Surgery to treat DCIS
Surgery is the main treatment for DCIS.
Surgery for DCIS usually involves an operation that keeps as much of the breast and its shape as possible – called a wide local excision (WLE).
Removing the whole breast (mastectomy) may be recommended for some women. In this case, breast reconstruction (making a new breast shape) can often be done at the same time as mastectomy or later.
Some women are offered a choice between WLE and mastectomy. Your surgeon and breast care nurse will talk this over with you and answer your questions.
Wide local excision (WLE)
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In this procedure, the DCIS is removed along with an area (margin) of normal-looking tissue surrounding it. Before the operation, you may have a mammogram done and a fine wire inserted into the breast. This acts as a marker for where the tissue should be taken from.
We have more detail about wire guided procedures available.
WLE may be the only treatment you need. Some women may have a test called a sentinel lymph node biopsy. This is to check whether the lymph nodes in the armpit contain any cancer cells. There’s more information about this procedure below.
After WLE, most women are advised to have radiotherapy to reduce the risk of DCIS returning or of an invasive cancer developing. If the area of DCIS was very small and low-grade, you may not need radiotherapy.
After your operation, the tissue that’s been removed will be sent to the laboratory for a pathologist to examine under a microscope.
It’ll be checked to make sure that there’s an area of healthy tissue surrounding the removed DCIS, which is known as a clear margin.
The chances of DCIS coming back are reduced by having clear margins.
Up to 1 in 3 women (35%) will have DCIS cells in the margin – this is known as a positive margin. If this happens, you’ll need another operation to have more tissue removed. This is sometimes called a re-excision. If your surgeon thinks a second operation is unlikely to clear all the DCIS cells, you may be advised to have a mastectomy.
Being told you need more surgery, especially a mastectomy, can be difficult news to hear. Support from family and friends, your surgeon or breast care nurse, or support organisations can help at this time.
It can be difficult to understand why mastectomy is sometimes advised to treat a non-invasive cancer. But in certain situations it’s the best treatment and usually cures DCIS. Women having a mastectomy for DCIS alone won’t need radiotherapy.
A mastectomy for DCIS removes all of the breast tissue. Breast reconstruction (making a new breast shape) can be done at the same time or later. There’s more information about breast reconstruction below.
Women with a larger area of DCIS who have bigger breasts can sometimes avoid mastectomy by having their breasts made smaller and reshaped.
Your surgeon may advise a mastectomy if:
your breast won’t look good after WLE because DCIS covers a wide area or it’s in the centre of the breast
DCIS is in different parts of the breast, known as multiquadrant or multicentric disease – if only small areas are affected it may be possible to have two WLE rather than a mastectomy.
Occasionally, women choose to have a mastectomy instead of WLE because it relieves their anxiety about DCIS coming back. Or they may want to avoid radiotherapy and its possible short- and long-term side effects. However, where both types of surgery are an option, the outlook following a mastectomy is no better than following WLE.
Women who have a mastectomy usually have a test called a sentinel lymph node biopsy (SLNB) done at the same time (see next page). If a small invasive cancer is found in the breast, the lymph nodes can also then be checked to see if they contain any cancer cells. Doing the SLNB at the same time as the mastectomy saves you having to have a separate procedure to check them later.
Losing a breast can affect your feelings of femininity, your sex life and relationships. When deciding about surgery, it’s important to take your time and to have all the information you need to make the right decision for you.
Your doctors and breast care nurse can answer any questions you may have and tell you what to expect. They may have photographs of other women who’ve had the same surgery, which they can show you.
Talking to other women who’ve already had surgery can also help – you can contact them through Breast Cancer Care. Your breast care nurse may know of a local cancer support group where you can talk to someone who’s had a similar operation.
Sentinel lymph node biopsy (SLNB)
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A sentinel lymph node biopsy is a way of checking a few of the lymph nodes in the armpit to see if they contain cancer cells. The sentinel nodes are the first ones that lymph fluid drains to from the breast, so if a breast cancer spreads, they are the most likely lymph nodes to contain any cancer cells.
Women who need to have a mastectomy usually have an SLNB done during the operation. Some women having a WLE may have an SLNB, usually if the area of DCIS is large (over 4–5cm across) and high-grade.
The nodes that are removed are examined by the pathologist to make sure there are no cancer cells. If the sentinel nodes contain cancer cells, it means there is an invasive cancer in the breast. This is no longer DCIS. We have separate information about invasive breast cancer – call us on 0808 808 00 00.
Removing the smallest possible number of lymph nodes (usually 1–3) reduces the risk of side effects that can occur after lymph node surgery. These include swelling of the arm, known as lymphoedema and stiffness of the arm (see below).
How an SLNB is done
A tiny amount of radioactive liquid, which is harmless, is injected into the breast, usually around the nipple. This can be done the day before the operation, but it’s usually done on the day of surgery. During the operation, a blue dye, which stains the lymph nodes blue, is also injected into the area. The lymph nodes that have taken up the radioactivity or become blue first are the sentinel nodes. The surgeon uses a small handheld instrument to identify the lymph nodes that have picked up the radioactivity.
Only the blue or radioactive nodes (the sentinel nodes) are removed and tested to see if they contain cancer cells.
Breast reconstruction is an operation that makes a new breast shape after a mastectomy or improves the breast shape after surgery to remove part of the breast. Women with DCIS are usually asked if they want to have breast reconstruction done at the same time as mastectomy. Having it done at the same time might help some women cope better with the loss of their breast, and it may also result in a better cosmetic appearance. It usually means a longer stay in hospital and a longer period of recovery.
Although breast reconstruction can often be done at the same time as a mastectomy, it’s common for women to need two or three operations in order to achieve a good breast shape to match the unaffected breast. It’s important to discuss the possible advantages and disadvantages of having a mastectomy with breast reconstruction with your doctor.
Some women prefer to leave reconstruction until a later time, and others may decide not have it done at all. It depends on what’s right for you.
The aim of breast reconstruction is to match the appearance of the new breast to the other breast as closely as possible. The new breast shape can be made using an implant, or skin, fat and sometimes muscle from another part of your body. Sometimes, a combination of both methods is used.
Occasionally, women with bigger areas of DCIS and larger breasts can have the DCIS removed and both breasts reshaped. The treated breast will be smaller than before, so the other breast is reduced in size to leave you with a symmetrical appearance. There is a higher risk of short-term complications following this operation, but often only one operation is needed and the results are usually good.
Your breast surgeon and breast care nurse will tell you more about the types of breast reconstruction that are suitable for you.
We have more information about breast reconstruction.