Lumpectomy done, but now second surgery

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Remali
Remali Member Posts: 36
edited April 2017 in Surgery - Before, During, and After

So, my lumpectomy went well, the surgical team was wonderful, and I was always comfortable, before, during, and now, after.  I am just two days out from the surgery, and I get a phone call this morning from the surgeron.  Seems the tumor was much larger than they thought, and it also appears that the margins on one side were quite close... so, in other words, the surgeon wants me to come back for a second surgery to get the rest of that area... fairly soon.  My issue with this is... I am only 6 months out from a heart attack and stent placement, so going off of the Plavix, again, this soon, is risky.  There is a possibility of the stent restenosing and/or blood clot forming, and of my having another heart attack because of that.  Cardiologists want me on Plavix for a full year, but of course I do need these surgeries, so then we stop the Plavix for 5 days.  I am not so sure we should proceed quite so quickly with the second surgery, and I feel as if i should be back on the Plavix for awhile again, at least a couple of weeks.  I am waiting to hear back from my cardiologist about this.

I am thinking and wondering... was my surgeon perhaps careless, and messed up?  How often does something like this happen?  Seems rather sloppy to me, in this day and age, to not take out enough of the tumor.  Any thoughts on this (??), or people out there who have had experience, or knowledge of, second surgeries due to this occuring is appreciated.  Thanks!

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  • SpecialK
    SpecialK Member Posts: 16,486
    edited April 2017

    Roughly 20% of lumpectomies need re-excision after the first surgery, usually for exactly the same reason as you - a close or inadequate margin.I have a good friend, diagnosed at 69 who needed one, but her surgeon did allow her to take a pre-arranged 3 week trip to London and Tuscany first. Have you spoken to your cardiologist about the Plavix plan to get an opinion in light of the need re-excision?

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  • Icietla
    Icietla Member Posts: 1,265
    edited April 2017

    No, it is not at all unusual for re-excision to be needed to get better margins, nor is it unusual for prior imaging to indicate some substantial difference from the actual tumor size.

    My excisional biopsy was meant to get all of my tumor, but the excised tissue had a diseased margin. My tumor was more than twice the size indicated from imaging.

    I hope your re-excision will go just as smoothly as your recent surgery.

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  • mustlovepoodles
    mustlovepoodles Member Posts: 2,825
    edited April 2017

    I wouldn't jump to the conclusion that your surgeon is inept. The trouble with biopsies is that cancer tissue often looks like normal tissue., especially in a small tumor. Re-excision is fairly common and very safe.

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  • LisaAlissa
    LisaAlissa Member Posts: 1,092
    edited April 2017

    And in fact, you probably want a surgeon who needs to clean-up margins sometimes. If you have a surgeon who never has to clean up margins in a second surgery, you undoubtedly have a surgeon who routinely removes healthy tissue. (Not sure what the "optimum" percentage would be.)

    Just another perspective...

    LilsaAlissa

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  • ruthbru
    ruthbru Member Posts: 57,235
    edited April 2017

    Another re-excision here. As others have said, it is pretty common.

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  • ChiSandy
    ChiSandy Member Posts: 12,133
    edited April 2017

    Latest thinking out of UCLA/City of Hope is that “no tumor on ink” constitutes clear margins not needing re-excision, despite how narrow that margin may be. Obviously, not all breast cancer centers are willing to take that chance…yet.

    I say “yet” because as recently as the early 1990s most breast cancer surgeons still believed that lumpectomy was foolhardy. And in 1974, modified radical MX—in which pectoral & arm muscles were not removed--was finally considered std.-of-care rather than “progressive:” most mastectomies until then took everything down to the chest wall, including all lymph nodes. The “simple” mastectomy—leaving non-involved nodes intact—was considered wild-eyed revolutionary. And few surgeons were willing to do a biopsy without an immediate mastectomy should the frozen section—sent to the path lab while the surgeons waited with the patient still asleep--show a malignancy—if you found a lump, you went under general anesthesia, and the only way you knew whether or not the biopsy was benign or malignant was if you woke up with or without that breast—as my MIL did at 64. She had radiation but no chemo, and lived till a massive stroke took her at nearly 96. Nobody knew back then about grades, subtypes, hormone-receptors, HER2, node status or anything other than stage, based purely on size and whether there was evidence of distant mets. (All nodes were removed, so there was no such thing as “sentinel node biopsy;” all biopsies were surgical and performed with the expectation that immediate mastectomy could follow). And obviously, no mammography, CT, MRI or ultrasound.

