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Medical Forum / Diseases and Disorders / Breast Cancer / November 2008Lumpectomy for large-ish tumor in thin woman?
Hi all-- I need to make a decision about which way to go--lumpectomy or mastectomy. There are a few complications, mostly related to my body size and the ratio of the tumor size to the breast size. I am 43 years old, pre-menopausal, and was diagnosed with invasive breast cancer about 2.5 months ago. The main tumor's dimensions are 3.3 cm by 3 cm by 1.4 cm, and it is located to the right of the nipple on the right breast without touching the nipple. There are apparently two small satellite tumors elsewhere in the breast, plus a small (6 mm) DCIS on the chest wall. The surgeon's best guess as to staging is Stage 2 or Stage 3, after two biopsies (one ultrasound-guided, one MRI- guided). He is still saying lumpectomy is a possibility (and indeed seems to lean that way), though he is saying the cosmetic results won't be so good. I am going to a very good hospital (UPenn). So far no evidence of bone or liver metastasis. I just had my sentinel node biopsy today, so no results yet. The issue: I weigh about 105-108 pounds. (I recently, for no reason, lost about 20 pounds and am now down to what I weighed when I was 21-30 years old. The doctors can't find a reason and are saying, essentially, "If it ain't broke, don't fix it" regarding the weight loss.) My normal adult cup size has always been about 34B to C, and even with the weight loss I haven't loss that much breast mass--am probably now closer to a 34B. I am trying to find photographs of and/or people's experiences with lumpectomies and mastectomies w/reconstruction in people of my size WITH TUMORS OF ROUGHLY THIS SIZE. The plastic surgeon has said that I probably don't have enough body fat to move fat from my belly or thighs to the breast. Both the plastic surgeon and the main breast surgeon have said that since radiation is definitely part of my future, that implants are out of the question. I'm guessing that my options are narrowed to: --lumpectomy with no reconstruction (how much breast is left over in someone of my size?) --lumpectomy with reconstruction (can such a thing be done?) --mastectomy with no reconstruction --mastectomy with attempts to reconstruct with minimal-ish body fat from SOMEWHERE (I do have some fat in my belly, enough to pinch an inch or so when I'm wearing pants--a vague muffintop effect--but not much when I'm not wearing pants). Does anyone have any advice, based on her or others' experience? Useful Web sites to look at? Photos to send? (I will keep them private, of course.) I've gone to the breastcancer.org photos, but to my memory no one has my body type except for a woman who had a full mastectomy. Thanks for any help--I'm agonizing a bit over this decision, as I suspect a large percentage of women on this site have done! -cowpattie Hi cowpattie, I'm sorry to hear about your diagnosis. On Oct 2, 5:45 pm, cowpattie...@yahoo.com wrote: > Hi all-- > [quoted text clipped - 7 lines] > seems to lean that way), though he is saying the cosmetic results > won't be so good. I am going to a very good hospital (UPenn). Will you be having chemo? Will you be having surgery before or after chemo? The reason I ask is that some oncologists will sometimes give chemo first, to shrink the tumor and allow for better surgical results. You may want to ask your oncologist and surgeon about this. Wishing you all the best. Ixia On Oct 2, 4:45 pm, cowpattie...@yahoo.com wrote: > Hi all-- > > I need to make a decision about which way to go--lumpectomy or > mastectomy. There are a few complications, mostly related to my body > size and the ratio of the tumor size to the breast size. I am a fairly large woman, but with average size breasts (originally, at least). The first time I had breast cancer, 20 years ago, I had a lumpectomy, did not get clear margins, then had what they called a "wide excision lumpectomy", basically taking a fist size area of tissue around the site of the original tumor. That didn't leave a lot lot of breast there. I did not have any sort of reconstruction. The imbalance was marked. But when I was dressed, I don't think anybody ever noticed. Friends who had seen me in a bathing suit were surprised when I told them. guys even, who were, um, LOOKING, I think they just didn't expect it, and so didn't notice. It is true that I almost never wear tight or low cut shirts. But I also didn't wear any prosthetic. Just stretchy bras that would accommodate both sides, or some that I had custom made in 2 different cup sizes. I am not necessarily advocating for this approach, just offering a data point. Best of luck in making your decision. Two and a half months ago you were diagnosed??? Oh, I am so envious of you, good for you for taking time to make the decision. I felt so rushed after my diagnosis, so frantic and jeopardized, they were telling me "we don't like to wait more than a couple of weeks to deal with this" and all I had was one small Stage 1 tumor...but I still felt so pressured, I frantically got two opinions on the reconstruction....no second opinion on the mastectomy....it's so stressful weighing all the options, I really feel for you! Unfortunately there really are no "perfect" decisions, you just weigh all the variables and go forward and try to be positive no matter what. I know people who have done each/both, and some have regrets and some don't. whichever you choose, you won't know what would have happened with the other. surgeons do "partial reconstructions" after lumpectomies, pulling fat and tissue from other parts of the breast (I didn't have a