returning once again :-(

MRI guided biopsy is when you lay down on the MRI bed and put your breasts into this hole. Sometime you are given a xanax or something to mellow you out. The will numb the breasts and then put them on this grid which will mark where the spots are on the MRI.  Once the MRI is completed they will use some sort of small cut to put in a tube or something (could not see I was laying down) to take out the suspicious spot. Sometimes they will leave a chip in there so the DR can see where the cancer is for surgery. The MRI guided biopsy is not painful other than the stick of the numbing meds. If you have anxiety ask for something to take.  I hope everything comes out B9. Take Care. Julie

"why can't I have the modified mastectomy (no lymph nodes removed) and *IF* the breast comes back cancerous, then have a lymph node or two removed. Does this make sense to anyone? "

You face some difficult decisions.  To your specific question, unfortunately it is difficult to do a sentinel node biopsy after a mastectomy has been done.  Normally an SNB is done by injecting dye and/or isotopes into the breast. The dye/isotopes travel through the breast into the lymph nodes and it's the specific lymph nodes that capture that dye/isotopes that are removed during an SNB.  Sometimes the dye and isotopes move into one node only; sometimes they enter 2 or 3 nodes; sometimes they move into even more nodes. Any affected nodes are removed during the SNB.

The reason an SNB is effective at checking the nodes for the presence of cancer is because the movement of the dye/isotopes from the injection site in the breast into the nodes mirrors the way that cancer cells would travel from the breast into the nodes.  So the nodes that have the dye and/or isotopes are the same nodes that cancer cells would enter first as they move from the breast into the nodal system.  

After a mastectomy, when there is no breast and no place to inject the dye or isotopes, the surgeon has no way of knowing which nodes the cancer cells might move into first. Therefore he wouldn't know which nodes to remove. As a result, to know if there is any cancer in the nodes, the surgeon would need to do an axillary node dissection, removing the entire first layer of nodes, and possibly some nodes in the second layer. This would mean the removal of many more than just a couple of nodes - significantly increasing the risk of lymphedema. If only one or two nodes were removed, without first having injected the dye into the breast, then it's very possible that those might not be the 'sentinel' nodes (the first nodes where cancer would enter the breast). So it simply wouldn't be an effective way to check if any cancer cells had entered the lymph nodes. I have heard of one case where the SNB injections were done in the arm but this is very unusual - basically it's assumed that once a mastectomy has been done, an SNB is no longer possible and a full axillary node dissection is required.

So if you are thinking that you want to have the mastectomy rather than go through the biopsy, but you don't want the SNB to be done, that's a somewhat risky decision.  On the other hand, if you have a prophylactic mastectomy, i.e. if you have the biopsy and the result is benign but you decide to have the mastectomy anyway, then usually it's not considered necessary to check the nodes. Of course there is still a risk that some cancer might be found once the mastectomy is done but that risk is much smaller after a benign biopsy than if you go ahead with the mastectomy without having the biopsy first.

Hope that makes sense.  And sorry that it's not the answer you want to hear. 

When I had nodes WITH mastectomy, they didn't do SNB with dye. I'd heard about it on the boards, asked if they were doing SNB at the LUMPectomy and was told no node touching at all. I didn't think to ask about nodes after that. The mx consent said "simple mx" and that was that. Everything else was about scheduling.

Although I was obviously asleep, I am quite sure they just did the axillary dissection with the level one nodes not SNB. So axillary dissection vs SNB: was the surgeon lazy or there is debate about the best practices? Nobody even told me nodes were touched until I saw it in the path report. I even asked why it was numb and surgeon said something about sewing up too tight. So lazy and chicken? That would be a point in Denise's dr's favour.

beacon, I assume that Denise meant a modified radical, i.e. a mastectomy with some nodes removed, vs. a simple mastectomy in which no nodes are removed.  For women who have aggressive DCIS who are having mastectomies, it's not unusual to have an SNB.  It's not always done, but it is done more often than not.  This is one area where DCIS is different than LCIS.

With DCIS, if there is a large area of DCIS or multi-focal DCIS, and/or if the biopsy pathology shows high grade DCIS and/or comedonecrosis, then often when a mastectomy is done, an SNB is done as well. Overall, in 20% of cases where a biopsy shows DCIS, the final surgery uncovers some invasive cancer. The risk is higher in cases where the DCIS is multifocal, high grade, has comedonecrosis or where there is a large area of DCIS.  Unfortunately all the screening and pre-testing in the world can't uncover a small area of invasion - it's pretty easy for a 1mm microinvasion to hide in a big area of DCIS. For this reason, although lymph nodes don't need to be checked for those who have pure DCIS, surgeons will often recommend an SNB to patients who are having a mastectomy with this type of DCIS diagnosis.  That's because once the mastectomy is done, an SNB can't easily be done (as I mentioned in my earlier post).  And if some invasive cancer is found, even just a microinvasion (as I had), then it becomes necessary to check the nodes. 10% of women who have invasive cancer as small as microinvasions are found to have nodal involvement. 

