Lumpectomy

Time enough to absorb the volumes of information provided, discuss issues with family, obtain second opinions if desired, and consult with other specialists such as radiation oncologists and plastic surgeons. Usually this will be two to three weeks. An MRI may be ordered as well, in the time between diagnosis and surgery. I usually allow a week between MRI and a surgery date to act on the results if need be. There is no set time limit. Some patients want surgery as soon as possible; others wish to research more themselves. Time enough to absorb the volumes of information provided, discuss issues with family, obtain second opinions if desired, and consult with other specialists such as radiation oncologists and plastic surgeons. Usually this will be two to three weeks. An MRI may be ordered as well, in the time between diagnosis and surgery. I usually allow a week between MRI and a surgery date to act on the results if need be. There is no set time limit. Some patients want surgery as soon as possible; others wish to research more themselves.

Generally lumpectomy is offered for unifocal (one site of disease), and the patient is willing to undergo radiation. If the tumor is large relative to the breast size, neo-
adjuvant (up-front) treatment may be given to shrink the cancer before lumpectomy.

Questions to ask would be:
How large is the cancer? Can clear margins be obtained? Should I receive chemotherapy or endocrine therapy prior to surgery to shrink the tumor? How will the incision lines be placed? Will oncoplastic techniques be used? How much deformity will there be? Is there a reason not to preserve the breast?
Generally lumpectomy is offered for unifocal (one site of disease), and the patient is willing to undergo radiation. If the tumor is large relative to the breast size, neo-
adjuvant (up-front) treatment may be given to shrink the cancer before lumpectomy.

Questions to ask would be:
How large is the cancer? Can clear margins be obtained? Should I receive chemotherapy or endocrine therapy prior to surgery to shrink the tumor? How will the incision lines be placed? Will oncoplastic techniques be used? How much deformity will there be? Is there a reason not to preserve the breast?

For me this was not a difficult decision. When I learned that there was no survival benefit for mastectomy in my case, I decided to keep my breast and have radiation therapy. The prospects of a smaller surgical procedure as well as my appearance and sensation all seemed positive.

However, if I had carried the BRCA gene or if any other medical situation had made mastectomy an appropriate choice, I would not have hesitated to choose it. For me this was not a difficult decision. When I learned that there was no survival benefit for mastectomy in my case, I decided to keep my breast and have radiation therapy. The prospects of a smaller surgical procedure as well as my appearance and sensation all seemed positive.

However, if I had carried the BRCA gene or if any other medical situation had made mastectomy an appropriate choice, I would not have hesitated to choose it.

I honestly never considered a lumpectomy. I wanted to be as aggressive as possible and leave no breast tissue behind. I was young and had a fairly large tumor and lymph node involvement so I felt like that was the best choice for me. I honestly never considered a lumpectomy. I wanted to be as aggressive as possible and leave no breast tissue behind. I was young and had a fairly large tumor and lymph node involvement so I felt like that was the best choice for me.

Thanks to early detection through screening mammography and self-exam, many women diagnosed with breast cancer have early-stage or small tumors. In these cases, breast conservation surgery, or lumpectomy, is definitely an option. The goal with a lumpectomy is to remove the tumor and a rim of normal tissue (the "margin") while preserving the cosmetic appearance of the breast as much as possible. Lumpectomy does need to be followed by a course of radiation therapy. It is important to note that there is no difference in long-term survival if a woman undergoes a lumpectomy versus mastectomy - lumpectomy with radiation therapy is a perfectly appropriate cancer treatment. Certain situations call for mastectomy for example very large cancers, or more than one cancer in the breast, but in many cases, breast conserving surgery is possible and is very appropriate. Thanks to early detection through screening mammography and self-exam, many women diagnosed with breast cancer have early-stage or small tumors. In these cases, breast conservation surgery, or lumpectomy, is definitely an option. The goal with a lumpectomy is to remove the tumor and a rim of normal tissue (the "margin") while preserving the cosmetic appearance of the breast as much as possible. Lumpectomy does need to be followed by a course of radiation therapy. It is important to note that there is no difference in long-term survival if a woman undergoes a lumpectomy versus mastectomy - lumpectomy with radiation therapy is a perfectly appropriate cancer treatment. Certain situations call for mastectomy for example very large cancers, or more than one cancer in the breast, but in many cases, breast conserving surgery is possible and is very appropriate.