big enough stomach for the flap but wouldn't have done that anyway, too gruesome, and I want my abs)....and some women are OK with a half-breast. I had a biopsy in 2001 (turned out benign) that left my breast flatter and saggier, and I was kind of self-conscious about it, and I'd give anything to have it back now, LOL! I had a mastectomy both for cosmetic reasons and because I didn't want to do radiation. if I had it to do again, I think I would, but with a different surgeon (sigh)....and I would have been less hopeful/more realistic about the outcome. they do a lot of pie in the sky about how great the new breast will look/be..... I wish you luck. I weigh a little more than you (117) but I was puzzled about "implants are out of the question" because radiation doesn't obviate implants as an option, at least not to my knowledge. contoured implants are available ("anatomical" is the lame term)...I loved your "muffintop" remark. very cute. you sound great; hang in there and just keep going, keep BREATHING no matter what! > Hi all-- > [quoted text clipped - 51 lines] > > -cowpattie > ... I felt so rushed after my diagnosis, so frantic and jeopardized, > they were telling me "we don't like to wait more than a couple of weeks to > deal with this" In fairness, I believe that most women don't want delays. In fact, here in UK it's a government decree that all diagnosed cancers are dealt with in a short time - I can't remember the number of weeks. My surgeon told me he didn't want to know what I'd decided (after he gave me the details and options) until he'd come back from his annual holiday, in two weeks. I was happy with that. I'm sorry you felt so bad about it. In Sarah's case I think the sooner it's dealt with the better, it's obviously further developed than yours and mine were. But I can't advise Sarah, things are so very different in other parts of the world. Except to stick around here and tell us your progress, then stay to help and support others. Hugs to both of you, Mary > but I was puzzled about "implants are out of the question" because radiation > doesn't obviate implants as an option, at least not to my knowledge. Radiation can damage skin and other tissues. If I understand correctly, the tissues become both less elastic and also less able to heal properly. I imagine that the degree of such damage will vary from person to person, depending on skin-type and so on. Some women may still be able to get good results with implants after radiation, but it might not be prudent for the surgeon to hold that out as a possibility ahead of time. cowpattie wrote: "even with the weight loss I haven't loss that much breast mass--am probably now closer to a 34B". To stretch radiated tissues enough to accommodate a B cup implant may not be possible, but if I were cowpattie, I'd want to hear from both the surgeon and the radiologist about realistic options. I personally can not imagine having implants under my radiated tissues - I can tell it would be very painful. Perhaps that sensitivity will change with time - I don't know. My oncologist recommended a lumpectomy and a reduction on the other side, for symmetry. I went with a mastectomy instead, and wear a prosthesis. This way I have exactly the same proportions as before, my clothes fit the same, and so on. Ixia On Oct 3, 12:45 pm, "pumpkin" <billowr...@att.net> wrote: ... > I personally can not imagine having implants under my radiated tissues - I can tell it would be very painful. Perhaps that sensitivity will change with time - I don't know. Mine did. Mary > "Ixia" <ixiaviridifl...@gmail.com> wrote in message > ... [quoted text clipped - 4 lines] > > Mine did. That's good to know. Ixia Thanks, everyone, for your experiences and feedback. I was told by the main surgeon (not the plastic surgeon) about pre- operative/neoadjuvant chemo (as a way to shrink tumors pre-emptively, so as to have less to remove), but no one explained the logic to me: okay, so the tumor is smaller, but since good tissue doesn't fill in the spaces, you are going to have a roughly equal amount of tumor (breast volume) removed: either by chemo or by surgery. (If by chemo, you'll then have the additional margin removed during surgery.) Confusingly, I've been told by the oncologist (who will manage my chemo regimen, if any), in capital letters, DO NOT HAVE PRE-OPERATIVE CHEMO. Then, later in the discussion, she said, "Well, depending on whether you decide to have pre-operative chemo, then blah blah blah." When I said she'd already said, very explicitly, NOT to have this option, she denied having said that. I had been taking notes and was not light-headed/overly emotionally fraught, to my knowledge! Anyway, I left the meeting far more confused than when I entered it. Any opinions? Her rationale against chemo was that chemo is very debilitating and if there's any reason NOT to have it, then don't. Okay, this sounds reasonable. But then she didn't explain her change of mind. (I am having an Oncotype DX test to determine whether I have low, medium, or high risk of recurrence.) She is saying that most likely I will still need chemo, since this is an advanced-ish tumor. But the main surgeon, who did my sentinel node biopsy on Thursday, originally said, pre-biopsy, "Have pre-operative chemo, then surgery, then radiation," but is now (an hour after the node biopsy) saying that I probably won't need chemo. He didn't say that the appearance of the nodes during the biopsy led him to change his mind. I want the two of them to get together and not to give contradictory advice--the oncologist is irritated that the surgeon is giving chemo advice, but she's giving confusing advice! I am getting