Studies on SNB?

Ellen, there are many factors we know about that contribute to lymphedema risk, and nobody-knows-how-many factors that we don't yet know about. Lymphology is a new and emerging science, with embarrassingly little good research yet done.

Some factors that increase risk are number of nodes removed or damaged, overweight, diabetes or other vascular conditions, previous surgeries or injuries to the chest/breast/axilla, surgical complications (infection, seroma, possibly axillary web syndrome), radiation (especially to some areas), certain chemo regimens, and most likely the make-up and functioning of your lymph system before treatment. (Recent research by Stanton in the UK indicates that those of us who develop lymphedema with cancer treatment had lower-capacity lymph systems to begin with -- but there is currently no way of knowing that beforehand.)

There are thin, fit women on these boards who had SNB with no surgical complications and few other risk factors who now have lymphedema. There are women here who had a couple dozen nodes removed, rads, chemo, infections, and they buck bales for a living and they've never developed lymphedema. I had a single node removed on the left (cancer) side and a prophylactic mastectomy on the right, and I have lymphedema on both sides. If you develop lymphedema, the risk was 100%.

On the other hand, there is some (also sort of nebulous) research, mostly from Scandinavia, that indicates that SNB + rads is resulting in an increased risk of truncal lymphedema over what might be expected with a mastectomy and ALND. That was a few years ago and I haven't seen recent figures on that.

In the face of all that, the National Lymphedema Network has recently published a Position Paper on Breast Cancer Screening that urges pre-surgical assessment and follow-up. It's here:
http://www.lymphnet.org/

Best bet is a referral from any one of your doctors to a well-trained lymphedema therapist for baseline arm measurements, personalized risk-reduction tips, learning a gentle prophylactic lymph massage, and possibly fitting for a compression sleeve and glove or gauntlet (fingerless glove) to use for exercise and travel. Here's how to find a qualified therapist near you:
http://www.stepup-speakout.org/Finding_a_Qualified_Lymphedema_Therapist.htm

There's a lot you can do to lower your risk. Knowledge is power!

Be well,
Binney

Ellen, keep in mind that 'sentinel' often means more than one node.  My SNB removed 5 nodes and I have very mild LE of the upper arm. I consider myself very lucky that it is mild.  I remain unconvinced that my SNB was actually necessary, and had I understood my LE risk (BS told me only 1-3%), I would have challenged the recommendation and done more research.  Kudos to you that you are pursuing it now!

Carol

Ellen, the NCCN are national guidelines, and to my knowledge no center is affiliated with them, but some centers are NCI cancer centers.

I know Mei Fu, and she has several active studies, and it's worth contacting her to see if you're eligible for one of them--she has a perometer, and is also studying biomarkers. 

She's not really a clinician: in that you wouldn't be her patient and she doesn't employ therapists, but she does research. She does seem to enroll patients into the "Optimal You" program.

The post op considerations are that lymph tissue reconnects in a 2-3 week window after surgery, so you want to avoid seromas (Mei Fu presented an abstract at the SABC last year about axillary seromas and LE risk) and avoid stretch through the axilla for the first 10-14 days.

Totally agree with all the comments about the under recognition and under diagnosis of LE

Kira

Ellen, the study was about the need to do full axillary lymph node dissection if only1-2 nodes were positive with a T2 or lower tumor--invasive--and no survival benefit was seen with those women who met the criteria.

Thanks for letting me know about the NCCN institutiions.

The study was in JAMA

http://jama.ama-assn.org/content/305/6/569.abstract

Axillary Dissection vs No Axillary Dissection in Women With Invasive Breast Cancer and Sentinel Node Metastasis
A Randomized Clinical Trial

Armando E. Giuliano, MD;
Kelly K. Hunt, MD;
Karla V. Ballman, PhD;
Peter D. Beitsch, MD;
Pat W. Whitworth, MD;
Peter W. Blumencranz, MD;
A. Marilyn Leitch, MD;
Sukamal Saha, MD;
Linda M. McCall, MS;
Monica Morrow, MD

