What is the difference between a lumpectomy and a segmental mastectomy?

What size tumors are indicated by the "T" classifications?

TO means there is no evidence of primary tumor. Tl refers to a tumor that is 2 centimeters or less in its greatest dimension. T2 refers to a tumor which is more than 2 centimeters but not more than 5 centimeters. T3 means that the tumor is more than 5 centimeters. A T4 designation indicates a tumor of any size with direct extension to the chest wall or skin.

Is there more than one kind of breast cancer? 

Cancer of the breast is not a single disease. There are at least fifteen distinct varieties. The doctor and the patient need to know which variety they are dealing with before making the decision as to how to proceed. Among the types of breast cancer are intraductal, inflammatory, medulluary, papillary, tubular, lobular and Paget's disease.

What is inflammatory breast cancer? 

This is a rare type of breast cancer which often spreads rapidly to other parts of the body. In inflammatory breast cancer, the breast looks like it is inflamed. Ridges may appear on the skin, or the breast skin may thicken, displaying the pitted appearance known as peau d'orange, or orange peel. Inflammatory breast cancer does not cause a fever or other signs of infection. The breast's redness and warmth develop as the result of cancer cells blocking the lymph vessels in the skin of the breast. Most inflammatory breast cancers are treated as Stage IIIB or IV.

Inflammatory breast cancer diagnosis and treatment

What is the difference between a lumpectomy and a segmental mastectomy? 

A lumpectomy removes only the breast lump with a small margin of surrounding tissue. A segmental or partial mastectomy removes the lump plus a wedge of normal tissue. The lumpectomy leaves only a small scar generally 2 inches or less with minimal puckering or distortion of the breast. The segmental mastectomy leaves a much larger scar. A separate incision is made for both procedures at the armpit to remove some lymph nodes. Both operations are followed by radiation therapy. Women with relatively large tumors and small breasts are probably not able to have a lumpectomy or segmental mastectomy, since taking out the tumor and some normal tissue would remove most of her breast tissue.

Is there any difference in the effectiveness of these two operations? 

No, there seem to be no differences. The National Cancer Institute is conducting clinical trials for both treatments. Results have been reported from the study of segmental mastectomy that was begun in 1976 and involved 1,843 patients with Stage I and Stage II breast cancers 4 centimeters or less in size. The 10 year results of that study show that the segmental mastectomy, with removal of underarm lymph nodes to determine if cancer had spread there and followed by 5,000 rads of radiation therapy given to the breast 5 days a week for 5 weeks, is as effective as total mastectomy (removal of the whole breast). Those women who had cancer cells in their underarm lymph nodes were treated with chemotherapy. The second National Cancer Institute clinical trial, begun in 1979, compares mastectomy with an option of breast reconstruction with lumpectomy. Women who receive lumpectomy have a much smaller scar than those who have segmental mastectomy. The early results of this study also show that the less disfiguring surgery followed by radiation is as effective as removal of the entire breast for many women with early stage breast cancer. Since these are early results of the second study, the findings will continue to be followed.

Is cancer more likely to spread in a woman who has had lesser surgery for her breast cancer? 

The results of the clinical trials presently being conducted will hopefully answer this question. It was once thought that more extensive surgery meant there was less chance of the cancer recurring in the breast and of it spreading to other parts of the body. It was believed that tumors spread in an orderly fashion, from the tumor to the lymph nodes and then to other parts of the body. Breast cancer does not seem to follow this pattern. Many scientists today believe that breast cancer is a systemic disease and that the different breast operations do not affect the spread of it to another part of the body. When it comes to surviving breast cancer, women who had segmental mastectomies and radiation therapy have so far fared as well as those who had their breast removed.

Are there some women who should not have the lesser surgery? 

Yes. There are several groups. Among them are those with small breasts, those who have a lump fixed to the skin or underlying muscle, those with more than one cancerous lump or area in the breast, and those who are too sick to undergo the radiation therapy following the operation.

Can cancer recur in the breast after lesser surgery? 

Yes. But if and when that happens, a woman can still have a mastectomy.

Is it necessary to take out the lymph nodes as part of lesser surgery? 

It is important, because taking out some or all of the underarm lymph nodes allows the doctor to tell whether or not the cancer has spread beyond the breast area. If cancer cells are found in a lymph node, the node is said to be "positive" for cancer. A node is "negative" if there is no evidence that cancer cells have spread to it. If the lymph nodes are positive, chemotherapy treatments will probably be given.

What happens during lymph node surgery? 

