Sentinel Lymph node Biopsy

I had a lumpectomy on 11/22/13 with sentinel node biopsy.  First the injections to track the nodes hurt like nothing else, but I think it was necessary.  In surgery cancer was found in 4 of 6 sentinel nodes, none in 5 axillary nodes.  At surgery they removed a couple, found them to be positive then removed a couple more, they were positive so they took two more.  Just kept working through until they got it all.  The pathologist was on duty, they also did not get good margins the first time, went in and took more tissue until I was clear.  The whole surgery was less than an hour and when I came out I knew they had all the nodes and good margins.  No reason to have surgery then to have to wait for pathology results, they should know when they have you open the first time.  I am not having any problems with lymphedema at this time, crosses fingers.  Hope this answers a few questions.

Patti

Is it common that pathologist at operation room to do biopsy and will know if it's node is positive right away?   Both doctors said biopsy of nodes will be done after work and I will know result later.

Nao, were the doctors saying that the surgery on the nodes, i.e. the actual removal of the nodes will be done later?  

Or were they saying that the pathology work on the nodes will be done later?  

It's the surgeon who performs the SNB and surgically removes the nodes.  It's the pathologist who takes the nodes, once removed by the surgeon, and analyses the nodes under a microscope to see if there are any cancer cells in the nodes. 

The sentinel node biopsy surgery itself normally is done by the surgeon at the same time as the lumpectomy or mastectomy.  Then the assessment of the nodes is turned over to the pathologist.  As I explained in my previous post, sometimes a preliminary assessment of the nodes is done by the pathologist while the surgery is underway, but the more thorough assessment is not done until later.  So the final pathology on the nodes cannot be known until after the surgery - whether a quick assessment is done during surgery or not.  That quick assessment is just a preliminary finding.  

For women who are unlikely to have positive nodes, this preliminary pathology assessment sometimes is skipped.  That's what happened in my case.  As my surgeon explained it, because my risk of nodal involvement was so low, if my nodes were to be found to have cancer, there probably would only be a very small amount of cancer.  And in that case, the quick pathology assessment could easily miss finding the cancer.  So my surgeon didn't feel that the quick pathology assessment would yield reliable results in my case and therefore he didn't want to waste the pathologist's time.  He felt that it was better to have the pathologist do just the one more thorough analysis of the nodes after the surgery was done.  While I would have liked to have preliminary results from the surgery, once I understood that those results wouldn't be final and would be pretty meaningless, I was fine to wait.

Not having this assessment done during surgery doesn't mean that you will have more nodes removed.  It's the opposite.  If the quick pathology assessment of the sentinel nodes is done while you are in surgery and if any of the nodes are found to be positive, then more nodes may be removed.  But if no assessment is done, then the only nodes that will be removed during the surgery are the sentinel nodes, the nodes that 'light up' from the dye/isotope injections.  And you can't reduce the number of nodes that light up - that's determined by the biology of your body.

My surgeon did the lumpectomy first but when she found 2mm of IDC, she has now scheduled the SNB for 2/20.  I was given a lidocane patch that I have to put on about 6 hours before they inject the dye/isotopes - I'm hoping that the injections won't hurt.   I've been very lucky in the pain department so far on this journey (very little pain during the biopsy, minute pain during the guide wire insertion and absolutely no pain after the lumpectomy), so I'm hoping to continue that track record. 

My surgeon did say that she would do the quick path exam/report during surgery, even though she thinks there is only a 5% chance that mine has spread - I'd be okay either way, but it will be nice to get the initial report right after surgery -- I'll have to give my husband the question in writing so he remembers to ask her (and have him write down her answer so he doesn't muck it up)!

Good luck!

Nao,

I appreciate that you want to avoid lymphedema, but I'm assuming that first and foremost, you want to ensure that you are properly diagnosed and get all the appropriate treatments to treat your breast cancer .   

If you are thinking "so why do I want to risk?" the SNB, then you might as well tell your doctor to not bother having your removed breast tissue analysed by pathology.  Because not having the SNB, and not knowing if you are node positive or node negative, has as much effect on your diagnosis and treatment plan as not knowing the pathology of your cancer. 