pressured to make a decision soon--part of the drawn-out time is that I am a student and am having some trouble getting referrals, but it's not the sort of Kafka-esque nightmare through the U.S. healthcare system I've heard about--just a little drawn out. What I need most help with is making a decision about surgery. (I have been told about irradiated tissue not being compatible with implants, which sounds like lxia's experience.) A further question: if one has a mastectomy with reconstruction, are people finding that the loss of sensation is too hard to live with? Would you rather have had a lumpectomy, with uncosmetic results but maintaining the ability to feel? (Again, the oncologist is warning me not to give up breast sensation so easily, even if one breast will be 50 or even 100% larger than the other...is there any way to have my cake and eat it too, i.e., keep a relatively cosmetic breast AND sensation? That's why I was hoping there was someone with a lumpectomy-cum-reconstruction experience--) In any event, I am no closer to making a decision, and part of the problem is that I need the doctors not to make the decision for me, but at least to decide TOGETHER (they're part of the same practice) what is practicable and what is not, and what are the ramifications of each decision. I don't want conflicting information, concerns about doctorly territory, and seemingly capricious mind-changing to muddy the waters! Thanks for any feedback, and sorry for the rambly-ness of this post. -cowpattie > Thanks, everyone, for your experiences and feedback. > [quoted text clipped - 57 lines] > > -cowpattie You are being asked to make a decision on inadequate information. This is an abdication of responsibility by the doctors involved. I am a professional engineer and I do not say to my customers "Well, you can build a bridge or dig a tunnel, it's up to you." If I did they'd have every right to refuse to pay for my consultation. (OK I'm not actually a civil engineer either, but you get the idea.) My duty is to lay out the risks and benefits associated with each option, and make a recommendation. As far as I know the same duty applies to any other professional giving advice to laymen. My customer may well decide that other factors override my recommendation, that's fine, but if he has no conflicting interests then he can confidently follow the recommendation without having to involve himself in technical detail. That's what I'm for. I think you'll find with reconstruction that after radiation, the skin is a lot less able to tolerate expanders, so your options are greatly reduced, but not eliminated altogether if there is sufficient skin remaining. My understanding of neo-adjuvant (preoperative) chemotherapy is that it is usually used where reducing the tumour size can make a quantum step in reducing surgery, eg where the tumour has attached to some structure that makes surgery difficult. I suspect that in other cases it complicates matters by compromising the healing process. I don't know many breast cancer cases where it was used unless the chest wall was attached. But I'm not a doctor and I don't have direct experience of either of these issues, it's just my lay opinion. My main advice is to have the confidence to bang the doctors heads together, have them discuss your case at their Monday morning case review meeting or whatever they have in their practice, and come up with a recommendation and some explanations of risk and benefit of the choices. Failing that, go for a second opinion. Tim Jackson > My understanding of neo-adjuvant (preoperative) chemotherapy is that it > is usually used where reducing the tumour size can make a quantum step > in reducing surgery, eg where the tumour has attached to some structure > that makes surgery difficult. My oncologist recommended neo-adjuvant chemo because it allowed her to monitor exactly how the cancer responded to the chemo. If the cancer did not shrink, as sometimes happens, she'd be able to switch to a different regimen. When chemo is given after the tumor is out, there is no way to monitor the effectiveness of the chemo. I think this is worth taking note of, because chemo is not a trivial undertaking! In my case, the tumors responded dramatically, and were completely gone by the time I had surgery. This happens only about 30% of the time (according to my oncologist) and gives you a better prognosis. I do not remember the numbers or details. To my thinking, with locally advanced bc and positive nodes, you want to kill cancer-cells not only in the breast but in the rest of the body where they may also be hiding out. That can't happen unless the chemo you are getting is actually effective against your particular cancer. All in all I was happy with the neo-adjuvant chemo option, and would recommend it, but I don't think it's for everyone. > I suspect that in other cases it > complicates matters by compromising the healing process. In what way? > I don't know > many breast cancer cases where it was used unless the chest wall was > attached. In my case the tumors were not attached to anything, but neo-adjuvant chemo was strongly recommended by the surgeon to "make surgery easier" and to enable me to have a lumpectomy instead of a mastectomy. Ixia >> I suspect that in other cases it >> complicates matters by compromising the healing process. >> > In what way? The healing process requires cell division, which is what most chemotherapies attack. So it is generally the case that wounds won't heal well while chemotherapy is in progress. This is one reason for a delay between surgery and chemotherapy. It also depresses the immune system, so increasing the risk of