18: Like a Surgeon

So, my surgery story really isn't all that remarkable. Perhaps the most notable thing is that 10 days before I was scheduled for surgery, I realized why my conversations with the surgical nurse had been so confusing. It turns out that all of the pre- and post-op information I had been given was guidance for melanoma patients. The surgical team (minus the surgeon) thought I had melanoma, not breast cancer. Whoops. Except that's a big "whoops," guys. At my appointment with the oncologist the next day, I requested a different surgeon. She agreed, and by the end of the visit, I had a new surgeon and a new surgery date. (The new date was a day before the previously-scheduled surgery, so it was no big deal.) Anyway, perhaps I'll get into all of that charlie-foxtrot another time. 

I am lucky in that I was able to have a lumpectomy. This may be TMI, so for those of you who don't feel comfortable hearing about my boobs, just skip to the next paragraph. Back to the lumpectomy...It turns out that whether or not a patient can be effectively treated with a lumpectomy (rather than a mastectomy) is the ratio between the size of the breast and the size of the lesion. It makes sense, but it wasn't something I had ever really considered before last November. (Is there a medical term for this? Is it the Breast to Tumor Ratio? BTR? These are the things I ponder...) By the time I had surgery, the primary tumor had decreased from 3cm to 0.6cm. That, combined with the fact that I have a fairly large cup size, all of the physicians were comfortable with the lumpectomy option.

The genetic testing came back showing no abnormalities in any of the 30+ genetic markers, so there was no clinical advantage to doing anything surgical to the contralateral breast. Due largely to the reasons I mentioned above, there was no clinical advantage to having a unilateral mastectomy, either, and the lumpectomy had the added benefits of being less invasive, having fewer side effects, and, of course, being much less noticeable. So, lumpectomy, it was.

The surgical prep involved an injection of radioactive material (Tc-99) followed by a mammography-guided needle localization. (They put some very thin wires into the breast to mark where the lesion is. They can confirm the needle placement through mammography.)

The surgery, itself, was pretty unremarkable. They made two incisions, each about an inch and a half long - one horizontally, just under my armpit, and one vertically on the outer side of my left breast. They removed the tumor and three lymph nodes. It was an outpatient procedure, so when I was finished at about 6 or 6:30pm, my SO and I went to get some dinner, and then we went home. The recovery was also pretty unremarkable. There was some discomfort and some lymph-related pain, but compared to other surgeries I've had, it really wasn't a big deal. I have my wonderful surgeon to thank for that! (Thanks, C.M.!) 

I waited a several days for the pathology results from the surgery. (For the 3 lymph nodes + primary tumor that they removed.) The results were...mixed. And, in keeping with the trend for my experience with this disease, the results were mixed. On the plus side, all of the lymph nodes were "clear." They either had no visible tumor cells, or the number of tumor cells present was so low that the lymph node was considered to be free of tumor cells. That's very good news, because it meant that there was no need to go back in and remove additional lymph nodes. The pathology from the tumor, itself, was less straight-forward. Typically, the goal is for the tumor margins to be "clean." In other words, during surgery, they remove the visible tumor and a small amount of tissue surrounding the tumor, to try and make sure they remove any non-visible (i.e., microscopic) disease. If the pathology results come back showing clean margins, it means that the tumor cells are very unlikely to extend beyond the tissue that was removed during surgery. 

But let's get back to me. My tumor margins were clean. But when the pathologist looked at the tumor under the microscope, there were lots of live, active tumor cells smiling back at them from the center of the tumor. I was told that this was a clinical "gray zone." In other words, there is no clear clinical guidance as to what to do in this situation. On the one hand, those happy little tumor cells (that I imaging as sitting there flipping off the pathologist) may have been the only remaining tumor cells in my entire body. However, there was no way to know if that was the case. If there were live tumor cells in the tumor, there may very well be live tumor cells elsewhere in my body. 

So what did all of this mean? For me, it meant more chemotherapy. I would start in late May - about a month after surgery, so I had time to heal from that. This time, the chemo-de-jour would be carboplatin. By this time, I knew that carboplatin is really the only other chemotherapy drug that has been demonstrated to be effective in treating triple negative breast cancer (or TNBC, as the kids call it these days.) On the one hand, if I have a recurrence down the road, I'll know that I did everything I could to treat this cancer. On the other hand, I knew this was it. If I have a recurrence, there really isn't anything else I'll be able to do, short of there being new therapies to try.
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