The sooner you can resume normal activities the better off you are. I don't mean push it, and I don't mean start doing jumping jacks. Start walking and add distance incrementally. And do this every day. One block, two, three, until you're comfortably walking a mile or so.

Equally important is the rehabilitation of your arm. If you haven't had physical therapy many excellent resources are mentioned above. You can run through arm exercises in fifteen minutes or so. I still do so to this day. After full lymph dissection and radiation the natural tendency of the arm and skin is to retract and tighten.

One of the best things I'e found is yoga. Many cancer treatment centers (in Houston through MD Anderson and Memorial Hermann) now offer yoga for cancer survivors. It's excellent and a gentle way to reduce stress.
I would assume that if you are back to work you are at least 6 to 8 weeks out of surgery. Most doctors will recommend you don't start an exercise program until you are 6 to 8 weeks out of surgery, so make sure you have your doctor's permission to exercise before starting a program. That being said, I always start with flexibility and range of motion. After surgical procedures related to breast cancer, we have a tendency to sort of hunch over in a forward position which causes tightening in the chest muscles and weakness in the upper back muscles. If you are going back to work in an office, this would probably mean you are sitting at a desk and working on a computer, which puts you automatically in the above-mentioned position. So, what are some exercises you can do at work to regain range of motion and flexibility?

I would start by sitting up straight in your chair, and doing some shoulder rolls. Shoulder rolls are great because they "set" your posture. So sit up straight in your chair and squeeze your shoulders up towards your ears, then drop them down while squeezing them back towards each other, then drop them down as if you are putting your shoulder blades in your back pocket. This is an exaggerated version of a shoulder roll, but it gets your shoulders moving and pulls them down and back where they belong. Try a few of these by doing the exaggerated version first, then simply roll them up, back and down.

Let me know if this helps!!

For a video of flexibility exercises you can do at home or at work, go to http://www.movingonfromcancer.com

It's very important to realize that there is NO difference in overall survival if a woman undergoes mastectomy versus lumpectomy + radiation therapy - this is why we can offer women with relatively small breast cancers the option of breast conservation. It is still thought by many women that they will live longer if they undergo mastectomy, but this simply is not true.

With modern treatment, the risk of local recurrence (in the skin or chest wall) after mastectomy is approximately 1-3%. After lumpectomy and radiation therapy it is slightly higher, but with attention to obtaining clear margins, it can be less than 5%. It's very important to realize that there is NO difference in overall survival if a woman undergoes mastectomy versus lumpectomy + radiation therapy - this is why we can offer women with relatively small breast cancers the option of breast conservation. It is still thought by many women that they will live longer if they undergo mastectomy, but this simply is not true.

With modern treatment, the risk of local recurrence (in the skin or chest wall) after mastectomy is approximately 1-3%. After lumpectomy and radiation therapy it is slightly higher, but with attention to obtaining clear margins, it can be less than 5%.

In general, a lumpectomy (most often performed with a sentinel lymph node biopsy) is done as an outpatient surgery, meaning the woman will go home the same day. The usual time to return to fully normal activities can be anywhere from 1-4 weeks, depending on the patient, underarm discomfort (generally this is worse than the breast discomfort) and various other factors.

After a mastectomy, some patients go home the same day, although I think most commonly patients are in the hospital for 24-48 hours. I will also depend if reconstruction is performed and what type - patients that undergo muscle flap reconstruction may spend 3-5 days in the hospital. Recovery can vary from just a few weeks up to 6-8 weeks, again depending on the type of surgery / reconstruction, amount of pain, and other factors. After mastectomy, drainage tubes are commonly left in place and may remain for 1-2 weeks. In general, a lumpectomy (most often performed with a sentinel lymph node biopsy) is done as an outpatient surgery, meaning the woman will go home the same day. The usual time to return to fully normal activities can be anywhere from 1-4 weeks, depending on the patient, underarm discomfort (generally this is worse than the breast discomfort) and various other factors.

After a mastectomy, some patients go home the same day, although I think most commonly patients are in the hospital for 24-48 hours. I will also depend if reconstruction is performed and what type - patients that undergo muscle flap reconstruction may spend 3-5 days in the hospital. Recovery can vary from just a few weeks up to 6-8 weeks, again depending on the type of surgery / reconstruction, amount of pain, and other factors. After mastectomy, drainage tubes are commonly left in place and may remain for 1-2 weeks.

