Lumpectomy then Mastectomy - WHY?

jessie123 · January 2019

My hope now is Lumpectomy, However, I see quite a few members on this board have a mastectomy soon after a lumpectomy. What causes the need for this? How many nodes need to be involved to need further surgery? What about that prognostic test that many take to determine if they need chemo.-- is that the reason?

santabarbarian · January 2019

There seem to be a variety of reasons... genetic risk, avoiding chemo, peace of mind, required for an invasive cancer, family history, etc. It could be their tests suggest it will reduce their future risk. But generally I notice there is quite a bit of wiggle room and often the patient has a deciding voice in the matter. Many women opt for mastectomy when the doctor is not absolutely insisting on it.

In my case, which is a bit odd as it's TNBC, M & L have even odds of survival. So for me lumpectomy was no brainer. (However, my surgeon was careful to call it a "partial mastectomy" because she does not want to minimize the possible severity, or pain in healing.) My surgeon did a fabulous job and my breasts look VERY even and yet she took a chunk. She did it in such a way that it is hard to see and I do not have large breasts. I am thrilled with the outcome and avoiding plastic surgery.

I also asked for, and got, many fewer nodes taken than would have been strictly standard, but I asked, and I promised my surgeon she could go back for more nodes if I she found any live cancer in the sentinels. Luckily she did not. If I had not objected at the thought of removing so many nodes when my images were perfect for no cancer, but had just nodded my head, I would have had all all my axillary lymph nodes taken.

For me the medium sized risk of lymphedema and mobility/pain issues way more than counterbalanced the tiny risk of there being some micron of cancer that radiation can't take care of, as I have to get radiation regardless, and my known cancer had died but good.

jessie123 · January 2019

Santabarbar --- I have read so much trying to make the decision -- the radiation after lumpectomy was kind of scary. Want to let you know that they have a new radiation machine or equipment that protects your heart and lungs. You lay on your stomach and your breast goes through a hole. I did not think my mid sized city would have it, but after calling the different hospitals I found it. You might want to look into it also.

santabarbarian · January 2019

Yes I heard about those but I think I will actually pursue proton radiation. I have left sided cancer. With TNBC you have to get rads period, even w mastectomy.

AliceBastable · January 2019

I thought a lumpectomy IS a partial mastectomy. That's what all the literature at the surgeon's office said.

santabarbarian · January 2019

Yes, that's right but most people say lumpectomy and don't necessarily consider that it is a partial mastectomy.

Salamandra · January 2019

I don't *think* it's generally about involved nodes, nor about oncotype (that's the test that helps determine chemo).

I think that common reasons are:

Difficulty getting clear margins - either if it seems like it may take a bunch of tries or may not be possible
Later imaging that shows the possibility of problematic masses or calcifications elsewhere in the breast or in the other breast
Getting the result back of a genetic test that shows increased risks - BRCA, etc - for an unrelated local or contralateral recurrence

The last two - presumably the lumpectomy procedure could have been avoided if the timing of the imaging or genetic testing had worked out better. I hope that insurance companies will start making it easier and faster for women to get those.

Less common reasons:

A woman wants to preserve her ability to breastfeed, but then get the peace of mind of a mastectomy later
A woman is not able to follow through with radiation in a timely way, and opts for mastectomy instead

If the sentinel nodes are positive for cancer, that could lead to a future axillary dissection surgery (although that is getting less popular). But not a mastectomy.

jo6359 · January 2019

santabarbarian-my images from breast MRI and PET scan showed no node involvement. My surgeon informed me the only way to know for certain is with the SNB. I ended up with one positive node out of 18. I definitely had concerns about lymphedema. Under normal circumstances he would have only taken a few but unfortunately my breast MRI found a second tumor so he wanted to be sure. initially I was scheduled for a lumpectomy. My surgeon did inform me a lumpectomy is a partial mastectomy. The second tumor removed the option of a lumpectomy. A few women on these threads did have a lumpectomy even with two tumors. According to them it depending on the size and the location of the tumors.

MDRR · January 2019

My lumpectomy was followed by a mastectomy based on the pathology of the excised tumor; it was found to be invasive but had not appeared that way in the tests. I could have had a much bigger piece of tissue removed in a 2nd lumpectomy, but decided to do the mastectomy once I knew it had become invasive.

jessie123 · January 2019

When I say mastectomy I mean or think of total breast removal. If a tumor is small enough and in my case the patient has large breasts it seems the scar won't be that noticeable. My tumor is on the outer side of my breast at 2;00. The tumor is 1.3 cm according to ultrasound. It seems like I won't notice it that much after everything heals. Am I thinking right? I wish this board had pictures. Like what does a healed total breast removal without reconstruction look like. What does the different types of construction look like. My friend told me she has a scar over her reconstruction. Is that correct --- she had the expanders and then reconstruction. This board needs a special pictures page in their help section. It would be helpful to people in making their decisions.

Salamandra · January 2019

I think a site with pictures could be very useful.

My imaging showed a 1.3cm tumor, that turned out to be 1.8cm, plus about 3cm of DCIS. But the surgeon was able to get it all out with clear margins on the first try, and to me my breast doesn't look any different. Even though, between all that, she must have actually taken out quite a chunk!

I don't know about the question about reconstruction. I know there are many different options for reconstruction surgery, and I guess it depends somewhat on which option a person takes.

I agree that images could be a very helpful resource for BCO to incorporate or link to if they already exist elsewhere.

NoWhyToIt · January 2019

jessie123,

When it comes to this it is really individual, based on size of tumor, breasts, position etc. I don't think images would help you all that much. With a lumpectomy how it looks later depends on if you get radiation, and tumor size most of all. Radiation has an effect on the firmness of the breast overall. I would not expect it to look exactly has before, but I'm sure that has happened to people, too. The best person to ask is your doctor who has seen it all.

bella2013 · January 2019

I had BMX after lumpectomy because I had two places in the margins that were in question. The were also a far distance apart. There was no breast tissue in those areas, just skin and muscle. My BS would be taking a huge area of skin...sounded like a mastectomy to me. Also because of the lumpectomy there was a lot known about my cancer. I decided both breasts with reconstruction. I have not regretted my decision.

I believe there is a very private forum on here with photos. You have to request access

SpecialK · January 2019

You can join realself.com and see many photos of lumpectomy and different types of mastectomy.

You can also google and find photos of different types of breast cancer surgery on plastic surgeon websites for ideas about how these procedures look afterward.

The photo forum that many BCO members participate on is a privately managed siteand not part of BCO proper.

Lumpectomy then Mastectomy - WHY?

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