    And mastectomy, the default being at least a modified radical, was considered so traumatic and mutilating that nobody would ever dream of suggesting a BMX without finding a lump or nipple-inversion in the other breast.

    Obviously, standard-of-care has changed to offer more options—both more and less invasive—than a generation ago.

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  • Lexicoe
    Lexicoe Member Posts: 66
    edited April 2017

    Sandy is right--guidelines were revised in 2014 to say that even one cell clean margin is enough after a review of the research showed there was no advantage to getting wider margins. (Article here although I think NIH has even more recent research on the issue http://www.breastcancer.org/research-news/20140402).

    I just recently went through this debate because two of my margins were close (only 0.03mm on one side) and RO wanted wider margins and consulted a second surgeon, who agreed with first surgeon that re-excision was not needed because of this research.

    So the decision was made not to re-excise, as long as nothing was seen on an breast MRI that I had earlier this week. (Post-op MRI isn't normal, but an MRI wasn't done before surgery, as it should have been with ILC.) It is only because the MRI saw suspicious spots not consistent with healing that I'm having a re-excision this coming week.

    But if I had the concerns that you have about going off the Plavix again, I might have pushed back about doing another surgery. After all, radiation should eliminate any potential stray cells.

    I only mention the point about my MRI because that could be an option to ask your doctor about if he/she is insisting on re-excision.

    But you may want to start by askingyour surgeon about this research and or/get a second opinion about the margins.



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  • Remali
    Remali Member Posts: 36
    edited April 2017

    Thank you so much everyone, you have all really been so helpful.  I agree, I do want a surgeon who is careful and will want to do another surgery if it is needed.  I just wasn't quite sure, and now that I know more about this... I can see that my surgeon is being careful and doing a good job....whew.

    I am uneasy that he has not consulted oncology yet or my cardiologist.... but I did put in a call to my cardiologist, and he suggested I stay on my Plavix for now, until the surgeon gives me a date for the second surgery...so I am relieved about  that.  I have also made an appointment with an oncologist (he was my mother's oncologist so I know him and trust him).

    Appreciate all of your helpful advice and information... I am going to now read the links you provided.  Thank you!  



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  • Apalmat1
    Apalmat1 Member Posts: 3
    edited April 2017

    For those talking about IDC vs ILC there is a big difference in how the tumors grow, what you should know before surgery, as well as what's recommended for follow up.

    ILC is much trickier to get clear margins with it. It is often much, much larger upon surgery than known with scanning as the tumors can hide in dense breast tissue. Many ILC Tumors do not show up at all on Mammography and some may not show up on MRI as well.

    Also important for those with ILC to know that more often than with IDC, ILC tumors can grow in both breasts, and with the way they can hide, it is now recommended people take all this into consideration when they decide on surgery.


    ILC also does not respond well to adjunct chemotherapy. 3-5 % response rate, so surgery choices are very important.

    Lastly, follow up is also more difficult with ILC. It's important to understand that there is no good affordable follow up scanning to remaining breast tissue that gives you more than about a fifty percent chance of finding Tumors in your breasts if they are dense tissue. Mammograms are only about 48% effective at finding Tumors in dense tissue, and Digital mammograms are only about 60% effective.

    If you have a reoccurrence it can also be difficult to find with scans due to unigue way it spreads and grows. It has more of a tendency to grow in the peritoneal space thickening tissue rather than forming lumps and nodules.


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  • SJI
    SJI Member Posts: 69
    edited April 2017

    I have ILC and may be looking at a second surgery. It was really difficult to mark the ends of my "string of pearls" so the surgeon wants another MRI once I've healed up from the lumpectomy. He wants to make sure he got both ends. It makes me wonder if a mx wouldn't have made more sense. As it is now I will need to have annual MRIs.

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  • ShetlandPony
    ShetlandPony Member Posts: 4,924
    edited April 2017

    Amalpat, please cite your source for your comment about chemotherapy for ILC. It is my understanding that ILC is less likely to have pathological complete response (PCR) to chemotherapy, but this does not mean that chemotherapy is ineffective for ILC.

    http://ascopubs.org/doi/full/10.1200/jco.2005.03.1...

    https://academic.oup.com/annonc/article/22/11/2532...

    https://link.springer.com/article/10.1007/s10549-0...



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