I went into my pre-op appointment thinking that I was going to go with a lumpectomy and then I spoke with my oncology surgeon. She said that I could go with a lumpectomy and radation but because of my age (26yrs old), the odds of recurrence doubled versus going with a mastectomy. If I chose a lumpectomy, the odds of a recurrence in my case were 10-20% versus a 5-10% recurrence rate with a matectomy. I did not want to blame myself for a recurrence if I chose a lumpectomy so for me it came down to doing everything in my power to lower my chance of ever having to go through this again. My choice was solely based on peace of mind,although my right breast was never infected. I had four tumors and lymph node infected on the left side. For me, it made more sense to reduce the amount of breast tissu available to make sure I had less chances of recurrence. Was I right? I hope so. Anyway, I don't stay up at night wondering if I should have. That way, I feel like I have done everything in my power to make sure it wouldn't come back. Being only 34 at the time of the diagnostic and with two toddlers, it was the only choice that made sense. I choose the live and not having to go through this again. Besides, doing it both sides helped to facilitate reconstruction, which was not a small benefit! :)

Mary

There is no real difference between the two. It is more a matter of technique than of the goal of removing the tumor. The problem with DCIS is that is can spread microscopically, unseen by the eye of the surgeon who is performing the surgery. So, even though you may have only a small area of microcalcifications, it is often prudent to remove a larger portion of breast tissue to be sure that all of the DCIS is removed - which will be confirmed by the pathologist at the time the specimen is examined under the microscope. There is no real difference between the two. It is more a matter of technique than of the goal of removing the tumor. The problem with DCIS is that is can spread microscopically, unseen by the eye of the surgeon who is performing the surgery. So, even though you may have only a small area of microcalcifications, it is often prudent to remove a larger portion of breast tissue to be sure that all of the DCIS is removed - which will be confirmed by the pathologist at the time the specimen is examined under the microscope.

The minimum amount of breast cancer that can be detected depends on what type of cancer you are dealing with. In terms of a lump or mass (usually representing an invasive ductal cancer), a tumor as small as 3-4 millimeters (25 millimeters = one inch, so 3-4 millimeters is well under 1/4 of an inch) can sometimes be seen on mammogram, ultrasound or MRI, depending on the density of the breast tissue. DCIS, or in-situ (or noninvasive) cancer often does not form a mass, and typically is detected when microcalcifications are seen on mammogram - again the amount of disease can range from just a few millimeters to a much larger area. Unfortunately both non-invasive and invasive cancers can be present without microcalcifications or a mass on imaging, so sometimes it is very difficult to get a true idea of the extent of disease before surgery. Once the tissue is removed, the pathologist will measure the size of the cancer - it may be larger or smaller than what was anticipated based on the imaging studies.

As far as the minimum amount of breast tissue removed at lumpectomy - it really varies tremendously - there is no standard. The goal of a lumpectomy is to remove the tumor and a "margin" - a rim of normal breast tissue - and still preserve as best possible the cosmetic appearance of the breast. There remains considerable debate on what an adequate margin is - some will be comfortable with no cancer cells right at the edge of the specimen, and some like to go for a wide margin, as large as one centimeter (10 millimeters) or greater. As in many areas, the truth is probably somewhere in between - usually 2-5 millimeters is generally acceptable for invasive cancer and 5 millimeters or greater for DCIS. But as I mentioned in the paragraph above, it can sometimes be difficult to estimate the true extent of the cancer, which makes it very difficult to give a good estimate prior to surgery of just how much tissue will be removed. In addition, at the time of surgery sometimes areas of adjacent tissue look or feel abnormal - it's sometimes a judgement call how much to remove. We try to balance between not having to return to the operating room due to positive margins, versus the poor cosmetic results of removing too much normal breast tissue.

