Micro invasion-Absent

Christine take a deep breath. Try not to focus that you're not out of the woods. The suggestions above are very good. Wishing you well.

Hi fellow Calgarian!

Hoping for good news from your pathologist!

Who is your surgeon? Thing to bear in mind is that the path results from the biopsy only shows the pathology of that small sample. Mine said 1mm area suspicious for invasion, which my GP told me was not concerning. My final diagnosis was idc greater than 8cm after my lumpectomy and node dissection!! But of course, the converse can also be true!

In my case, one sentinel node was positive, but none in the axilla apart from that. With 11 nodes removed, I have developed mild lymphedema, but it is well controlled, even though I don't wear my garments full time. The Lymphedema Clinic at Holy Cross is an excellent resource

Once this is all done, think about joining the Sistership Dragon Boat Racing team. It's a fabulous group, and I've found it very therapeutic in getting my strength, fitness and confidence back! Come see us on the Glenmore Reservoir. We practice Tuesday and Thursday evenings, and there is the Calgary Dragon Boat Festival August 8/9!

Also investigate the Breast Cancer Supportive Care Foundation in Calgary. I can highly recommend them!!

Feel free to private message me if you want to

Hugs to you. Scary time, but you will get through it!

Yes, Barred Owl, great post.  Very thorough. As you mentioned, it is not uncommon to need additional re-excisions to get clean margins.  It took me three surgeries to get there.  There would have been ample opportunity to go back in and do a snb if microinvasion or IDC were present. I chose not to do mastectomy, in large part, due to the concerns about snb, even though I had enough DCIS that the lumpectomies would cause cosmetic changes. About the 3-5 percent risk of lymphedema following snb, I think that more research will need to be done in that area.  I think that lymphedema, in its subtler forms, is much more common than recognized.  That's my lay opinion. Even I, who had no snb, but extensive surgery to that breast (three prior surgeries--for a total of six), have swelling in certain fingers and other sensations since the surgery. It may not be lymphedema, but just some other odd side effects (periodic cramping of the pec muscles on that side only). I found that there is no point to bringing this stuff up to MD's, because I think I would be looked at as crazy.  So long as I have no pain, and I take care in other respects (using keyboards and remote mouses when on the computer, etc), I'm doing OK.

BarredOwl I think your post was great, and I think you made it clear that there are choices and decisions to be made, and a case can be made for both SNB and no SNB with BCT, depending on the circumstance and the risk/benefit ratio; the important thing is to always make an informed decision, and your data and links will help us all to do that!

December I'm so sorry you are being tested and challenged by these side effects and symptoms. Hang in there!! And you make a very good point: it is never too late to become your own advocate, and only allow medical treatment that you understand, and that YOU deem necessary for your care. It is so easy for all of us (me included) to feel that just because someone is wearing a white coat it means that they are automatically right. Well, they're not. And they're not in charge, you are. And they're not the boss of you. They offer their opinion based on their education and experience and then WE make the choice of the best course of action. It is a daily reminder, and December had that brought home forcefully (but it is still not too late -- next decision is yours!).

Thanks ispy. I am reentering the link:

http://www.breastcancer.org/research-news/node-sur...

BarredOwl

Hi chocomousse:

Regarding the bc.org summary you cite from, the full text free JAMA Oncology paper is here:

http://oncology.jamanetwork.com/article.aspx?artic...

The article states: "The rate of axillary evaluation was 63.0% among women undergoing mastectomy, with 15.2% of patients undergoing full ALND and 47.8% having SLNB."

In the Discussion section of the article it states:

"Our analysis revealed that from 2006 through 2012, rates of axillary evaluation increased in patients undergoing mastectomy . . . Almost two-thirds of patients had an axillary evaluation, and rates increased over time."

With respect to mastectomy, the current version of the NCCN Guidelines (3_2015) for pure DCIS treated with mastectomy say:

Total mastectomy with or without sentinel node biopsy ± reconstruction

But the notes thereto state (emphasis added by me): ". . . a small proportion of patients with apparent pure DCIS will be found to have invasive cancer at the time of their definitive surgical procedure. Therefore, the performance of a sentinel lymph node procedure should be strongly considered if the patient with apparent pure DCIS is to be treated with mastectomy or with excision in an anatomic location compromising the performance of a future sentinel lymph node procedure."

Again, that is because after mastectomy, the lymphatic system has been disrupted and the identification of the sentinel node(s) is no longer possible.

Who's having mastectomy without SNB? Good question. I would guess this might include women who have had certain kinds of breast or axillary surgery previously and might not be able to have sentinel node biopsy done (because of prior disruption of the lymphatic system), or possibly women with a tiny area of low grade DCIS.

The Discussion section of the JAMA Oncology paper goes into more discussion of this question, and I recommend you read the original.

Remember that if a patient had invasive disease at the outset, SNB would be recommended. So the decision in women undergoing mastectomy for DCIS seems to be based on the risk of discovering invasive cancer on final pathology. Clinical factors like a large area of DCIS, higher grade, and palpable lesions which may increase the likelihood of finding some invasive disease seem to be factors.