So it's a question of weighing the risks and benefits. There's a not insignificant chance (more than 20%) that someone with DCIS will be found to have invasive cancer once all the surgery is done. For those having a mastectomy, they can choose to have an SNB at the time of surgery, before they know if there is invasive cancer present, opening themselves up to an approx. 3% - 7% (or possibly higher) risk of lymphedema.  Or they can wait until after the mastectomy and then have an axillary node dissection if invasive cancer was found.  The risk of lymphedema after a full axillary dissection is around 25% - 30% (not sure on that; someone please correct me if I'm wrong). 

It's a tough choice.  In my case I consider myself to be lucky that my microinvasion was discovered when I had my excisional biopsy; I knew that I had to have the SNB when I had my mastectomy.  If the invasion had not been found during the biopsy, I might not have agreed to the SNB and then I would have ended up needing to have more nodes removed, increasing my risk of lymphedema. 

Denise, usually the injection of the dye and/or isotopes is done prior to surgery - it can be done up to 24 hours before - but there are some doctors who do the injection right at the start of surgery. So yes, some women are already asleep on the operating table when the injection is done.

I had my injection done a couple of hours before surgery. I had 4 injections around the nipple; each injection was aimed in a different direction.  I was lying under the camera (or whatever that machine is that follows the injection as it moves through your breast) and I was able to watch on a computer screen as the isotopes from the four injections all moved first into different areas of my breast but then turned and converged at the very same place under my arm.  So I could actually see that they all went to the 'sentinel' node.  If I recall, for me the process took about 15 to 20 minutes, maybe a bit less.  So certainly it's possible to do this during surgery, although it means that the surgeon has to delay starting the mastectomy.  

I hope that the biopsy today was successful.  And good luck with the results.  Hoping for benign all the way!  

Crystalphm,

I had a stereotactic biopsy and also an MRI guided biopsy.  I have to say that the MRI guided was so much "better". They do an IV so they can inject the contrast dye and you get to slide in and out of the MRI tunnel half a dozen times, but it was not for long periods of time. 

I took a xanax to help relax me (ask your doctor for one!!) and I also practice visualization.  They had a fan blowing on my head from the end of the tunnel, and I pictured myself laying on the beach in the warm sun with a clear blue sky overhead. You lay face down with your breast(s) through a hole, but I just kept my eyes closed and imagined my favorite place.  It is amazing what you can make yourself believe when you need to!!

The whole procedure lasted probably 45 min to an hour.  I am glad I had the MRI because it revealed another area that wouldn't have shown up on a regular mamm and I would be going through all this probably a year or two from now.  Good luck and try not to get too worked up ahead of time :-)

Sarah,

I remember posting about SNBs with you a month or so ago. At the time, I was surprised that you were not getting SNBs with a cancer diagonsis. You must be relieved now to know your nodes were clear. I initially I thought I would want an SNB with my prophylactic MX, and my insurance would have covered it, but I have come full circle and decided against it. I don't want anyone digging around in my good armpit.

Denise,

Did you have your biopsy yet? 

Re: dissection, I agree with others who have suggested SNB. I urge you to not let your surgeon do a full dissection. You can always opt for radiation and chemo if the SNB is positive. Radiation and chemo are highly effective cancer treatments with temporary side effects. ALND is not an effective treatment, but it does have permanent side effects. Please read the newer studies that have shown it does not extend life.

I had ALND and still had to have radiation, my oncologists did not consider ALND "good enough." Ten months later, I am still having problems with my left arm and shoulder. The diagnostic benefits of ALND are not worth getting lymphedema or frozen shoulder, or having to do months or years of physical therapy.

I am sorry you are sad. I think you need a new surgeon for sure. I had a skin sparing double mastectomy with an immediate reconstruction.  I can out of the OR with two wonderful breast mounds. 

It didn't even feel or look like I had a mastectomy! I was so grateful to feel the way I did. I had this surgery at the Hospital of the University of Penn. Dr. Brian Czernecki and Dr. Liza Wu.

The best thing about having my double mastectomy is knowing that I can't great breast cancer in the fat removed from my stomach and moved into the breasts!

Find a new doctor who wants what you want.