Anyone with DCIS with lymph node positive?

Isn't it true that just as it's possible to miss a tiny microinvasion on pathology of breast tissue, it's also possible to miss a tiny amount of cancer present in a node w/ a SNB?   I wonder how many false negatives there are in both situations.

Best wishes to you, Zoegr.

If I am reading this correctly, those with high grade DCIS should have the a SNB?  Am I understanding that incorrectly?  Now I am really nervous.  This waiting and then more waiting is so hard.  I was told 3-5 days for path results after lumpectomy.  I am hoping to hear Mon or Tues.  Thanks for all the info.

I am really sorry. I should not have posted just a snippet from an article, because I think we may not fully understand the context.  I am going to try to post a link to the article.  It may not work because you may have to go through my university access.  I will hope that Beesie can help us sort through this.  I did my first post because it seemed to me that the person who Zoe first cited (Dupont) had more recent work that suggested not everyone who has DCIS should have SNB.  I am not sure I completely understand this second article, but I think they are saying that in patients who (upon final pathology) are upstaged, a SNB is necessary (which we all know); they are further saying that it may make sense to do a SNB before upstaging in patients with highest potential to be upstaged (I think this is the controversial part).  But I don't know that one can automatically draw that conclusion is warranted based on just their study, especially since NIH and NCI guidelines are pretty clear about doing SNB after the upstaging (at least as far as I can tell).  Thinking of you Mom3, hoping that I didn't add to your anxiety (really sorry about that) and hoping for good results.  .      

 http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6VHS-4H3GWGH-C-1&_cdi=6074&_user=134779&_pii=S0002961005005453&_orig=browse&_coverDate=10%2F31%2F2005&_sk=998099995&view=c&wchp=dGLzVtz-zSkzV&md5=e830320a8872fafc65b94b7e378ec53c&ie=/sdarticle.pdf

If you can't get it, here's the abstract

Keywords: Ductal carcinoma in situ; Sentinel lymph node mapping; Breast cancer; Lymphatic mapping; Upstaging; DCISm; DCIS with microinvasion

And here's the introduction.

Sentinel lymph node biopsy has evolved to become the

primary means of axillary lymph node evaluation in patients

with node negative breast cancer [1-3]. The morbidity of

the procedure is low [4,5], and a negative sentinel lymph

node reliably predicts node negative disease, allowing 60%

to 70% of breast cancer patients to avoid axillary lymph

node dissection [1].

Ductal carcinoma in situ (DCIS) comprises 25% to 30%

of breast cancers detected by mammographic imaging [6].

Ductal carcinoma in situ with microinvasion (DCISm) is

less frequent [7] and is defined as ductal carcinoma cells

extending beyond the myoepithelial layer of the duct in foci

less than 1 mm. The published axillary nodal metastases rate

in DCIS is less than 1% [8], and because of this low

metastatic potential, nodal evaluation in patients with DCIS

is not routine. However, published studies have relied on

tumor registry data, where the definitive diagnosis of DCIS

is established [9,10] to draw conclusions about treatment

planning. Herein lies a major flaw because definitive diagnosis

cannot be achieved until the final pathology review

and may vary greatly from the biopsy diagnosis. The focus

of this investigation is based on the data derived from the

initial biopsy report as the patient would present to the

surgeon for preoperative decision making.

Because DCIS and DCISm are not usually palpable and

are mammographically detected calcifications, the diagnosis

is usually based on stereotactic core biopsy. There is a high

degree of concordance between histopathology of specimens

obtained at stereotactic core biopsy and surgical open

biopsy, but in 20% of cases of DCIS diagnosed by stereotactic

core biopsy, invasive cancer is found after definitive

surgical resection [11,12]. Surgeons make treatment deci-

sions based on stereotactic core biopsy data, and the presence

of invasive cancer at the time of lumpectomy would

require a second operation to evaluate axillary sentinel

nodes. In addition, if a mastectomy is performed for DCIS

and invasive cancer is found in the mastectomy specimen, a

sentinel lymph node biopsy is no longer possible and an

axillary dissection would be required.

Currently, there are no reliable prognostic factors to

accurately predict the probability of invasive carcinoma in

patients with a biopsy diagnosis of DCIS or DCISm [13].

There is some correlation with a palpable or mammographic

mass [14,15] and microinvasion on biopsy histology [13,15].

