Mastectomy & Reconstruction Surgery

hmr

As I previously posted, my mother was diagnosed with DCIS and had a lumpectomy. The margins weren't clear so she had to have a second lumpectomy ( aka re-incision surgery ? ). The pathology report from this second surgery came back unfavorable. The general surgeon phoned her and informed her that she will need a mastectomy. I spoke with him and this is the explanation that he gave me regarding the mastectomy and reconstruction surgery :

 At the same time that the mastectomy is performed a plastic surgeon will be there to implant a tissues expander. This tissue expander will remain in place for 3 to 4 months then be removed and the breast implant inserted. The general surgeon told me that the pathology report from the mastectomy will dictate whether or not radiation is required ( how clear the areas are adjacent to muscle, etc. ). He did state that tamoxifen tx would very likely be recommended as a preventative measure to protect the other breast. Back to the plastic surgeon ... her general surgeon mentioned to me that some plastic surgeons don't like to start the reconstruction process, including impanting the tissue expander, until radiation is complete. What do you think ? Does it matter. Her general surgeon doesn't seem to think so and the plan is to do the mastectomy and tissue expander implant together.

Thanks much for any input !

lvtwoqlt

Hmr, I was dx with DCIS and did bilat mast with recon. Because my cancer was contained within the breasts and not near the chest wall, I didn't need rads and the plastic surgeon was able to put the expanders in at the time of my mastectomy surgery. Your best bet is to get a consultation with a couple of plastic surgeons to see what their opininon is on rads and expanders. There are differing opinions regarding when to do rads and expanders. Some like to expand fully before rads where others want to wait to expand after rads a lot will depend on your mother's specific dx.

Sheila

mom3band1g

I asked my ps about the tissue expanders and rads and he was fine with it.  I think they would just delay the rest of the recon process until we were done with rads.  Hope this  helps.

concernedsis

Get your mom to an oncologist b4 further surgery if you can. You need someone who sees the whole picture not just the tumor.

If she is having a mastectomy, your reasons offered above are not clear - why now - were the margins still not clear? Were any tests done like MRI b4 surgery? Will she have or did she have a node biopsy?

To strictly answer your question - see a plastic surgeon preferably at a cancer center. Choices include no reconstruction, imediate or delayed reconstruction and implants vs tissue transfers.Every place seems to do it differently. You can have rads with TE in but some rad oncs dont like it.

My sis' PS said if she had had surgery without an immediate TE then he would not offer an implant as an option after rads. She did not want a tissue transfer so that made her decision right there. She had her surgery with TEs, fills and then rads and will have an exchange to implant in 6 months. Tissue transfers like DIEP may not work really well on irradiated skin.

Sounds like you need more info to make an informed choice.

Good luck

roseg

If your Mom thinks she wants reconstruction then she needs to go see the plastic surgeon before surgery. They all have opinions about how they want to do things.

Usually implant reconstruction is more complicated after radiation because the tissue expands differently and is sometimes more prone to post-operative infection.  Some plastic surgeons will advise a different type of reconstruction if you've had radiation while others like to do their part before you have radiation to avoid the stiff tissue problem.

 Thus - see the plastic surgeon first and get the facts from them before you schedule anything. You have many appointments with a plastic surgeon so you may want to interview several to find the one that you like and works out for you.

DCIS is not an emergency so several weeks spent working out the plastic surgery details is not a problem. Take your time and do you homework on this for the best results.

hmr

P.S. My mother is having a difficult time making a final decision on the mastectomy. Do any of you have any statistical data on DCIS outcome if she doesn't get the mastectomy ? ( I assume that she would still receive the radiation tx and tamoxifen tx ). She has had a lumpectomy and re-incision surgery. I haven't seen the pathology report for the second re-incision surgery. Her surgeon phoned her earlier in the week and told her that she now needs the mastectomy. Part of the confusion for her is that her surgeon is throwing around too many terms, conditions, stats, etc. in addition to performing two unsuccessful surgeries ( that he thought would do the trick ). She is experiencing  DCIS overload at the moment.