There are some devices being evaluated that are looking at intraoperative margin assessment - being able to tell during the surgery if breast tissue at the edge of the tumor has cancer cells or not. These devices are under investigation, but do seem promising for providing the surgeon more information during the procedure regarding how much tissue to remove. The minimum amount of breast cancer that can be detected depends on what type of cancer you are dealing with. In terms of a lump or mass (usually representing an invasive ductal cancer), a tumor as small as 3-4 millimeters (25 millimeters = one inch, so 3-4 millimeters is well under 1/4 of an inch) can sometimes be seen on mammogram, ultrasound or MRI, depending on the density of the breast tissue. DCIS, or in-situ (or noninvasive) cancer often does not form a mass, and typically is detected when microcalcifications are seen on mammogram - again the amount of disease can range from just a few millimeters to a much larger area. Unfortunately both non-invasive and invasive cancers can be present without microcalcifications or a mass on imaging, so sometimes it is very difficult to get a true idea of the extent of disease before surgery. Once the tissue is removed, the pathologist will measure the size of the cancer - it may be larger or smaller than what was anticipated based on the imaging studies.

As far as the minimum amount of breast tissue removed at lumpectomy - it really varies tremendously - there is no standard. The goal of a lumpectomy is to remove the tumor and a "margin" - a rim of normal breast tissue - and still preserve as best possible the cosmetic appearance of the breast. There remains considerable debate on what an adequate margin is - some will be comfortable with no cancer cells right at the edge of the specimen, and some like to go for a wide margin, as large as one centimeter (10 millimeters) or greater. As in many areas, the truth is probably somewhere in between - usually 2-5 millimeters is generally acceptable for invasive cancer and 5 millimeters or greater for DCIS. But as I mentioned in the paragraph above, it can sometimes be difficult to estimate the true extent of the cancer, which makes it very difficult to give a good estimate prior to surgery of just how much tissue will be removed. In addition, at the time of surgery sometimes areas of adjacent tissue look or feel abnormal - it's sometimes a judgement call how much to remove. We try to balance between not having to return to the operating room due to positive margins, versus the poor cosmetic results of removing too much normal breast tissue.

There are some devices being evaluated that are looking at intraoperative margin assessment - being able to tell during the surgery if breast tissue at the edge of the tumor has cancer cells or not. These devices are under investigation, but do seem promising for providing the surgeon more information during the procedure regarding how much tissue to remove.

Pain can occur after lumpectomy due to fluid collection, scar tissue as well nerve involvement. The pain does usually resolve over time. Everyone is different and it depends how extensive the surgery was and how long your body takes to reabsorb the fluid and scar tissue. If the pain is caused by nerve involvement this might take longer to recover from. Pain can occur after lumpectomy due to fluid collection, scar tissue as well nerve involvement. The pain does usually resolve over time. Everyone is different and it depends how extensive the surgery was and how long your body takes to reabsorb the fluid and scar tissue. If the pain is caused by nerve involvement this might take longer to recover from.

This is true. In the United States, most surgeons cannot get clear margins approximately 20% of the time after lumpectomy. This is because of microscopic disease which is disease that is too small to see with the naked eye. I always explain to may patients that some tumors have these microscopic extensions which is impossible to see during the surgery. Only the pathologist can see this small disease when examining the tissue under the microscope. Some surgeons always take additional margins at the time of lumpectomy in order to decrease the 20% need for reexcision. This is true. In the United States, most surgeons cannot get clear margins approximately 20% of the time after lumpectomy. This is because of microscopic disease which is disease that is too small to see with the naked eye. I always explain to may patients that some tumors have these microscopic extensions which is impossible to see during the surgery. Only the pathologist can see this small disease when examining the tissue under the microscope. Some surgeons always take additional margins at the time of lumpectomy in order to decrease the 20% need for reexcision.

Oncoplastic surgery combines the principles of breast cancer surgery with complete removal of the disease with plastic reconstructive methods to maintain a normal breast appearance. The advantages are preserving normal body image. The potential disadvantage is that the surgery can take longer to perform. It can be used both for mastectomy and breast conservation surgery. Oncoplastic surgery combines the principles of breast cancer surgery with complete removal of the disease with plastic reconstructive methods to maintain a normal breast appearance. The advantages are preserving normal body image. The potential disadvantage is that the surgery can take longer to perform. It can be used both for mastectomy and breast conservation surgery.

I think this is a difficult choice for many women faced with this decision. Historically, mastectomy was the only operation available for breast cancer, and when the early clinical trials were conducted comparing mastectomy to lumpectomy, the surgeons and researchers faced a lot of criticism as it was a widely held belief that a radical operation was necessary if there was any chance of cure.

