Additional Evaluation and Treatment

After your surgery and radiation treatment, you may consider several other possible steps, depending on the type, size, and location of the DCIS.

Lymph node evaluation

Most women with DCIS do not require sentinel lymph node removal. DCIS rarely spreads to the lymph nodes. But with some types of DCIS, there is an increased risk of a hidden area of invasive cancer cells within the breast. And these invasive cells might spread to lymph nodes. Also, if you are under 50, particularly if you are under 40, your doctor might wish to do evaluate your lymph nodes.

Your doctor might recommend removal of the sentinel lymph node if you have:

• high-grade DCIS
• very large DCIS
• DCIS with early signs of possible invasion

The sentinel lymph node—the one closest to the breast—is the "watchdog" node that's responsible for filtering out cancer cells that may be trying to go beyond the breast. So it's the most likely lymph node for cancer to travel to. After the node is removed, the pathologist examines it under the microscope, looking for any cancer cells. The results of this evaluation are included in the pathology report.

The role of sentinel lymph node removal may be decided after your first biopsy results come back or after your breast surgery is done and you have final pathology results. The decision about lymph node surgery is important because this information helps your doctors tailor the treatment plan to your specific situation.

If you have a very low risk of lymph node involvement, then there is no benefit to taking out the lymph nodes and you want to avoid any side effects that go along with removing them.

If you are at increased risk for lymph node involvement, then you want to get them checked out. The results will have a significant impact on your treatment. If they are clear, then your treatment will be relatively simple. If they are involved, then you will need more aggressive treatment.

Traditional (axillary) lymph node dissection is only considered if the sentinel lymph node or nodes contain cancer cells.

If you have already had surgery and already know the results of your pathology report, you have several possible scenarios to consider when it comes to lymph node involvement.

Does the report say you have pure DCIS?

• You don't need lymph node removal
• The risk of cancer cells going to the lymph nodes is almost zero.

Does the report say you have DCIS with microinvasion (DCIS-MI)?

• Your risk of lymph node involvement is slightly higher, but still very low.
• The cancer cells are starting to work their way through the duct or lobule but haven't gotten all the way through.
• If only a small spot of microinvasion is seen, then you probably don't need lymph node removal.
• If there are many areas of microinvasion, then your doctor may recommend a lymph node evaluation.

Does the report say you have invasive cancer between or mixed in with the DCIS (IDC-DCIS)?

• The risk of lymph node involvement is increased
• The cancer is no longer considered Stage 0
• It will be classified Stage 1 or higher, depending on tumor size and whether lymph nodes are involved
• Your doctor will probably recommend lymph node evaluation

If you have not yet had surgery and only have the results of your first biopsy report, you will still need additional surgery (lumpectomy, re-excision, or mastectomy) if all the cancer was not removed during the biopsy. If there is reason to believe there may be some invasive breast cancer as well, your doctor may recommend lymph node removal along with your next surgery. Here are some possible scenarios to consider after your biopsy report:

Does the report say that the initial core biopsy removed all microcalcifications and only DCIS was found in one area?

• You probably don't need a lymph node evaluation

Does the report say that DCIS-MI was seen?

• Your doctor might recommend a lymph node evaluation

Do other screening reports (mammogram, MRI) indicate that there are many areas of concern?

• If the biopsy was only done on one or two areas, there is not enough information about the rest of the breast
• Your doctor may recommend mastectomy if the area of involvement is too large for lumpectomy
• A sentinel lymph node procedure may be recommended at the same time as mastectomy

Do you have a large, high-grade DCIS and areas that might look like microinvasion?

• Your doctor may recommend lymph node removal.

Do you have an underarm lymph node that's enlarged or suspicious, although the biopsy only showed DCIS?

• Your doctor may recommend more than just a sentinel lymph node evaluation in case cancer cells are found in the enlarged nodes
• Remember that a normal immune reaction after a biopsy may initially cause enlarged nodes, however

Are you going to have immediate reconstruction after mastectomy?

• If there is concern about lymph node involvement, your doctor will probably recommend a lymph node procedure because it is harder to do after reconstruction, particularly with a back flap.

There are many possible situations that might arise with DCIS. If you have questions or feel uncertain about your doctor's recommendations for lymph node evaluation, seek a second opinion from another surgeon and/or radiation oncologist who will be able to get you a second pathology and radiology review.

A diagnosis of DCIS can change as more is known about the cancer. Because it is Stage 0, you have time to get the opinions you need so that you can make the best decisions for YOU.