dcis dx so no SNB for MX this week?

lollyo

I am scheduled for RMX next Wednesday with immediate DIEP recon. I had a wide excision lumpectomy with bad margins last March. I met with pre-op nurse this morning and she said that my BS had thought that no sentinel biopsy would be needed. I was surprised because she and I talked about doing one during the MX last time we spoke. I think her thinking was I had a pathology report on the lumpectomy, 29 blocks of tissue and there did not appear to be any invasions. I have seen this path report and it is "all dcis." I have a call into her and will certainly speak with her about this further, but does anyone have any thoughts? Is the SNB overkill? Are there advantages to not having a SNB? I think for my peace of mind I would like it, but I'm not sure...

tea

My surgeon did do a SNB for a mastectomy for DCIS.  Once you have a mastectomy, you can't do a SNB (you need to inject the dye into the nipple), so you have lost that opportunity for the less invasive option to check your lymph nodes should they find any invasive cancer on the final pathology.

mom3band1g

I also had an SNB with my mast for DCIS.  I started, like you, with a lumpectomy and went from there.  I think it's pretty 'standard' with large amounts of DCIS to do a SNB with a mast.

Beesie

Tough call.  Since you've already had the lumpectomy and nothing but DCIS has been found - and according to your signature line, it's Grade 2, I can see why your surgeon is saying that an SNB isn't necessary.  Although you had dirty margins, her assumption clearly is that most of your DCIS has been removed and given what's already been found (no microinvasions in all that DCIS), it's unlikely that a microinvasion will be found in whatever DCIS is left in your breast.  If you have pure DCIS, an SNB is unnecessary.

This is good, since having an SNB does put you at risk of lymphedema, and this is a risk that you will have for the rest of your life.  Lymphedema can develop at any time so you would have to be cautious in the use of that hand/arm forever.  Having had an SNB (my microinvasion was found during my excisional biopsy so I had no choice about the SNB when I had my mastectomy) this need to be careful all the time is, frankly, a pain in the butt.

On the other hand, the more DCIS you have, the more likely it is that there could be a microinvasion in there.  And sometimes microinvasions aren't found - in a small percent of cases, cancer is found in the nodes even though the microinvasion wasn't found (however when cancer is found in the nodes, it's assumed that the microinvasion was there).  So in that sense, the SNB is something of a safety check.  And if it happens that a microinvasion is found during your mastectomy, then you will need to have your nodes checked, and at that point, after a mastectomy, an SNB can't be done so you would need to have more nodes removed.

I can make the case for not doing the SNB and I can make the case for doing the SNB.  Honestly, if it was me, I don't know what I would do.

Sorry, that's probably not helping much! 

Stanzie

What do you mean by needing to be careful with the use of your arm or hand if you had the SNB?

I knew there would always be the rish but didn't know there were things to do or not to do.

mom3band1g

stanzie - you should never have a blood draw or your bp taken on your SNB side ...ever.

Beesie

Agree re blood draws and blood pressure - not a good idea.  Also be careful with any cuts on your hand - you don't want to get an infection.  I try to remember to use gloves if I'm going anything that might result in a cut or the infection of an existing cut (gardening, washing dishes, etc.).  And if I get a cut, I immediately dab on some Neosporin and put on a bandaid - something I never bothered with before, and still don't worry about with my other hand.

lollyo

Thanks for all the thoughtful answers. Beesie, I'm pretty sure that is what my BS is thinking. I'm balancing the very small, but lifetime risk of lymphedemia (about 1% with just SNB, I think?) with the also small risk of an involved node. I'm not sure what the numbers are for choice #2, but I'd bet they are small also. Seems to me that the risk of an involved node is potentially more serious, but thank you for your clarification because I now see that there will be another path report run on all the removed breast tissue and if a microinvasion is found then we will need to go after more nodes post this surgery. Another round of breast cancer casino....Thanks again for everyone's thoughts.

Binney4

The risk of lymphedema with SNB is not accurately known, but the lowest current estimates are about 6% for arm lymphedema. Breast lymphedema is a possibility as well, which goes up with radiation.

The good news is, no matter what surgery we have, there are simple life-style adjustments we can make that will reduce our risk of developing lymphedema. Here are two reliable sites for information about risk reduction:

http://www.lymphnet.org   (see their position papers on Risk Reduction, Exercise, and Air Travel)

http://www.stepup-speakout.org/riskreduction_for_lymphedema.htm

Lymphedema is not in any way the threat that cancer recurrence is, so do whatever needs to be done to beat the bc beast, and know that lymphedema can be managed. Knowledge is power!

Really sorry about the maddening difficulty of these decisions, Lollyo. Wishing you peace with your decision, and long years ahead to enjoy it.

Be well,
Binney

lollyo

You guys are the best! I'm leaving the solution I arrived at with my surgeon on this thread in case anyone else ends up with this dilemma.

After a conversation today with my BS she and I struck a compromise. We decided to move ahead with the SNB during the surgery. She noted that it might be difficult to get a node to light up with the blue dye given the wide excision I have had previously. If that occurs, we agreed that she would not do a larger node excision (that normally would need to take place if SNB procedure fails) and wait for pathology results of all the breast tissue.

lollyo

Great news! I am home from my rmx and diep surgery and healing fine. I do not have the final pathology report back, however, as a result of the advocacy for the snb I had 2 nodes checked and both were negative, this peace of mind is priceless, thanks everyone for your support.

speech529

lollyo

Thanks for the update and congratulations on your successful surgery.  I wish for you a full and quick recovery!  This thread has been helpful for me because I am now in a similar situation.