I cried I would move, and would have to repeat the process. So I couldn't communicate with them how much it hurt. They saw my face and gave an injection of local lidocaine, which hurt as much as the bracket insertion, and didn't do a thing, then they hit the wrong place several times (you have several constant mammograms to make sure the bracket was at the calcifications), so had to pull out the fishhook brackets several times. Then, someone knocked at the door and asked if they could come in (I said yes because I didn't know what else to say), no one identified themselves, and about a dozen pair of feet walked in. (The room was adjoining the waiting room, so I had no idea if it was a family member of a patient who was looking for a bathroom.) I was dripping blood, and one person asked if I was in pain. Again, I knew if I said I was in pain I would cry, and if I cried I would move. There was the other issue of modesty since of course I was naked and had no idea who kept on entering and leaving the room; no one identified themselves. (I also work at that hospital, so some of these people could have known me professionally.) As one male co-worker later suggested, I felt like I was on display. I was so grateful for his understanding. (He is from a minority group, so I'm sure he understands being marginalized.) That understanding was healing for me. I wrote 2 letters to the radiologist, complete with Pubmed references and stories from bc.org on people who passed out during their procedure, or refused to get any mammograms for the next 10 years and subsequently got bc. That radiologist gave me a reply that 'he'd have to give sodium bicarbonate to everyone'. No apology. Sodium bicarbonate is 'supposed' to increase the effect of the lidocaine, but I've seen Pubmed papers that refute that. In any case, whatever he did did NOT NOT NOT NOT work for me.

I'm not sure how long the bracket insertion took, but it felt like about 1.5 hours. (I stole my mammograms, so I'm roughly estimating from the times listed on them. Now they do it all digitally, so you don't have to carry your mammograms around.) You are squished by the mammogram machine for about 90% of that time, not just momentarily as they do for routine mammograms.

I have a history of trauma, so I'm sure that upped my pain score a LOT. I did a survey here in about 2006, and most people rated their bracket insertion pain as a pain score of about 5/10 (not 9/10). When I had my last MRI-guided biopsy early last month (where obviously they inserted a needle to get the breast tissue), my pain score was more like 3/10.

Hope this helps,

leaf




Classic LCIS.If knowledge can create problems, it is not through ignorance that we can solve them- Isaac Asimov Dx 12/8/2005, LCIS, ER+/PR- Surgery 1/24/2006 Lumpectomy: Left Hormonal Therapy 7/15/2006 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Oct 10, 2017 09:15PM Kerri_Oz wrote:

Oh, Leaf, you poor thing. What a terrible experience. It sounds like some very unprofessional, if not downright unethical, behaviour on behalf of the radiologist and everyone else involved. I would be horrified if there were people coming in and out whilst I was having a procedure like that. I am hoping like hell that I don't have to have an excisional biopsy. The mammogram guide core biopsy was bad enough and is something I never want to go through again. I found it all very traumatic. The idea of those brackets makes my blood run cold.

OK, so I've just done some more reading on the forum, and it's looking like I won't be able to avoid the excisional. Holy Mother of God ... how am I going to deal with that? I feel sick. If you wanna stick a needle in my vein and put me to sleep, I am absolutely fine with anything you want to do with me afterwards, but getting procedures and stuff done while I'm awake is a nightmare for me. I think it stems back to having complications when I had my tonsils out at 5 years of age. I know I certainly feel like a terrified 5 year old whenever I need something done.

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Oct 11, 2017 12:06AM cyclegal wrote:

Hi Kerri, just to give you another experience (not discounting leaf's at all...just giving you a variety of info), my excisional biopsy was not painful and not a bad experience. It was done to make sure that the LCIS was not lurking around invasive cancer. To help the surgeon identify the location of the marker from the needle biopsy, they inserted a J-wire with the aid of mammogram. They did have to take it out and reinsert it once, but I honestly couldn't feel much, so it didn't bother me from a pain standpoint, just more annoying having to go in and out of the mammo machine so many times. After the J-wire was placed (it extends out of your breast, so they cover it up so you don't have to look at it), the anesthesiologist put me under, and I was asleep during the procedure. Because I was leaning towards the BMX for the future, the BS consulted with my PS on incision location, and she was able to make it around the border of my aerola. It did make a visible dent (small breasted) that filled in over a few months. The biopsy showed extensive LCIS throughout the removed tissue, but thankfully no invasive cancer or DCIS. I Was glad to have the peace of min

Dx 2/2017, LCIS, Right Surgery 5/9/2017 Lumpectomy: Right Surgery 8/24/2017 Mastectomy: Left, Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement
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Oct 11, 2017 01:25AM Kerri_Oz wrote:

Thanks, cyclegal. I am such a complete baby when it comes to procedures. I tell myself to put on my big girl panties and just get on with it, but it doesn't help at all at all. Did you eventually go on to have a BMX? (I'm guessing that's a bilateral mastectomy?) That is something that's been on my mind for the last 5 months or so (well before the LCIS dx) because of other risk factors, and now it's seeming like an even better option.