It will depend upon your doctor and your hospital, but the general procedure is as follows. Lymph node surgery can take from one hour to several hours, depending upon the number of lymph nodes taken out. When you awaken from surgery, your underarm area will be bandaged, and a tube may have been placed at the site of surgery to drain any fluid that may accumulate. You may feel some discomfort: tingling, numbness, or pain in your chest, shoulder area, or upper arm. The numbness under your arm will go away gradually, but you may not have total feeling back for a long time. You will be in the hospital 7 to 10 days for a lymphnode dissection; the stay is 2 to 4 days if only a sampling of nodes is taken. Before you leave, the tube that drains fluid from your incision will be taken out. Your stitches will be taken out in 1 to 3 weeks at the doctor's office or clinic.

What should I do to take care of my scar from the lymphnode surgery? 

Before you leave the hospital, ask the doctor or nurse for instructions on taking care of your incision. When you have permission to bathe or shower, do so gently and pat, don't rub, the area of your incision. To keep your skin soft and to promote healing, you may want to massage your incision gently with vitamin E cream or cocoa butter. As time goes by, the redness, bruising, or swelling will disappear. But you should watch for any signs of infection such as inflammation, tenderness, or drainage. If you develop any of these signs or a fever, call your doctor. Although each woman recovers from surgery at her own rate, most women are ready for the next part of their treatment, radiation therapy, about 1 to 2 weeks after their lymph node surgery.

Will I need to do arm exercises after lymph node surgery? 

At first you will have to be careful not to move your arm too much. But by the second or third day, you may be ready to begin exercises to ease the tension in your arm and shoulder. If you have lymph-node sampling rather than dissection, you will probably recover your arm motion more quickly, because the operation is not as extensive. The nurse, doctor, or physical therapist will show you what exercises to do.

You will probably begin with these simple movements and be given others to do at home:

• Lie in bed with your arm at your side. Raise your arm straight up and back, trying to touch the headboard.

• Raise your shoulders. Rotate them forward, down, and back in a circular motion to loosen your chest, shoulder, and upper back muscles.

• Lying in bed, clasp your hands behind your head and push your elbows into the mattress.

• With your elbow bent and your arm at a 90 degree angle to your body, rotate your shoulder forward until the forearm is down, then up.

• With your arm raised, clench and unclench your fist.

• Breathe deeply.

• Rotate your chin to the left and right. Cock your head sideways.

Lymph nodes and breast cancer

Does radiation therapy have to follow the lesser surgery? 

Yes. In the National Cancer Institute study, women given radiation treatment after their segmental mastectomies had much lower rates of the cancer recurring in the breast.

What is involved with the radiation therapy following lesser surgery? 

High energy x-rays are aimed at the breast and sometimes at nearby areas that still contain some lymph nodes, such as under the arm (if only a sample of lymph nodes was taken during surgery), above the collarbone, and along the breastbone. The goal is to destroy any cancer cells that may still remain in the breast or surrounding areas. The highenergy x-rays are delivered by a linear accelerator or cobalt machine. Usually treatments are given 5 days a week for about 5 weeks. A single treatment takes about 20 to 25 minutes. Only a few minutes of this time are for the treatment; most of the time is spent putting you in the proper position. Most people continue with work or their regular activities during the treatment period.

About 1 to 2 weeks after the treatment has been completed, most women receive a concentrated "booster" dose of radiation to the area where the breast lump was located. The dose is given either externally, using an electron beam, or internally with an implant of radioactive material. The electron beam booster is delivered by a type of linear accelerator machine and requires daily visits for 5 to 10 days. You may notice an increase in skin redness at the site of the treatment. This is normal. The implant procedure requires a short hospital stay of 2 to 3 days. Thin plastic tubes are threaded through the breast tissue where the original lump was removed; the tubes are then filled with radioactive seeds. The implant will remain in the breast for 2 to 3 days.

Does it cost more to have a lumpectomy than a mastectomy? 

Lumpectomy is a more expensive treatment. Although you stay in the hospital less with a lumectomy, you must pay doctor bills to both a surgeon and a radiotherapist, along with the extra cost of radiation therapy.

I want to have lesser surgery, but my doctor does not want me to. What shall I do? 

First, you need to find out why your doctor does not want you to have it, because there are times when mastectomies are the best treatment. Second, you need to get another opinion at a medical center where doctors are experienced in doing lesser surgery, node samplings, and radiotherapy. Call the nearest large medical center and ask for a radiation therapist or a surgical oncologist. Call the 1-800-4-CANCER line and ask for the name of a major medical center near you or of physicians who specialize in breast surgery.


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