will I need chemo or total axillary dissection

3girls

Hi new to boards.  Just dx with stage 2 grade 2 with positive sentinel node.  Had lumpectomy and did not get clear margins.  i need to have re-excision and to decide if I want to have total nodal axillary dissection.  BS says studies say it is not necessary anymore and does not improve outcome and I am very concerned about lymphedema.  I meet with MO on Tuesday to help with decisions.  Do you think he will say I need chemo.  Initially told by PCP that it was insitu, then microinvasion stage 1 and now stage 2.  Did not expect this with the pathology report.  Anyone have similar situation?  Thanks!

CookieMonster

My BS told me that the latest research shows that axillary node dissection does not improve outcomes. I haven't done a ton of my own research, but she's been spot on so far on other stuff. My understanding is that if you're node positive, they'll want to do chemo because the cancer could have spread to other areas of your body.

My situation is similar to yours, but not as bad. I was told DCIS & had a lumpectomy. The supposedly 2 cm tumor turned out to be almost 8 cm and contained a 1.1 cm IDC area. That was a shocking follow up with the BS. This necessitated a SNB and without clear margins, also a reexcision. My nodes came back negative though, but I do need a third excision now. I'm hoping this is the last one, but I guess we'll see.

Best of luck to you!

sweetbean

How old are you?  I'm guessing that they will recommend chemo.  How involved was your lymph node?  Ask about Reverse Arm Mapping, also known as Axillary Reverse Mapping.  It is when the surgeon inject a dye into your arm right before they do the lymph portion.  The dye travels to your arm lymph nodes and turns them a different color.  The surgeon then avoids those nodes and takes just the ones associated with your breast.  Before this surgery, surgeons would just take all the nodes because they couldn't tell the difference.  however, the ones they need are the breast lymph nodes.

This is a new procedure - only a few years old.  I found a surgeon that would do it for me.  He took 15 nodes, out of which 2 were positive.  However, no arm lymph nodes were taken.  I am extremely active and do not have any lymphedema, although I do have some cording. 

exbrnxgrl

If you can, you might want to avoid AND. It carries an increased chance of developing LE but remember that even with only SNB, there is still a lifelong risk of LE development. Will you be having the oncotype dx test?

Caryn

ProudMom_Wife

3girls - we have a few similiarities, but I had a BMX because of family history mainly.  I opted not to have the ALND because I was concerned with LE, and knew that because of the two positive nodes that I would be doing chemo.  Also the nomogram had my risk of additional lymph node involvement at 9% probability.  And since I was 100% ER+/PR+ the most important part of treatment for me is hormone suppression.  

The majority of the doctors I consulted said I could forgo the ALND but needed to discuss radiation of the lymph nodes.  A few thought it was a mistake not to do the ALND because I would not now the extent of lymph node involvement.  I did ask about the Axillary Reverse Mapping, but no one in my area was doing it last year when I had to make the decision.

I did have radiation to my axillary and supraclavical lymph nodes because of several studies which showed that for certain pathologies you can do regional radiation instead of ALND and have the same regional recurrance rates.  Here is a quote and link to one of the articles.  "Regional recurrence rates after regional radiotherapy are very low and equal to an axillary lymphnode dissection." http://www.ro-journal.com/content/2/1/40  

There are other studies too, just linked to one though.  But this is dependent upon pathology, it may not be the correct path for all early stage cancers.

Please ask questions, and go for second or third opinions if you aren't sure about the recommendation(s) being made by your doctor(s).  You need to be comfortable with whatever decision you make.

Hope this helps. 

Edited:  Here is another study out of Milan "Axillary Radiation Matches Node Dissection for Disease Control http://www.medpagetoday.com/MeetingCoverage/ESMO/22750 

3girls

Thanks so much for all the great info.  I am hoping to feel more comfortable with things after meeting with the MO on Tuesday.  Someone asked my age and oncotype.  I am 50 but not through menopause.  I haven't had the oncotype that I know of.  I will ask on Tuesday.  Did people with node positive tumors have bone scans initially when BS thought it was stage1 she said it wasn't necessary but now I think I would be more comfortable if I did.

ProudMom_Wife

Since I was clinically node-negative before the BMX and SNB, when 2 lymph nodes came back positive and there were discussions around whether or not to do the ALND I asked if I could have a PET/CT Scan and my Surgical Oncologist agreed.  After I had it done and spoke for the first time with a Medical Oncologist she said that she would have ordered a bone scan instead since I was ER/PR positive.  Since I already had the PET/CT, and it came back clean, she did not want to put my body through another scan.  

FYI - My insurance would not pay for the Oncotype DX Test because I was node positive.  I know some insurance companies will pay with a positive node or two.  So don't be surprised if insurance won't pay.  My doctors all said that the result of the test would not change the recommendation for chemo in my case and that I should save the money for something fun to do instead.   So we had a family vacation after I was done with all invasive treatments.

coraleliz

I had 2 positive nodes & was told I need to decide for myself on the chemo, My MO said he was bias in favor of chemo & but gave me low percentages of reoccurence. Originally he said no to the oncotype test because it wouldn't change his mind. I had pretty much decided against chemo but asked for the 3rd time if I could get the oncotype test run. He finally agreed. I was going to do chemo if it came back high or intermediate. It came back low at 4. I skipped chemo.

As for the ALND, my MO thought I should have it done but my BS & RO thought the risk of LE was too great. More than 30% lifetime risk. They said it was a "quality of life" issue. I did do RADS but declined the ALND.

I was diagnosed at 52 & premenopausal. My tumor was grade 1. I see your's was grade 2. Not sure how this really differs or if it would have changed my decision. The whole decision making process was difficult for me.