"My other doctor said node biopsy is not always accurate and does not change mortality rate"  My advice is to not go with this doctor.  SNBs - if properly done - have a very high accuracy rate.  However if it's the surgeon's policy to only remove 1 or 2 nodes regardless of how many nodes are lit up by the dye/isotope injection, then the SNB is not being properly done and that will impact the accuracy.   

And to say that having an SNB and knowing one's nodal status doesn't impact the mortality rate is, frankly, absurd.  If you find out that you have several positive nodes, it will change your treatment plan, possibly quite significantly (chemo vs. no chemo, for example) and that can save your life.  Alternately, if you find out that you are node negative, it may mean that fewer treatments are necessary, avoiding over-treatment and having to deal with the side effects of these extra treatments.

What has been shown to be true is that if a patient has an SNB and is found to be node positive, and if the patient will be having chemo, then there is no survival benefit to having any more nodes removed, i.e. doing an axillary node dissection in addition to the SNB.  And this is the reason why it really doesn't matter if the nodes are checked during surgery.  The only reason to check the nodes during surgery is to allow the surgeon to remove more nodes, i.e. do the axillary node dissection, while the surgery is underway, if it's found that the SNB nodes are positive. But if you don't want more nodes removed than necessary, you probably wouldn't want to have the axillary node dissection done anyway.  So this means there is absolutely no reason to have your nodes checked while you are in surgery. 

wyo, I've been on this board a long time, and I've seen lots of situations where the SNB nodes are sent for a frozen section while surgery is underway and come back clean, only to find when the permanent pathology is done that there is a small amount of cancer in one or more of the nodes.  Larger amounts of cancer in the nodes will be found by a frozen section but when dealing with something as small as micromets, it's easy to miss.  Usually when this happens, the nodal involvement is micromets or an area of cancer just slightly larger.

I would take saving my life over the possibility of developing lymphadema.  I had 4 nodes taken out and fortunately they were clear.  I'm out over 4 years and I could possibly get lymphadema but I'm very comfortable with my decision.  Please know that I am not minimizing lymph.

Nao, I am so sorry to hear what you're going through.

I too, have Rheumatoid, I was Dx with it about 17years ago. 

I was Dx with DCIS and decided to have a Mx, 13 months ago. My surgeon explained that  it would be "remiss" of him if he didn't do a SNB at the time. It was a case of 1or2 nodes to make sure there was no invasion, against taking no nodes, then finding invasion in the final Pathology, and having to do a full Axillary clearance which would greatly increase the possibility of LE. 

Try not to jump too far ahead, The waiting game is a terrible thing and we have all experienced the negative thoughts that go with it.

I am confused about your RA drugs, have you been told not to take anything? There are several of us with RA on these boards, you may want to search and chat! take care, and let us know how you're doing. 

chicopeach, PETs normally are given to check for distant metastasis in situations where the diagnosis indicates that this is a risk.  So whereas PETs are often not given to women with small early stage cancers (where the risk of mets is low), they are usually given to women who have more advanced diagnoses. However to my understanding, PETs usually aren't used to diagnose/assess the breast cancer or nodal involvement prior to surgery - MRIs are used more often for that.  One big concern about PETs is the amount of radiation, and for that reason, if another form of imaging can serve the same role, that is generally preferred.  

As you indicated, PETs (and MRIs) unfortunately don't catch everything. So in the case of the nodes, if there is only a small amount of cancer in one or several of the nodes, the PET or MRI most likely wouldn't show it.  And for that reason, I don't think there is any surgeon who would say that an SNB isn't necessary because the PET or MRI showed the nodes to be clear.  The surgeon would say that the SNB is needed regardless, because there still could be nodal involvement despite having a clear scan.

I agree that it's important for the surgeon (and the patient, of course) to have as much information as possible prior to surgery.  In my case, the MRI indicated that my DCIS appeared to cover a larger area than what showed on the mammogram, and that led to my decision to have a MX instead of a lumpectomy - although to be fair, both my first opinion surgeon and my second opinion surgeon told me that they felt that a MX was the best approach because it was likely that my DCIS was widespread; the MRI just confirmed their suspicions.  If I had not had the MRI, the extent of DCIS would have been uncovered by the surgery.  Your PET scan may have told you in advance that you had nodal involvement, but if you had not had the PET, the SNB would have provided the same information the next day when you had surgery.  

In the end, it's only surgery that can provide a definitive diagnosis, either of the nodes or of the extent of cancer in the breast.