infection taking hold. Your point about monitoring response to chemo is an interesting one. Tim > >> I suspect that in other cases it > >> complicates matters by compromising the healing process. [quoted text clipped - 6 lines] > delay between surgery and chemotherapy. It also depresses the immune > system, so increasing the risk of infection taking hold. I see what you mean. There was a delay of surgery for that reason - 3 weeks I think. I do not know how long they wait before they start chemo /after/ surgery, but the first dose of AC knocked my white cells out. I got really ill, and was hospitalized within 10 days of starting chemo. It was hard getting back on my feet, and was grateful I was not recovering from a mastectomy also. Later on in treatment low white count was not a problem, as they gave Neulasta to stimulate wite-cell growth. Worked well. > Your point about monitoring response to chemo is an interesting one. Yes. As I was finishing up chemo last year, a report http://www.msnbc.msn.com/id/21225760/ came out that "The widely used chemotherapy drug Taxol does not work for the most common form of breast cancer and helps far fewer patients than has been believed, surprising new research suggests." I was on Taxol at the time, a nasty drug with many side-effects, some still linger. I did not have to wonder about Taxol being effective in my case, however, because the tumor shrank noticeably with each treatment. It helped me tremendously to have concrete evidence that chemo was working, as it was very difficult to get through at times. Ixia > I was on Taxol at the time, a nasty drug with many side-effects, some > still linger. I did not have to wonder about Taxol being effective in > my case, however, because the tumor shrank noticeably with each > treatment. I know it well, my wife had Taxol in the secondary phase. It didn't work for her. Tim > I am trying to find photographs of and/or people's experiences with > lumpectomies and mastectomies w/reconstruction in people of my size [quoted text clipped - 3 lines] > surgeon have said that since radiation is definitely part of my > future, that implants are out of the question. -------------- I had a modified radical mastectomy followed by radiation, and I can assure you that implants are *not* out of the question! I've had one for the past 2 years. I had an enormous tumor -- 8 cm. I live in the US and don't really know what a cm is, but it was the size of a tennis ball. I'm slim too, though not quite as slim as you, but I also didn't have enough belly fat to make a complete breast. The problem was that I had to wait a year before I could get the reconstruction, because I had to heal completely from the radiation first. The procedure I had was a latissimus flap over an implant. It's not completely symmetrical with my remaining breast but under clothing it looks just fine. If your plastic surgeon says this can't be done I encourage you to get a second opinion! Eva > I had an enormous tumor -- 8 cm. I live in the US and don't really know > what a cm is, There are about 2 1/2 cm to the inch. > but it was the size of a tennis ball. I'm slim too, though not quite as > slim as you, but I also didn't have enough belly fat to make a complete > breast. Today I got below 11 stones! (154lbs). The only advantage I can see in being fat is having enough belly fat for a reconstruction but I really don't want to get up to 13 stones 3lb again. (185lbs) If it all happens to me again (bc) I shan't have a reconstruction :-) Didn't want one anyway ... > ... It's not completely symmetrical with my remaining breast but under > clothing it looks just fine. How many 'natural' breasts are completely symmetrical? Mine weren't (especially when breast feeding) but only I could see that. Since my lumpectomy there's a greater difference but only I can see it. We're too concerned ab out such things, I think. Few people go around comparing individual breasts on other people, I think. If they do, and judge people on that criterion, they're not worth worrying about! Mary Hi cowpattie, I'm also sorry to hear about your diagnosis. My wife Liz had a 2.5x2.5cm tumour in the upper outside quadrant of her breast, and weighed probably a little less than you. She had a latissimus dorsi reconstruction, which used muscle from her back. She's very happy with the results, five years later. Best wishes for your decision, Peter >> I had an enormous tumor -- 8 cm. I live in the US and don't really know >> what a cm is, [quoted text clipped - 23 lines] > > Mary > Hi cowpattie, > [quoted text clipped - 3 lines] > dorsi reconstruction, which used muscle from her back. She's very happy > with the results, five years later. but what about her back muscle? Can she do pushups? > Best wishes for your decision, > [quoted text clipped - 27 lines] >> >> Mary > > Hi cowpattie, > > [quoted text clipped - 5 lines] > > but what about her back muscle? Can she do pushups? Better: she can make that breast lift up anytime she feels like it.  Signaturemadiba > Hi cowpattie, > [quoted text clipped - 3 lines] > dorsi reconstruction, which used muscle from her back. She's very happy > with the results, five years later. More pertinent perhaps: are you happy with the results? Signaturemadiba > The problem was that I had to wait a year before I could get the > reconstruction, because I had to heal completely from the radiation first. It is 7-8 months since I finished radiation. I had some bad burns, and the area is still very sensitive. The thought of tissue expanders is / very/ unpleasant. Were you healed after a year in that sense, or was it very painful? Ixia |
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