The purpose of this study was to clarify the incidence of

patients with a biopsy diagnosis of DCIS and DCISm who

are upstaged to invasive carcinoma at the time of definitive

resection and the incidence of axillary metastases. Prognostic

factors were also evaluated to determine if selective

sentinel lymph node biopsy could be recommended in subgroups

of patients with a biopsy diagnosis of DCIS who are

at highest risk for being upstaged to invasive carcinoma.

In response to a question about whether an SNB is necessary for someone with DCIS who is having a lumpectomy, I recently scanned a lot of the literature about this.  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.

Not sure if that is reassuring to anyone, but I hope it helps in at least explaining that there are two valid sides to this debate and no "right" or "wrong" decision.

Edited to add:  dsj, I just saw your post after I posted mine. 

Thanks for sharing your story, but it raises some questions in my mind. I was told by an oncologist friend at MD Anderson that I should request a lymph node sample from my surgeon. However, I am getting a lumpectomy next week, and the surgeon tells me that they do not routinely do a lymph sample with a lumpectomy.   I know your situation has taken place over a number of years, but does anyone know how often lumpectomies are performed with a lymph node sampling?

Also, I find it strange that throughout this entire process, no one has taken a blood sample from me. We've done mammogram, stereotactic biopsy, MRI with contrast dye, Sonogram-guided needle biopsy, but yet no blood work has been taken. Shouldn't someone be looking at other things like white blood cell counts, vitamin levels, etc, etc? Or am I off-base?

Thanks for your insights, ladies.

dsj - it is hard to sift through all the info.  I sit here 2 days post-lumpectomy surfing the net because I want to be prepared for whatever my path report says.  For me, lumpectomy felt very right.  Best we could determine my 'lump' was 1cm of high grade DCIS.  I knew it needed to come out.  I am waiting until the path report comes back to decide the rest.  I am pretty sure rads is in my future.  With high grade I don't think I could not do them and be OK with the risk.  Without knowing my surgical margins I am already atleast an 8 on the VNPI.  I did do the gentic testing but won't know results until next Wed.  I found a surgeon I trusted and am taking it one step at a time.  good luck with your decision.

djs--

If you are having a lumpectomy you do not need to have a sentinel lymph node biopsy.  In the low probability event that you have invasive cancer after the lumpectomy, they can do a lymph node biopsy later.   

I agree that it is hard to avoid information overload.  I did literature searches and read most of the relevant journal articles.  I am not an MD but I do work in cancer research and am used to reading this kind of material.  Even so, at some point you just have to decide generally what you want to do and who you trust to do it right.  Reading medical papers should help you have confidence in those decisions. 

I'm bumping this one because I just had a bilateral mastectomy on June 24th with SLB due to large high grade comedo necrosis dcis in my left breast.  Some of the pathology has come back showing no invasive cancer in either breast but a microinvasion of cancer in the sentinel lymph node.  So, how does this happen?  If there is no invasion of the ductal carcinoma, how did it get in my lymph node?  I am so confused.  Also on pathology I found my right breast, which I had been told after mammograms and MRI was cancer free, had foci of lobular carcinoma in situ and atypical hyperplasia.  I feel I made the right decision to have the bilateral mastectomy after seeing this in pathology, but so confused as to how that happened.  My node is being retested for hormone receptor and her2 status now.  My initial biopsy in April showed negative hormone receptors.  Now I am worried, did it get in my bloodstream or other nodes?  How will they treat this if it is hormone receptor negative?  Cannot wait to get rid of the last 2 drains...they are driving me nuts.  Can anyone shed some light on this lymph node involvement with dcis?

I would agree with Jelson, that the most likely explanation (similar to what was being discussed in the older part of the thread) is that they missed a tiny micro-invasion.   When they examine the pathology of the breast, they usually take representative cross-sections (especially when it's a large sample), rather than looking at each and every cell, so if the micro was small enough, it could have been missed.   Now that they know about the positive node, they will be able to treat you appropriately, even if they never saw the original micro-invasion.

As to the unexpected LCIS and hyperplasia, that usually only shows up on mammogram if there is enough and it is growing rapidly enough for the dead  cells to show up as calcifications - it's very common, especially in women with "busy" breasts that it wouldn't show up.   Would it have turned into anything down the road?  No way to know, but not something you need to worry about now as it has been removed.

((HUGS)) to you as you continue down your path towards recovery!

My MO says my case was discussed at tumor board and they feel chemo is appropriate.  So now I'm getting ready for a port to be put in next week and chemo -ACTH starting the following week.  Not thrilled about it but if it gets rid of the cancer, then onward and upward.