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Oct 12, 2017 02:46PM NicolaSue wrote:

I had a different experience. I'm in the UK. I had a vacuum assisted excision biopsy. I took advise as to whether this procedure was appropriate for LCIS from a leading breast surgeon who told me that yes so long as it was a consultant doing it.

I was sitting in a chair and there were several people present in the room and the procedure was done by a consultant radiologist. The pain was not dreadful but I was shocked by the machine which (sorry) just reminded me of a road digger. I didn't like what was happening and the fear made it all worse. It is normal apparently to hit a blood vessel from time to time and they are used to this and can deal with it but they didn't tell me beforehand and I got extremely scared thinking they might have punctured a lung. I think it if had had more information I might have found the whole thing perfectly manageable. As it was I tolerated it but not without quite a bit of shaking and swearing afterwards. It can be hard with a vacuum assisted biopsy to get all the LCIS out but of course they are not really aiming to do that, they are trying to look for anything else that might be lurking.

Lots of people on here have spoken about how actually LCIS doesn't need to be removed because the abnormal cells are contained/in situ. I get that but - and this may seem daft - when you have any kind of excision that doesn't remove all the LCIS then doesn't the tissue get disturbed and the 'rogue' cells 'let out' to do damage elsewhere? I have this fear that during the excision biopsy I had that some of the LCIS was removed but due to the damage to the delicate structures the rest of the LCIS may be who knows where and spreading. I hope that's an unfounded fear....

LCIS diagnosed Spring 2017. Finding my way slowly.
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Oct 12, 2017 04:34PM - edited Oct 12, 2017 04:45PM by leaf

when you have any kind of excision that doesn't remove all the LCIS then doesn't the tissue get disturbed and the 'rogue' cells 'let out' to do damage elsewhere? I have this fear that during the excision biopsy I had that some of the LCIS was removed but due to the damage to the delicate structures the rest of the LCIS may be who knows where and spreading. I hope that's an unfounded fear....

All LCIS cells by definition are contained within the lobules/ ducts which are surrounded by the basement membrane. (To clarify, you can have 'pagetoid spread into the ducts' - which I have - so the LCIS cells also are partly in the duct too. Pagetoid means the cells look like soldiers standing in a row.)

You have asked a VERY valid question. It is totally reasonable to ask - as you say, can 'go rogue', and metastasize. (This is also called seeding.) Well, what you probably REALLY want to know is if the cancer cells are moved during a biopsy, can they survive and continue to grow?

During a biopsy, the cancer cells certainly CAN be moved and found along the biopsy tract. But the question is - do these cancer cells survive?

This can be a very difficult question to study. If you biopsy a cancer, and later it metastasizes, how do you know that it was from the biopsy, or whether the cancer would have metastasized anyway? I've read papers that claim that IF an invasive breast cancer is going to metastasize, it often metastasizes YEARS BEFORE the initial (primary) breast cancer can be detected. So _if_ that happens, then how can you tell if the rogue cells got there 'naturally' (in other words, that's what the cancer was going to do anyway regardless of whether or not you biopsy it), or if the rogue cells got there because they were disturbed by a biopsy/excision?

There are also some other considerations:

a) Most doctors are NOT going to give you chemotherapy or radiation therapy unless they KNOW you have cancer because these treatments normally have some moderate to severe adverse effects (not to mention expense).

One of the papers below said that in one group that about 9% of people with pancreatic cancer (which is VERY deadly) had surgery and they found the pancreatic lesion was BENIGN. (Pancreatic cancer surgery is VERY extensive: its like a major re-plumbing of your GI system. I've heard that people can take 6 months to recover just from the surgery, and this 6 months is the lifespan of many people with pancreatic cancer after they get diagnosed. These numbers may be rather old and off by a few months,but you get the idea.)

Most breast cancers are diagnosed by pathologists looking at a piece of tissue under the microscope.

b) Often/almost always, if the do find a breast cancer, they give treatment to the biopsy tract. So for example, if you have invasive breast cancer, normally they give you radiation with or without chemotherapy with or without excision, which will not only effect the tumor bed, but also the biopsy tract.

Well, probably IF seeding occurs in breast cancer, it probably occurs at a VERY low rate. I've read papers that speculate that many breast cancer cells normally need some hormones to grow, and this doesn't happen when they are disturbed. It is certainly true that what happens in tissue culture (in a plate or flask) does NOT necessarily happen in a person.

