Sentinal Node Biopsy

I will tell you my surgeon did not feel it was neccessary.  My DCIS is high grade too.  She felt that if something was found that indicated a SNB was needed we could go back and do it then.  I was comfortable with this.  From what I have read it isn't really needed with pure DCIS.  Hope this helps and that Thursday is over with quickly for you.

The question of whether an SNB is necessary for someone undergoing a lumpectomy for DCIS (and particularly, DCIS that is not high grade), has come up several times over the past few weeks.  I've checked a lot of the recent literature about this; what follows is a copy of an answer I wrote to an earlier post with this same question.

While there isn't universal agreement, overall the consensus seems to be that an SNB is not necessary for those having a lumpectomy, the possible exception being those who have a large amount of high grade DCIS (grade 3, particularly with comedonecosis).  Here's some of what I found:

• In a review of NSABP DCIS Protocols B-17 (lumpectomy +/- whole breast irradiation [WBI]) and B-24 (lumpectomy plus WBI +/- tamoxifen), the risk of axillary recurrences in patients was less that 1%. A similar finding of very low axillary recurrence in long-term follow-up of DCIS patients treated with lumpectomy and WBI was reported by the City of Hope Cancer Center. This extremely low rate of recurrence is less than the positive axillary metastasis rate associated with undiagnosed invasive cancer within the presence of DCIS. Thus, the routine use of sentinel node biopsy (SNB) in patients with pure DCIS is not indicated, since there is no survival data of any magnitude in patients treated by SNB who have an axillary recurrence.....In summary, at the present time, based on currently available data, the routine use of SNB in all patients with pure DCIS is not warranted. For patients with proven invasive or microinvasive disease with DCIS, SNB is supported. In patients undergoing mastectomy for DCIS, SNB is recommended at the time of mastectomy. A case-by-case decision should be made for the use of SNB in patients who have high-risk DCIS or large tumors.   http://consensus.nih.gov/2009/dcisabstracts.htm#julian
• We conclude that based on the current literature, there is in general no role for a SNB in DCIS. A SNB should only be considered in patients with an excisional biopsy diagnosis of high risk DCIS (grade III with palpable mass or large tumour area by imaging) as well as in patients undergoing mastectomy after a core or excisional biopsy diagnosis of DCIS, although SNB may be contraindicated in many of the latter patients because of lesion size and/or multifocality. http://www.ncbi.nlm.nih.gov/pubmed/17300928
• INR (ipsilateral nodal recurrence) in patients with DCIS treated conservatively is extremely rare. Our findings do not support the routine use of SNB in patients with conservatively treated, localized DCIS. http://www.ncbi.nlm.nih.gov/pubmed/17534687
• SNB as a diagnostic tool in DCIS remains controversial as the number of cases of axillary lymph node metastases is minuscule. The biggest clinical challenge in this situation is a group of patients with primary diagnosis of DCIS in which invasive components are seen by mammotomic biopsy.  http://www.ncbi.nlm.nih.gov/pubmed/18723312
• A different opinion: SNB positivity in pure DCIS is rare. In view of the high rate of underestimation of invasive carcinoma in patients with an NCB diagnosis of DCIS in this study, SNB appears justified in this group of patients. http://www.ncbi.nlm.nih.gov/pubmed/19190009

From what the studies show, if it were me, I wouldn't have an SNB if I was having a lumpectomy for DCIS, unless my pathology indicated a high risk that invasive cancer might be present.  For me, it's a question of risk vs. benefit. After an initial diagnosis of DCIS, once all the surgery is done, approx. 15% of women will be found to have some invasive cancer as well, either a microinvasion or something more. This risk is higher for those who have large amounts of high grade DCIS and comedonecrosis; the risk is lower for those with less aggressive pathologies.  If a microinvasion is found, there is approx. a 10% chance that some cancer cells will have moved to the nodes.  So for the average woman with DCIS (i.e. not someone with a large amount of high grade DCIS), there is a 1.5% chance that some invasive cancer will be found and the cancer will be in the nodes.  On the other hand, the risk of developing lymphedema from having an SNB ranges from 3% to 7% (depending on the study).  So the risk of permanent side effects from the SNB is quite a bit greater than the risk that there might be a positive node.  And although some microinvasions are missed when the breast tissue is analysed, the majority of microinvasions are found during surgery, so for women who have a lumpectomy, if invasive cancer is found, an SNB can be done afterwards (this is not feasible for those who have a mastectomy and that's why the decision process is different for those having a mastectomy for DCIS). This means that most women who have positive nodes after an initial diagnosis of DCIS will end up with an accurate diagnosis; the positive node(s) will be found.  For those few that aren't found (at least until later), the studies seem to all agree that long-term prognosis doesn't change. 

As someone who had a microinvasion, and also because I was having a mastectomy, I had no choice but to have an SNB.  I can tell you that the pain and recovery from the SNB was a whole lot worse than the pain and recovery from my mastectomy, and from my previous excisional biopsies (i.e. lumpectomies).  I had horrible shooting pains down my arm, and my arm down to my elbow and in the underarm area remained numb for 6 months; some women never regain their full feeling.  Now I have to be careful with the use of my right arm for the rest of my life (no blood draws, no blood pressure, avoid infection from cuts, etc.).  Knowing what I know now, if I could have avoided the SNB, I would have.

