Lymph Node Removal Decisions

Jennie93

Sugarcakes, my situation is not the same as yours (we had no reason to suspect any positive nodes beforehand, they did not show up on ultrasound or PET scan - so I was not expecting to need chemo or rads at all) but I can tell you what my docs said about the subject. My BS ended up taking out 6 nodes with the SNB. I'm not sure if that's how many "lit up" or if he could see cancer in 3 of them so took twice as many to be safe. But they knew I had 3 positive right after surgery. Later the path report said there were microscopic cells in the 4th. But both the BS and the RO told me that in the past, they would have gone back and taken the rest out, but now, they know it's just as good, maybe better, to leave them and just radiate them. So that's what we did. The rads do raise your risk of LE some, but nowhere near as much as taking them out.

SugarCakes

It was unclear to me if they had control of how many lymph nodes they could remove. It baffles me when I see things like "4 of 20 nodes positive". I'm thinking, why the heck was 20 taken out?!? Then I read that it's a cluster of nodes and they don't know until removed how many lymph nodes are there. So, Am I correct in now understanding that it could be a complete ALND - I, II or III OR they can take out individual lymph nodes?

I'll meet with my BS on Tuesday to discuss options.

I heard back about the study. Even though it's all Duke, I would have to change my MO and BS. I really like my current MO. Still, if he and the BS highly recommend ALND,I feel I should go for the study if I qualify.

SpecialK

sugarcakes - the goal of SNB is to take as few nodes out as possible.  If the surgeon is lucky there is a single node that lights up, but often there are several, or since nodes are encased in a fatty pad, they end up with several.  That is why you sometimes see 0/4, or 0/1, or a low number out of a low number.  In cases of a large number of nodes one of two things happened - one is that the SNB was positive in the operating room and the patient consented to ALND, and the surgeon felt this was the best course of action - either because that is their SOP, the positive node(s) removed in the SNB presented with gross disease, was extranodal, or it was clear to the surgeon that more nodes should come out based on what he/she saw, or two, they had a false negative in the OR and the decision was made to perform a subsequent surgery. It is very difficult to remove individual nodes because they are not clearly visible, and how would you pick and choose which nodes to take?  Also, each individual has a differing number of nodes - I had clearance surgery five weeks after BMX/SNB and had levels 1&2 removed, but it was only another 11 nodes.  I am a person without a large number of nodes, others could have both levels removed and have 30.  My BS, who is progressive and prudent and one of the pioneers of SNB - so in favor of removing fewer nodes, insisted on ALND due to my Her2+ status.  My MO backed him up even though this meant a delay in starting chemo and Herceptin.  The BS was correct in insisting on this for me as a sample of one, my SNB has only 20 IST - clinically node negative - but I had a much larger positive node further up.  I would not have wanted to rely on chemo and rads to completely clear a node the size of a stage 1 breast lump. A complete axillary dissection is the removal of levels 1&2 - level 3 is quite a ways up.  Here is a diagram:

MJS1266

I had Neoadjuvant chemo and knew that one definitely probably two lymph nodes were positive for cancer. I had lumpectomy and am scheduled for rads. I originally thought I had a choice between SNB and ALND. However, the current standard of care is to do an ALND if you had neoadjuvant and have positive nodes at the time of surgery. The thinking is t^{hat SNB with Rads will be the future Standard of Care for patients who receive neoadjuvant chemo and still have one or two positive nodes. There is currently a phase three study on this which I agreed to with a 50% chance of SNB if I still had positive nodes and a 50% chance of ALND. They took out 3 nodes during surgery, one was the sentinel and the other two looked suspicious to the surgeon. The nodes were all negative and so was the original tumor which as you know is a complete pathelogical response. Because I had no positive nodes at surgery time, they only did the SNB. The MO said later that because of my ER/PR + status, she had not expected a complete pathological response, so it was really good outcome of chemo.}

SugarCakes

I had my 5th of 6 infusion yesterday. My MO had already received word that I was inquiring about the study: AXLD + rads vs rads only. I will meet with the BS today, assuming she has heard as well. Though they all fall under Duke, I would have to change doctors for the study. It's going to be more input from the BS, but MO explained they could look for and go for 1 or multiple sentinel nodes, but if they are difficult to detect, they would go in for more individual nodes and possibly all AX nodes. That's something I would have to sign off on going into surgery. Question: is the blue dye US performed just prior to surgery? I assumed it would be days beforehand and I would have time to discuss before surgery. I will get clarification this afternoon.

SpecialK

My dye/tracer was injected in pre-op before surgery, but some people have it the night before if they are having a very early surgery the next morning.  The locating of the node(s) is usually done after you are anesthetized and asleep. My singular sentinel was removed during BMX, through the IMF incision for the mastectomy (I did not have an incision under the arm) and was declared negative in the operating room so no further nodes were removed.  It was found to be positive later in the lab, and I had a separate surgery five weeks later to remove levels 1&2, and another much larger positive node was found in that surgery.  I did not have radiation either to the breast or axilla.

Rockym

I am almost 4 years out and I recall always wondering what was up with the 0/1 lymph node. My cancer was very close to my underarm and while that was great for a small scar, it wasn't that cool for lymph nodes. My BS did a SNB while I was on the table and after surgery told me all was clear. When they did the final pathology report later, they found 2 nodes with micromets out of 6 taken. It appeared my BS took a few more while he was in there. I was so caught off guard. I had my slides sent to Johns Hopkins for a second opinion since all this cancer in the nodes stuff meant chemo versus no chemo. Of course, then I found out that many doctors don't considered micromets to be a positive node. Talk about obsessing! I did end up doing the chemo and since I had a lumpectomy I did the RADS. They had to zap under my arm since that was where the cancer was and the node deal too. I ended up with truncal and breast lymphedema. It was hard to get anyone to recognize it as that. It is under control now, but not a great way to end treatment.

SugarCakes

BS says SNB can be done at the start of surgery and if found negative, she will not remove more nodes. If they are positive, she'll do the ALND. Guess I would wakeup with a surprise. Sigh. Makes sense, I guess. I'm really hoping for a pCR.

Other thing she told me today was that I'm a candidate for lumpectomy now. And when she spoke of mastectomy, she spoke of unilateral.

At first she clearly favored double mastectomy and said SNB was out of the question. Man! She just made all the decisions harder. LOL!

Hopeful82014

Congratulations, SugarCakes. Clearly, you've had a strong response. I know what you mean about all the decisions, though. It ain't easy.