Multifocal Invasive Breast Cancer

sanet2004, so sorry to hear of your diagnosis, but you'll find much company here. I too had ILC and one year ago a mastectomy preceeded by the sentinel node biopsy. Fortunately, the three nodes removed were clear, so no additional nodes were taken. I feel very fortunate because, as I understand it, the life-long problems that can arise from having all (or most all?) of your lymph nodes taken can be significant (something called "lymphedema"). If you have a skilled, experienced surgeon, I'd think they'd recommend a SNB first to see if it's even necessary to take the rest of your nodes. Bottom line, though, you have to do what's best for you and your future in consultation with your surgeon & oncologist. Good luck & keep us posted on what you decide.

sanet 2004,

Sorry to hear you are going through this!  I don't have advice, but I will share my similar path.  I was diagnosed with ILC on 09/29/09 after I found two lumps in one breast.  I opted for a bilateral mastectomy.  This turned out to be a very good idea!! I had 4 areas of ILC in one breast and ILC (in situ) in the other. I wasn't given a choice regarding the nodes.  My surgeon took 2...the sentinal and another.  1 was positive, so I went back for an outpatient surgery to take 7 more nodes (all tested clear) I feel my surgeon is outstanding and I trust her. 

I think if I was given a choice about my nodes I would have sought a second opinion.

I've also just recently been diagnosed with invasive ductal/multicentric and there's lobular features also, so may be mixed. I'm having left mx on Dec 11th and my surgeon told me that while SNB is an option he feels it's best take out between 8 to 10 nodes (level 1 and 2) to be sure he gets enough to have a thorough look. So, that's what I'm going with.

Good luck with your decision, I know none of this is easy.

Wow...your surgery was scheduled quickly. I'll be thinking of you Wednesday.. Best of luck to you Sanet.

The differences in approach sure can be confusing.  I was told that SNB would not be appropriate for my mutifocal lobular.  All 3 oncs that I talked to told me neoadjuvant and then mast will both sets of lymph nodes removed.  This has been the one treatement issue that has bothered me the most.  I want them to take out as many lymph nodes as needed for a good prognosis but I don't want them taking out more than they need.  I'm concerned about lymphedema. 

sanet2004 good luck with your surgery tomorrow.  I will be thinking of you.

Does anyone know or think that the size of your ILC also has a factor in deciding how many nodes they check and/or remove? My 2 areas are 5mm and less than 1mm, so I was told they will check sentinel node and can end up taking anywhere from 1-7, depending on what the dye shows.

Thanks hyla.  That is what I thought.

My surgical oncologist does seem to think that because it is small she is optimistic that there won't be node involvement, BUT at the same time she did say that my case hasn't gone the way she thought it would, and at this point nothing would surprise her. Seems to be the same way all of my doctors feel right now.

Thanks Cathy

As far as I know right now, I have PLCIS and classic? ILC (is that what you call it?).  Although at the time of my appointment she didn't have the grading yet.  I am trying to get copies of the pathology.

In the meantime, I did find a section on the Sloan Kettering website, that has a tool to help predict node involvement.  Since I don't have all of the grading info yet, I wasn't able to use it, but it might be helpful for someone else.

Cathy

All 3 oncs that I initially went to did not want to perform an SNB.  When I asked about it they felt it was unreliable but I suspect that it had to do with my particular presentation and not ILC in general.  I have multiple tumors of measurable size and many small leisons that show up on the MRI.  All four quandrants are involved so it probably comes in to question which lymph nodes the tumors could be draining into.  

However I did find the following excerpt from this link:

http://erc.endocrinology-journals.org/cgi/content/full/14/3/549

The study is actually related to HRT and Breast Cancer but it contains some interesting info about ILC.  And it's hard to find much on ILC that has any meat to it.  This study concludes that SNB is useful for ILC.

Sentinel lymph node biopsy feasibility and accuracy of intraoperative assessment

The presence of axillary lymph node metastases is the most significant prognostic factor for patients with early stage breast cancer. The specific nature of ILC, as difficult to detect and often multifocal and/or multi-centric, has brought into question the feasibility of nodal staging with sentinel node biopsy (SNB). Moreover, because ILC usually has low mitotic rate with uniform appearance of bland tumour cells that lack cellular atypia, and tends to infiltrate lymph nodes in a single cell pattern, the distinction between lobular carcinoma cells and lymphoid cells can be extremely challenging (Cocquyt & Van Belle 2005). Therefore, particular attention should be given to histological specimens of lobular carcinomas because nodal metastases are more often missed with ILC, and false negative results are more frequently reported when compared with ductal carcinomas (Cocquyt & Van Belle 2005). Old studies have excluded patients with multifocal breast tumour on the assumption that tumours located in different breast quadrants drain to different sentinel lymph nodes and, therefore, SNB would result in inaccurate axillary lymph node staging. Conversely, different techniques adopting subareolar and peritumoural injection sites have demonstrated the identification of the same sentinel node, thus suggesting that the drainage of the different quadrants of the breast have a final common lymphatic pathway to the axilla (Tuttle et al. 2002). A recent analysis of 75 patients with multifocal tumours and 559 patients with unifocal tumours did not show any difference in the false negative rate, overall accuracy and negative predictive value of the SNB technique between the multifocal and the unifocal groups (Goyal et al. 2004).

A prospective study have compared the detection rates and false negative rates in patients with ILC and IDC of SNB; the false negative rate was 7.6% for IDC and 9% for ILC (Classe et al. 2004).

Creager et al. have evaluated the intraoperative imprint cytology of sentinel lymph nodes for ILC. The sensitivity of this technique for ILC was 52%, the specificity 100% and the accuracy 82%. Compared with IDC, these parameters were not significantly different. However, the sensitivity for detecting micrometastasis of ILC was only 25% (Creager & Geisinger 2002). Hence, if micrometastases are used to determine the need for further axillary dissection, more sensitive intraoperative tools will be necessary to avoid a second surgical intervention. Despite these limitations, SNB can be considered a valuable and accurate technique to stage the axilla in ILC.