Freaked myself out this morning with a horrible what-if...

CreativeMaven

Will check with breast surgeon when I go in for post-op in a couple weeks, but thought I'd throw this out there to see if anyone can pacify my freak-out...

When the surgeon does a SNB after the MX, do they start over with new sterile surgical equipment? I know the plastic surgeon does, he told me that himself. It didn't dawn on me until this morning that the same surgeon was dissecting for my sentinel node right after removing the cancerous cells and now I'm freaked out that one DCIS cell that was non-invasive could've gotten freed in my lymph tissues while looking for the Sentinel Nodes. Wouldn't that now make it invasive? Couldn't a single cell that was contained before now be the cause of a future invasion of growth because of surgery? 

Hoping someone has thought through this question before and can put me at peace!

chrissyb

Hi CreativeMaven, the usual surgical practice is a complete new sterile set of instruments for each location.  Please don't freak out, even if it is the same surgeon the practice is the same so there is no cross contamination.

Peace, strength, love n hugs.  chrissyb

Beesie

The doctor should use a new set of equipment although I suspect that sometimes they don't.  We've had situations here where ITC (isolated tumor cells) has been found in the nodes after an SNB. If the pathology of the breast tissue shows pure DCIS, and if upon examination of the nodal cancer cells it appears that these are DCIS cells and not invasive cancer cells, then it's assumed that the patient is node negative and that these cells were accidentally placed there by the surgical instruments. For those who have pure DCIS, this diagnosis is still Stage 0; in the TNM system it's stated as Tis / pN0(I+) / M0.  ITC are explained on page 58 of the NCCN Treatment Guidelines:  http://www.nccn.org/professionals/physician_gls/PDF/breast.pdf  You may have to register and sign-in in order to be able to view this document.

That's the bad news.  The good news is that, based on the latest scientific understanding, even if a DCIS cancer cell is accidentally placed in the nodes or in the breast tissue, it's not going to become an invasive cancer cell.  Of course as we all know DCIS cancer cells can and do convert to become invasive cancer cells  - this is in fact the normal progression of most invasive cancers.  But in order for this to happen, there needs to be one final biological change to the DCIS cancer cell  - it needs to lose it's layer of myoepithelial cells.  Without this biological change, the dissolution of this protective layer, the cancer cell will not become invasive.  So simply moving a DCIS cancer cell into open breast tissue or nodal tissue isn't going to turn the cell invasive.  If it's a DCIS cell, it does not yet have the ability to invade.   The following article explains this: http://www.medpagetoday.com/HematologyOncology/BreastCancer/9348

CreativeMaven, I hope that this helps reassure you.   

sunnyhou

curious about something.. so if you get a mastectomy and the displaced cell of DCIS is not removed.. (since they cannot remove all of the tissue) is this what happens to someone who has a mastectomy and then has a recurrance? The DCIS that is misplaced sits there for years in that left over tissue and become invasive?

Beesie

sunnyhou,

No, I don't think so.  If what you described is the way that it happens, then most if not every recurrence after a mastectomy would be invasive.  In actual fact, only about 50% of recurrences are invasive; the rest are still DCIS.  My understanding is that a DCIS cell needs the safe environment of the milk duct to live, grow and multiply; a DCIS cell that is misplaced outside of the milk duct is going to die. 

My surgeon explained to me that there is less risk of a DCIS recurrence after a mastectomy because although there always will be some breast tissue left against the chest wall or skin, it is less likely that there will be any milk duct tissue left.  But it's still possible, and I believe that this is how a recurrence would happen.

agada

Working in a hospital I can tell you your insruments are sterilized big time! No instrument is resused so put your mind at ease about that.  They are also counted so nothing is lost inside of you.  The nurses and docs are great at that. I have DCIS PN0(i+) due to free floating cells in my lymph nodes.  I still freak out over it, but am getting better with time and so will you.  Beesie posted a wonderful article on DCIS with PN0 (i+) results.  Perhaps she can show you the article and its location on line?

I think working in a hospital and performing HER2 testing really freaked me out over my diagnosis.  Hang in there, things will calm down for you with fewer moments of panic. And once again do not worry over the instruments used in your surgery.  I dont know if they gave you a calming medicine before you went to surgery but you probably missed the STACKS of instruments used for the surgery so nothing is reused.

Agada

MarieKelly

I think the original posters main concern was the possibility that a surgeon could be using the same instruments to do both the SNB and the mastectomy. I'm sure all hospitals sterilize instruments between patients, but I'm not so sure all surgeons trade out for a new instrument set between doing a SNB and then a mastectomy or lumpectomy on the same patient  If not, this could be a problem. 

For example, if the same set of instruments that were used to remove a concerous lymph node are then used to do mastectomy or lumpectomy, it's possible those instruments have touched cancerous cells, If those instruments are then used to close the wound, there's a possibility of tumor seeding in any remaining breast tissue or in the surgical scar that those instruments touched. This is one of the main reason why radiation is advised after  a lumpectomy. It's also sometimes why some develop recurrences on the mastectomy or lumpectomy scar. 

Beesie

MarieKelly, I agree with you that the original question was about whether the surgical instruments are changed between the lumpectomy or mastectomy and the SNB.  And I think that what agada was saying is that for each operation, they have stacks of instruments so that none will be reused, even during the operation.  Certainly they should be not reused although I'm not sure that this always happens. However, as I explained, for those with DCIS, if there is any accidental seeding, it should not be a problem because DCIS cancer cells seem to not be able to grow and multiply in an open environment (based on the latest scientific understanding of DCIS).  So a seeded DCIS cell is not going to become invasive cancer.  That was the specific concern raised in the first post and that's the most important point for anyone with DCIS.