Lumpectomy Planning: intraoperative margin techniques and need for a sentinel lymph node biopsy
I'm trying to help my spouse plan out a lumpectomy for her early stage breast cancer. Two things have come up in research:
- "no ink on tumor" margins are difficult to ensure and there is a risk for reexcision. It looks like there are techniques like Frozen Section Pathology or Fluorescence Guided Imaging that helps lower the risk for positive margins and the need for reexcision. How effective are these and are they worth seeking out?
- Does a sentinel lymph node biopsy ever not get performed? She has a T2 tumor with mucinous features, N0 clinical node status and is young for developing cancer.
Comments
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@sometimes.me - Welcome, and thank you for being here to support your wife. She's lucky to have you by her side!
You might find these sections on our main site helpful as you plan for surgery:
Also, we have a discussion thread specifically for husbands and partners supporting someone with breast cancer that might be helpful to you:
We hope this helps, and hope you find support and information in this community. We're here for you!
The Mods0 -
Hi @sometimes.me,
Surgeons generally aim for a margin of 1 or 2 mm but the tumor location sometimes makes this difficult. No ink on tumor means the margin is less than 1 mm but the entire tumor is removed. My tumor was in the fascia of the chest wall so the surgeon’s goal was to remove it without damaging the pectoral muscle. The final pathology was no ink on tumor which is considered a clear margin. There is some research that shows larger margins lead to better recurrence free survival but no ink on tumor is currently the definition of clean.
My surgeon was using OnLume fluoroscopy in a clinical trial to test margins during surgery. That machine was later approved by the FDA but she didn’t think I was a good candidate due to my tumor location. She knew one of the margins would be problematic so a pathologist checked that (not a frozen section) during the surgery. This was done at a large teaching hospital which has many resources. According to statistics about 15 to 20% of margins are not clear and require re-excision. Studies indicate that surgeons who specialize in breast cancer have better outcomes so having the surgery done by an experienced breast surgeon is probably the best recommendation.
Studies have shown that sentinel node biopsy can be skipped for people over 70 with a T1 tumor. SNB is much less invasive than the axillary clearance which was done more frequently in the past. I had 3 nodes removed with just the first one positive so I didn’t need ALND. Removing many nodes increases the risk of lymphedema. Having SNB is advisable since my nodes all looked good on ultrasound.
I live in a rural area so I travelled 100 miles to have an experienced breast surgeon. She was trained in oncoplastic techniques so I also had a great cosmetic outcome. In my opinion finding a good surgeon is the best thing you can do. I hope your wife’s surgery goes well.
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thank you for the detailed response! what was the cosmetic work during your surgery?
Appreciate your call out around surgeon experience being a key factor. We're lucky to have been assigned someone who has a ton of experience. She is just focused on tumor removal though. They can work with a reconstructive surgeon, but the plan they laid out is to remove the tumor, radiation treatment and then in 6 months revisit for potential fat grafting. They use the Vitality System. I don't know how it compares with others. I read about oncoplastic techniques like volume displacement and localized flap reconstruction during a lumpectomy. None of those came up during our consultation with the reconstructive surgeon though.0 -
Hello, I'm sorry you & your younger spouse are unexpectedly finding yourselves here, but this is a good space for resources. A warm welcome!
If the patient has a tumor with Mucinous features, then the tumor is on the Mucinous Carcinoma spectrum. Also known as:
• Mixed Mucinous Carcinoma
• Hypercellular Type B tumorIt's suggested a pre-surgical MRI always be given for Mucinous tumors. Ultrasound & mammogram are known to not see ~38% of mucinous tumors. (Not all my tumors showed until after my second surgery pathology from a double mastectomy).
Knowing what you told us, I wouldn't not want a sentinel lymph node biopsy. You wouldn't want to not follow surgical protocols and your medical team's advice. Mixed Mucinous is the more aggressive version of a more indolent BC subtype, which subtype is more typical in younger patients. These Mucinous tumors can be sneaky sometimes because they know how to hide from imaging. Mixed Mucinous is a very rare subtype of BC, but I'm fine 12 years later so your spouse should hopefully do quite well.
You can visit the Mucinous Carcinoma thread on this website for more info. Best wishes to both of you.
Mucinous Carcinoma of The Breast
https://community.breastcancer.org/en/discussion/comment/5774036#Comment_5774036?utm_source=community-search&utm_medium=organic-search&utm_term=mucinoushttps://www.pathologyoutlines.com/topic/breastmalignantmucinous.html&lang=en
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