[+] Author Affiliations

Author Affiliations: John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California (Dr Giuliano); M. D. Anderson Cancer Center, Houston, Texas (Dr Hunt); Mayo Clinic Rochester, Rochester, Minnesota (Dr Ballman); Dallas Surgical Group, Dallas, Texas (Dr Beitsch); Nashville Breast Center, Nashville, Tennessee (Dr Whitworth); Morton Plant Hospital, Clearwater, Florida (Dr Blumencranz); University of Texas Southwestern Medical Center, Dallas (Dr Leitch); McLaren Regional Medical Center, Michigan State University, Flint (Dr Saha); American College of Surgeons Oncology Group, Durham, North Carolina (Ms McCall); and Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Morrow).

Abstract

Context Sentinel lymph node dissection (SLND) accurately identifies nodal metastasis of early breast cancer, but it is not clear whether further nodal dissection affects survival.

Objective To determine the effects of complete axillary lymph node dissection (ALND) on survival of patients with sentinel lymph node (SLN) metastasis of breast cancer.

Design, Setting, and Patients The American College of Surgeons Oncology Group Z0011 trial, a phase 3 noninferiority trial conducted at 115 sites and enrolling patients from May 1999 to December 2004. Patients were women with clinical T1-T2 invasive breast cancer, no palpable adenopathy, and 1 to 2 SLNs containing metastases identified by frozen section, touch preparation, or hematoxylin-eosin staining on permanent section. Targeted enrollment was 1900 women with final analysis after 500 deaths, but the trial closed early because mortality rate was lower than expected.

Interventions All patients underwent lumpectomy and tangential whole-breast irradiation. Those with SLN metastases identified by SLND were randomized to undergo ALND or no further axillary treatment. Those randomized to ALND underwent dissection of 10 or more nodes. Systemic therapy was at the discretion of the treating physician.

Main Outcome Measures Overall survival was the primary end point, with a noninferiority margin of a 1-sided hazard ratio of less than 1.3 indicating that SLND alone is noninferior to ALND. Disease-free survival was a secondary end point.

Results Clinical and tumor characteristics were similar between 445 patients randomized to ALND and 446 randomized to SLND alone. However, the median number of nodes removed was 17 with ALND and 2 with SLND alone. At a median follow-up of 6.3 years (last follow-up, March 4, 2010), 5-year overall survival was 91.8% (95% confidence interval [CI], 89.1%-94.5%) with ALND and 92.5% (95% CI, 90.0%-95.1%) with SLND alone; 5-year disease-free survival was 82.2% (95% CI, 78.3%-86.3%) with ALND and 83.9% (95% CI, 80.2%-87.9%) with SLND alone. The hazard ratio for treatment-related overall survival was 0.79 (90% CI, 0.56-1.11) without adjustment and 0.87 (90% CI, 0.62-1.23) after adjusting for age and adjuvant therapy.

Conclusion Among patients with limited SLN metastatic breast cancer treated with breast conservation and systemic therapy, the use of SLND alone compared with ALND did not result in inferior survival.

Sounds like it's time to have a discussion with your treating physicians

Kira

I have significant LE in my right arm--the side that I had a MX and 23 LN removed.  I am going to have the other breast removed this summer and I suspect they will want to do a SNB on that side.  Of course, I am worried about developing LE on the left side as well.  Any data/experiences to bring to the party to suggest that those with LE are more or less prone to developing it on the other side?

Here is a study from Jane Armer from 2004, using 5 point measurement and symptoms and found around a 22% incidence of LE in SNB. The incidence really varies by how it is measured and determined:

http://www.ncbi.nlm.nih.gov/pubmed/15328760

Lymphology. 2004 Jun;37(2):73-91.
Lymphedema following breast cancer treatment, including sentinel lymph node biopsy.
Armer J, Fu MR, Wainstock JM, Zagar E, Jacobs LK.
Source

MU Sinclair School of Nursing, University of Missouri-Columbia, Ellis Fischel Cancer Center, Columbia, Missouri 65211, USA. armer@missouri.edu
Abstract