Thank you very much for any input that you can share.

KAR

I second above comments about seeing an oncologist then plastic surgeon, for me the oncologist sealed the deal.  My surgeon told me that they could do a re-excision twice and that I didn't need a mastectomy but oncologist explained that I after re-excision and rads I would be left quite deformed (Im small chested).  In the end I trusted the Onc.  The Onc. would be able to explain the stats, as they vary depending on person and path rpt.  You definitely should see plastic surgeon before MX, as they will tell you how they would handle radiation, I think they like to get your Tissue Expanders filled before rads, but I'm not sure because I didn't need it.   There are also reconstruction methods that use your own tissue, so you always have options.  If you go to the reconstruction threads you might find some info on reconstruction and rads.

Good luck, and yes I remember the "DCIS overload" it will get better eventually    

3monstmama

I think overload is something we can all relate to.  The plus side of DCIS is that as it is not a fast growing cancer, you can take the time to step back and think and research a bit before you take big steps.  And a mastectomy is certainly a big step.

Like others, I would consult with a regular oncologist as well as more plastic surgeons.  If her surgeon isn't explaining the path report so she can understand it, thats unacceptable.  Make an appointment.  Have them draw pictures--whatever it takes.  Is the problem that there is DCIS everywhere so thats why they can't get good margins?  Unfortunately, your mother wouldn't be the first person to have that experience.

I will tell you that both plastic surgeons I met with said they would not do expanders/implants with radiation.  The problem is that radiated tissue typcially doesn't react the same as non-radiated tissue including the ability to stretch.The one in particular said that he had seen too many bad results with implants and rads.  Same guy was also a delayed reconstruction person because, per him, it is better to complete treatment and know that you are done [well, as best you can know it] than to go through a big procedure and then have to have more surgery for cancer before you are healed.To me, what he said made sense because they don't get the pathology reports back right away so how can they know for sure what my treatment was going to be or even exactly what my cancer was going to be?

Take deep breathes.  When you have more information, the overload fog will clear.

hmr

Thanks to all for the replies.  3monstmama asked if there was " DCIS everywhere " in the breast. I spoke with my mother's surgeon by phone earlier in the week and that's exactly what he stated. She ( and I ) have an appointment with the surgeon today. I plan to get more specifics from him and a copy of the pathology report from surgery # 2. I will post any new info from today's visit.

hmr

P.S.S. The office visit with the surgeon is over. He made a couple of interesting diagnostic comments that I'd like to share with you and, hopefully, get some feedback from you.

He stated that my mother has DCIS scattered throughout her breast. He added that he doesn't expect to find invasive cancer as both pathology reports ( from the first two breast surgeries ) came back " All DCIS ". He stated that usually if there is invasive cancer involved that the pathology reports would have revealed some indication of this. However, he said that this interpretation, while highly suggestive, isn't conclusive and that he's been tricked before. He said that he will be examining ( and maybe biopsy ) the sentinel lymph node during the mastectomy. She has an appointment scheduled for the end of the month with a plastic surgeon. The mastectomy / reconstruction is tentatively scheduled for mid-April.

Thanks again to all for the feedback. It's been very helpful and much appreciated.

mom3band1g

Your Mom's DCIS sounds exactly like mine.  My mast with SNB is scheduled for March 25th.  Here's hoping for no 'surprises' and clear margins for your Mom and myself!

KAR

hmr: Sorry to hear that your moms dcis is scattered throughout but thats exactly how mine was, a little here, and some atypical cells there.  Anyway, I also had Sentinel Node biopsy at the time of MX because there is no guarantee that there isn't some invasive component mixed in and you cant go back and do a SN biopsy after you've had MX because there is no breast tissue left.  The SNB is where they inject radioactive dye in the breast and then see what lymph node or nodes it drains to, they may remove the S node and send to pathology to check for cancer.   I would rather have the SNB than have a bunch of lymph nodes removed later if there is an invasion.  In my case my diagnosis stayed DCIS, and hopefully your mothers will too.  

mom3band 1g:  Good luck to you on the 25th, you'll do fine