Marianna, all that is a long way of saying that your surgeon is following accepted treatment guidelines, and personally, I think the approach she's taking (i.e. not doing an SNB with your lumpectomy) makes sense.

I was dx with high grade comedonecrosis DCIS in early Feb. after two excisional biopsies, neither of which came back with clear margins. My BS recommended a mx, but without a SNB. I obtained a 2nd opinion from another BS who ordered a MRI. Both the MRI and pathology reports indicate no invasive cancer. However, the pathology reports indicate extensive residual DCIS, the MRI confines the DCIS to the upper quadrant.

My mx is occurring in a few weeks and I feel the decision to have a SNB or not is a very important one. I understand the risk of lymphedema is low and the likelihood the nodes will be negative is high. If I choose to accept the surgeon's recommendation and not have a SNB, how will I know IF there is cancer in the nodes, albeit a 3%-7% chance? I am also ER-, PR-, and HER2-, which as long as it's DCIS poses no threat, but if it's in the nodes I've been told by an oncologist (friend of a friend) that I could be upstaged from DCIS to Stage II.

I don't want to over-react, but I want to be proactive enough to make sure I'm handling this diagnosis in the best way. I've read that DCIS, because it's non-invasive, does not indicate a SNB because theoretically it can't spread to the lymph nodes. I've also read that patients formerly diagnosed with extensive DCIS end up with lymph node involvement  because the pathologist misses a section of invasiveness when cutting the tissue sample.

Another aspect to the SNB is that isolated tumor cells can be found, which my understanding is they may never amount to anything, but the standard of care is to undergo chemo. Do I want to put myself through chemo for isolated tumor cells?

Do I risk the small possibility of a life-time of lymphedema by having a SNB or is the risk greater of missing the possibility of invasive cancer by not having a SNB?

I saw three breast surgeons two of which recommended SNB and one who did not.  While agonizing over what to do I read Beesie's previous post about this topic.  It helped me feel comfortable with choosing the breast surgeon who felt that it need not be done prophylactically.  She told me that if the pathology came back from the lumpectomy showing microinvasion or a different diagnosis from DCIS then we could confront the SNB as well as other treatment at that time.  For me, that seemed a good choice.  Having said that I also had to be comfortable with that small percentage that Rose mentioned. 

At that risk of sounding strange, I have also wondered during my short course of this journey how much of what doctors offer as standard treatment is based on what part of the country you live in. Are treatment protocols generally the same for DCIS in one part of the country as compared to another? For example, it's been my experience that the Van Nuys Prognostic Index isn't used in my area which I also wondered about.  Oh such much wondering...

Hope your lumpectomy goes well and your margins are good!  I had mine on Wednesday and I'm so thankful to be feeling so well.  For me the agony of deciding on treatment was more painful than the actual surgery if that makes sense! All the best.

Susan

I talked to Nurse Navigator about SNB for my mother, She said that grade 3 is very high grade, that is why doctor wants to do SNB. Because it will not be possible to do SNB after Lumpectomy. If the pathology report shows that it is invasive, then they need to do a big surgery for Lymph node. It scares me.

As Bessie said above, a SNB can be done after a lumpectomy. I was told that it cannot be done after a mastectomy.

I was dx in 2007. I didn't have a biopsy, as the doctors at the breast centre were certain that it was DCIS and within a fortnight I had been scheduled for a lumpectomy. The pathology report said that it was extensive, grades 2 and 3. My BS strongly advised a mastectomy. I read a lot and thought over the previous weeks. To begin with, only a tiny area of microcalcifications were seen on the mammogram and a lumpectomy was expected to be all the surgery I would need and even rads weren't a definite. Every time I heard from the doctors, my situation seemed to be worse. My BS was not pushing for a SNB but I decided to have it anyway because I was worried I might have IDC and would have to have a full axilliary clearance if this turned out invasive.

While I was in hospital, after the mastectomy, my BS visited me and told me "Some real cancer was found among the DCIS and you should prepare yourself for the possibility of some chemo". Yet, the final pathology did not mention an invasive component. I still wonder why he said that...did I actually have invasive cancer? Did I do the right thing by having a SNB? Mine didn't work properly anyway. The radioactive solution would not drain to the nodes under my arm. They used the dye to find the nodes but it seems that relying on the dye alone isn't as accurate. The final path report has a question mark after the word "nodes" every time they're referred to so there is doubt that the 2 nodes they removed were the sentinel ones.

Would I advise women like yourself to have a SNB? I really don't know! I have had mild lymphoedema since my mastectomy so that is certainly a factor you should consider. 

bumping for nwshannon.

sorry the first surgery was dcis.that was supposed to be ok...im soooo confused.

I had extensive DCIS, high grade.  I did have the SNB - and the dye traveled well to about 3 nodes so they took all three.  I have zero probs with my arms and I was really glad report on nodes came back 100% clear.  A little peace of mind.   I do have  a little numbness, but the doc said keep massaging it, some of the nerves may still grow and connect. It is not totally numb and so does not bother me day to day.