We now know thanks to that research, that there is no difference in the overall survival if a woman undergoes a mastectomy or a lumpectomy. However lumpectomy alone will result in a higher rate of the cancer returning in the breast, so radiation therapy after lumpectomy is necessary.

Absolute contraindications to breast conservation are multifocal cancer (cancer in multiple quadrants of the breast), inability to achieve an acceptable cosmetic result, and contraindications to radiation therapy (certain collagen-vascular diseases such as scleroderma). A history of prior radiation therapy to the breast is often a contraindication to breast conservation as well, but several clinical trials are examining the safety and effectiveness of limited radiation therapy in patients who have previously undergone whole-breast radiation.

Other than that, for most women with early-stage breast cancer, they do have choices. We tend to think having options is a good thing, but many women do struggle tremendously with this decision. I think this is a difficult choice for many women faced with this decision. Historically, mastectomy was the only operation available for breast cancer, and when the early clinical trials were conducted comparing mastectomy to lumpectomy, the surgeons and researchers faced a lot of criticism as it was a widely held belief that a radical operation was necessary if there was any chance of cure.

We now know thanks to that research, that there is no difference in the overall survival if a woman undergoes a mastectomy or a lumpectomy. However lumpectomy alone will result in a higher rate of the cancer returning in the breast, so radiation therapy after lumpectomy is necessary.

Absolute contraindications to breast conservation are multifocal cancer (cancer in multiple quadrants of the breast), inability to achieve an acceptable cosmetic result, and contraindications to radiation therapy (certain collagen-vascular diseases such as scleroderma). A history of prior radiation therapy to the breast is often a contraindication to breast conservation as well, but several clinical trials are examining the safety and effectiveness of limited radiation therapy in patients who have previously undergone whole-breast radiation.

Other than that, for most women with early-stage breast cancer, they do have choices. We tend to think having options is a good thing, but many women do struggle tremendously with this decision.

I think preparing depends upon the patient. Some of us prefer to be ignorant and nervous while others (ME) have to know every gory detail so I can be informed and nervous. For me, preparation was knowing what I could expect. My "lumpectomy" was actual a "surgical biopsy" and my lymph node biopsy was done in a separate procedure. I WISH I would have know the medical staff was going to refer to the "biopsy" as a lumpectomy. That freaked me out a bit. In fact, when I took my sister for the same type of biopsy, before she went off with anyone, I told her, "You are probably going to hear the word lumpectomy, just don't freak." She did and afterwards she thanked me for the heads up. The rest of it.... happy to share the "gory details" but not unless someone wants them. I'm a big believer in ..... we are all different and some of us prefer to have more of an overview than a play by play.... :)

AnneMarie Actually, surgery was the easiest part of my entire treatment! The lumpectomy was done as an outpatient and I had very minimal pain. I knew I wanted to "get the cancer out" of my body, so I was ready and willing to do the surgery. The biopsy was a little different as I had no idea what to expect and that was a little scary. I think I went into "get it done" mode and squashed my emotions about the whole thing until much later!

Great question! Your options would be very similar to those you would have if you had a mastectomy. Keep in mind that if your lumpectomy was followed by radiation, the behavior of the radiated skin and tissue can complicate a reconstruction procedure utilizing implants and your best option may be to use your own tissue to restore your breast size and shape. Nonetheless, it's your plastic surgeons responsibility to tell you all of the options available to you and let you choose how to proceed. Also discuss with your surgeon any procedure that may need to be done on your unaffected breast to achieve symmetry. Here's my short list of options:

1. Tissue expanders and subsequent replacement with permanent implants. Ask about silicone vs. saline implants. How about the use of a skin and tissue replacement like fat or a dermal matrix (like Alloderm).

2. Autologeous reconstruction with latissimus flap (back). Will implants be needed as well?

3. TRAM flap (transverse rectus abdominus muscle). Uses the muscle, skin, and fat of the abdomen to rebuild the breast. Make sure you have been told of the risks involved in removing this muscle.

4. DIEP, SIEA (deep inferior epigastric perforator or superficial inferior epigastric artery). Uses the skin and fat of the abdomen to rebuild the breast but leaves the muscle of the abdomen intact.