To compare the occurrence, signs, and symptoms of lymphedema (LE) the arms of women after axillary lymph node dissection (ALND), sentinel lymph node biopsy (SLNB), combined SLNB and ALND (Both), or neither as part of breast cancer diagnosis and treatment, a concurrent descriptive-comparative cross-sectional four-group design with retrospective chart review was carried out. In a convenience sample of 102 women treated for breast cancer and receiving follow-up care at a midwestern United States cancer center, sequential circumferential measurements at five selected anatomical sites along both arms and hands were used to determine the presence of LE (> or = 2 cm differences between sites). Participants self-reported LE-related signs and symptoms by interview and completion of the Lymphedema and Breast Cancer Questionnaire (LBCQ). Retrospective chart review was carried out to verify lymph node-related diagnostic and treatment procedures. Based on node group, LE occurred as follows: 43.3% (29 of 67) of women who underwent ALND alone; 22.2% (2 of 9) of those who underwent SLNB alone; 25.0% (3 of 12) of those with combined SLNB and ALND; and 22.2% (2 of 9) with neither SLNB nor ALND. LE-related symptoms were reported by women who underwent ALND alone, SLND alone, combined SLNB and ALND, and neither. Among the node groups, three symptoms were more common: larger arm size, firmness/tightness in past year, and numbness in past year. We conclude that circumferential measurements of the upper arm and forearm may be critical for distinguishing LE from no LE. Overall, the proportion of women who experienced LE-related signs and symptoms was higher among women who underwent ALND versus SLNB. However, numbness and tenderness frequently were reported by those undergoing ALND, SLNB or both; and by women without LE. It is possible that some frequently occurring symptoms, such as numbness and tenderness, may be related to breast cancer surgery and not LE. Findings from this study can assist health professionals in educating women with breast cancer about LE risk factors, as well as early detection and management of LE by using the LBCQ and sequential circumferential arm measurements to evaluate limb changes subjectively and objectively concurrent with each breast cancer survivor's follow-up care.

I also found studies that said there was a 5% incidence of LE with SNB and 18% with ALND--based on "clinician evaluation"--I need to see the article in detail to figure that out.

Ellen: I'd always go with the rule of you can't put things back, and if there's no need, why take it out. You can always go back in later for the SNB, if it's not clinically indicated up front.

Kira

If I were in your shoes I would first determine if you have IDC or DCIS.  The difference betwen the two has to do with location - DCIS is contained in the ducts, IDC has broken out of the duct and invaded the surrounding area.  Often IDC has some DCIS nearby or surrounding it.  If you have DCIS your physician may not feel a SNB is necessary at all, especially if you have a lumpectomy and not a mastectomy.  Some ladies have so much DCIS that a mastectomy is their only option, just because you have a scattering of suspicious areas it can still all be DCIS.  If you have IDC than I would advise a SNB because you would need to know if your IDC has moved beyond the breast. This will help determine treatment options.  My IDC was diagnosed with a hollow core needle biopsy, and confirmed with an MRI.  I was initially diagnosed with a suspicious lesion by ultrasound, it did not show up on mammography.  I had bi-lat mastectomy with bi-lat SNB.  In the OR it was thought that my (cancer side) SNB was clear, but post-op pathology  indicated a micromet.  My BS (an experienced and forward-thinking oncological breast surgeon coming from an NCI center) insisted on complete axillary node dissection, which was not done until 5 weeks later.  It revealed an additional 6mm positive node.  This was an outpatient surgery done at an ambulatory surgery center. Hope this helps! 

Ellen, you really need to discuss this all thoroughly with your treating physician.

I read path reports daily at my work. I do not see DCIS mentioned in your report, only "adenocarcinoma"

The bottom line is that this is a situation where you need to confer and discuss with the treating physician to arrive at a decision.

Good luck.

Kira

Ellen, fingers crossed for good news and rapid healing.

As Binney says "May all the hands that touch you be healing hands."

Kira

All the best to you tomorrow Ellen.  Becky

glad things have gone well so far, Ellen! 

Dawn