I think that LCIS cells look less wild than invasive breast cancer cells, so I think one could suggest that LCIS cells aren't 'wild' enough to metastasize???

This is very hard to study, but it looks like IF it happens, it happens very rarely. Probably there's some controversy too.

Gotta go catch some zzzzzzs....Best wishes

https://community.breastcancer.org/blog/what-my-pa...

https://newsnetwork.mayoclinic.org/discussion/mayo...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC40151...


Classic LCIS.If knowledge can create problems, it is not through ignorance that we can solve them- Isaac Asimov Dx 12/8/2005, LCIS, ER+/PR- Surgery 1/24/2006 Lumpectomy: Left Hormonal Therapy 7/15/2006 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Oct 12, 2017 06:31PM Mandycat wrote:

thank you for posting those articles. They are very interesting. I had core biopsy with vacuum and it was pretty pain. The lidocaine did not work. They thought I had DCIS but I had Lcis which later turned out to be pleomorphic lcis with a small area of invasio

Dx 4/11/2017, Right, <1cm, Stage IA, Grade 2, ER+/PR- Surgery 5/1/2017 Lumpectomy Hormonal Therapy Arimidex (anastrozole)
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Oct 14, 2017 04:33AM Kerri_Oz wrote:

NicolaSue - from my understanding, an excisional biopsy for LCIS is never intended to remove all the LCIS or get clear margins. It all about taking enough to make sure there isn't anything more sinister hiding within the LCIS. LCIS is not cancer has has been disproven even as a precancer, so spreading along the needle track would not be an issue (I think). It is often multifocal (in more than one place) and bilateral (in both breasts). To remove it all and get clear margins, one would need a double mastectomy. On it's own, LCIS won't cause any problems, but closer monitoring is called for as someone with LCIS is more likely to go on to get cancer, often in a totally different place from where the LCIS was found, and often in the ducts, not the lobules. In my case, because the LCIS was found in an area of microcalcifications, I imagine that if I did have an excisional biopsy, the aim would be to remove the whole area of microcalcifications. If the LCIS was found in some sort of lump or cyst, the idea would be to remove the entire lump or cyst. Also, I think you had a vacuum assisted core biopsy, like I did. An excisional biopsy is when they cut you open and excise (cut out) a whole area. There is also an incisional biopsy, where they only cut out part of the area for testing. (I've been reading up ... lol).

Leaf - you are so knowledgeable! It is wonderful that you stick around on here to help all us newbies understand more. Thank you so much :D

Mandycat - was the pleomorphic LCIS found during the biopsy or lumpectomy? And what was the invasion of? Was it ILC or IDC or something totally different? Did they get clear margins first time around? Are you clear now? What was it that prompted the biopsy in the first place? Did you have a lump? Did you have to have wires or hooks put in before the lumpectomy so they'd know what to cut out? I hope you don't mind all these questions.

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Oct 15, 2017 04:51PM Mandycat wrote:

it was found during both biopsy and lumpectomy. I had microcalcifications on mammogram. No lump. The LCIS can turn into cancer, just more slowly. They said my LCIS turned pleomorphic which is what caused the microcalcifications. I went to IU Med center where I got the correct diagnosis. The pleomorphic LCIS is aggressive and commonly invades about 60 percent of the time. It invaded and was then pleomorphic lobular carcinoma. Only a small area 1 mm. They didn't do wires or hooks or sentinel node because they misdiagnosed it and that it was non invasive DCIS. I insisted on a second opinion because the margins weren't clear if it was DCI

Dx 4/11/2017, Right, <1cm, Stage IA, Grade 2, ER+/PR- Surgery 5/1/2017 Lumpectomy Hormonal Therapy Arimidex (anastrozole)
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Oct 15, 2017 08:02PM panthrah wrote:

leaf... I commend you for staying still and tolerating that. there is zero chance I would have been silent about it. and everyone within ear shot would have heard my expletive filled thoughts about what they were not doing. I might have even told them, to kiss off and left. I have a pretty decent pain tolerance but if they are banking on someone just "dealing with it" ... oh hell no. My last excision (x3 this aug) .. wire is in.. they said " light compression mammo" .. they started...i loudly explained "light compression my a$$" all she did is say " dont move" .. when done i glared at the tech.. and pointed to the pinch marks ... " what part of that was the light compression" she rolled her eyes and left. .....this is why they need to feed me or drug me before procedures . I cant guarantee I will be doing this/ going through this again.

( but to answer the posters question.. surgery was great, healing as been great, swelling is gone, no dent.. all is well )

Dx 7/14/2014, LCIS, Both breasts, 1cm, 0/0 nodes Surgery 9/2/2014 Lumpectomy: Left Surgery 5/1/2015 Lumpectomy: Right Surgery 8/14/2017 Lumpectomy

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