5. GAP (gluteal artery perforator). Uses the skin and fat from the upper (inferior) or lower (superior) buttocks. Like the DIEP, no muscle is removed for this procedure.

6. TUG (transverse upper gracilis). Inner thigh donor area, utilizes skin, fat, and muscle of the upper inner thigh.

7. Intercostal perforator. Utilizes skin and fat from under the arm.

8. Maybe you're happy with the size of your post-lumpectomy breast but would like the shape addressed. Procedures such as mastopexy or reduction mammaplasty on the unaffected breast may be the procedures to investigate.

9. If it's a small defect, a simple fat transfer from another part of your body may remedy the problem.

Best Wishes,

The Center for Natural Breast Reconstruction Team

Great question! Your options would be very similar to those you would have if you had a mastectomy. Keep in mind that if your lumpectomy was followed by radiation, the behavior of the radiated skin and tissue can complicate a reconstruction procedure utilizing implants and your best option may be to use your own tissue to restore your breast size and shape. Nonetheless, it's your plastic surgeons responsibility to tell you all of the options available to you and let you choose how to proceed. Also discuss with your surgeon any procedure that may need to be done on your unaffected breast to achieve symmetry. Here's my short list of options:

1. Tissue expanders and subsequent replacement with permanent implants. Ask about silicone vs. saline implants. How about the use of a skin and tissue replacement like fat or a dermal matrix (like Alloderm).

2. Autologeous reconstruction with latissimus flap (back). Will implants be needed as well?

3. TRAM flap (transverse rectus abdominus muscle). Uses the muscle, skin, and fat of the abdomen to rebuild the breast. Make sure you have been told of the risks involved in removing this muscle.

4. DIEP, SIEA (deep inferior epigastric perforator or superficial inferior epigastric artery). Uses the skin and fat of the abdomen to rebuild the breast but leaves the muscle of the abdomen intact.

5. GAP (gluteal artery perforator). Uses the skin and fat from the upper (inferior) or lower (superior) buttocks. Like the DIEP, no muscle is removed for this procedure.

6. TUG (transverse upper gracilis). Inner thigh donor area, utilizes skin, fat, and muscle of the upper inner thigh.

7. Intercostal perforator. Utilizes skin and fat from under the arm.

8. Maybe you're happy with the size of your post-lumpectomy breast but would like the shape addressed. Procedures such as mastopexy or reduction mammaplasty on the unaffected breast may be the procedures to investigate.

9. If it's a small defect, a simple fat transfer from another part of your body may remedy the problem.

Best Wishes,

The Center for Natural Breast Reconstruction Team

There are several different types of breast surgery - the 2 basic categories are lumpectomy and mastectomy. Lumpectomy (also referred to as partial mastectomy) generally refers to removing the breast cancer with a rim of normal surrounding tissue, the margin. Mastectomy refers to removal of the entire breast, and often is accompanied by reconstructive surgery. With both lumpectomy and mastectomy, usually a sentinel lymph node biopsy is performed - a few underarm lymph nodes are removed to confirm if the cancer has spread or not.

For benign breast tumors (not cancer), generally an excisional biopsy is performed - this simply means removal of the breast lump. There are several different types of breast surgery - the 2 basic categories are lumpectomy and mastectomy. Lumpectomy (also referred to as partial mastectomy) generally refers to removing the breast cancer with a rim of normal surrounding tissue, the margin. Mastectomy refers to removal of the entire breast, and often is accompanied by reconstructive surgery. With both lumpectomy and mastectomy, usually a sentinel lymph node biopsy is performed - a few underarm lymph nodes are removed to confirm if the cancer has spread or not.

For benign breast tumors (not cancer), generally an excisional biopsy is performed - this simply means removal of the breast lump.

While it is not common, some patients do have persistent numbness, itching, or hypersensitivity, even years after surgery and radiation therapy. Usually there is not anything specific causing the sensation, but I would certainly recommend bringing this to the attention of your physician and make sure that you keep up with the recommended imaging studies and exams after surgery. While it is not common, some patients do have persistent numbness, itching, or hypersensitivity, even years after surgery and radiation therapy. Usually there is not anything specific causing the sensation, but I would certainly recommend bringing this to the attention of your physician and make sure that you keep up with the recommended imaging studies and exams after surgery.