You could discuss this question with your surgeon again, and ask what clinical factors you have that support the recommendation of SNB. Be sure to confirm that your surgical team is experienced in doing SNB.

You could also ask, if you did not have the SNB done and invasive disease was found, what axillary assessment procedure would be required, and what is the risk of lymphedema associated with that procedure? If you are still uncomfortable with the recommendation, you could seek a second opinion.

On biopsy, I had bilateral disease, and on the right side, it was multifocal DCIS, a mix of Grades 2 and 3, with some comedo necrosis. Both opinions I received recommended mastectomy with SNB. I guess sometimes, it may be the right decision, even if the risk of lymphedema is incurred. With the SNB option, your risk of LE is relatively low. That's something.

BarredOwl

Thank you for the informative posts Barredowl.

I received three opinions, one from a general surgeon and two from breast surgeons and all three recommended an SLNB. The first two said they'd remove 2-3 nodes, the third said he'd remove only one. The third BS is the most experienced and came highly recommended.

I read the entire report and found the passages below interesting. The conclusion seems to be that axillary lymph node dissection is generally unnecessary for DCIS. Hopefully, in the future, placing a marker in the SLN instead of removing it will become standard practice and remove the risk for lymphedema completely in women with pure DCIS.

..the incidence of axillary node metastasis in DCIS is low, with most estimates ranging from 0.5% to 3%.24,32- 39 The yield of identifying axillary metastasis can be increased with serial sectioning and immunohistochemical analysis.12,31,40- 43 The clinical significance of these metastases is unknown, with multiple studies demonstrating no prognostic significance of micrometastasis at long-term follow-up in women with invasive cancer.31,42,44,45 Even in women with invasive breast cancer, completion ALND after a positive SLNB does not lead to improved survival compared with patients receiving no further axillary-specific intervention.1The SLNB is known to reduce both short- and long-term surgical complications compared to ALND.46- 48 However, some risks remain, with a reported incidence of 6% to 7% for lymphedema and 3% to 9% for paresthesias, compared with rates of 11% to 75% for lymphedema and 19% to 68% for paresthesias in patients undergoing ALND...

Large, high-grade, and palpable DCIS lesions have an increased risk of occult malignancy.41- 43 However, though these features correlate with invasive disease, they may not be similarly predictive of axillary metastasis in women with DCIS, and efforts thus far have been unsuccessful at reliably identifying at-risk patients.

In addition to better predictive tools for axillary involvement, other surgical approaches should be evaluated, such as placing a marker in the node rather than removing it, thus allowing for sentinel node removal at a second operation should invasive cancer be identified on final pathology.

ChristineT:

Your update on this thread got buried in further discussion there. Congrats again on the clear nodes!! Good luck on the 14th for clean margins!

Let us know how you make out (as my Canadian Dad used to say).

BarredOwl

ChristineT- I hope your recovery is going well and congrats to negative lymph nodes! May your margins be clean. Chocomousse- I wanted to give you an update since I've had my SNB on both sides ( one on right and two on left) I am almost seven months out from my BMX with SNB and so far so good! My poor body has been put to the test too. On May 1st I had my reconstruction surgery and had an IV catheter placed in my right hand with no issues, early July I tripped on a rock while trail running and fell HARD on my right arm which hurt something bad and caused cuts and scrapes with no issues, on July 23rd I had a blood draw for yearly bloodwork from my right hand since the nurse couldn't get blood from my arm which took 20 minutes and a blown vein with no issues, and on August 10th I had my blood pressure taken from my right arm with no issues. I am very aware about lymphedema and guard my left arm since I still have numbness and slight pain on the back of my arm hence the reason my right arm takes all the abuse! Also, my sister had a BMX 11 1/2 years ago with 16 axilliary lymph nodes taken from her left side and 6 axilliary lymph nodes taken from her right. She has some weakness in her left but has no issue with lymphedema. She has flown to Europe countless times and has never worn a sleeve. Please don't worry yourself but be aware of triggers that can cause it.

Hi ChristineT:

Glad you are recovering more quickly. Keeping my fingers crossed for you.

BarredOwl

Hi Chocomousse:

Thanks for the update, and I am very glad you were able to discuss this in advance with your surgeon. Very, very good news on your sentinel nodes, and glad you are feeling well. I will be keeping my fingers crossed that your diagnosis remains pure DCIS.

Here is some more information about the evaluation of nodes, for information only. Intraoperatively, my institution used the standard hematoxylin eosin ("H&E") staining, and the nodes were completely negative by that criteria. Therefore, no additional axillary nodes were taken. Often, no further evaluation is performed and that is within guidelines.

From the post-surgical pathology, two intra-mammary nodes (in the breast tissue, not the axilla) were found on each side, and these were also clear. I never researched anything about that.

Sentinel nodes are sometimes evaluated by additional methods, such as immunohistochemistry (IHC) or reverse transcriptase polymerase chain reaction ("RT-PCR"). Again, this is not always indicated or performed. From what I can see, it is not recommended for DCIS.

For invasive breast cancer, the NCCN Guidelines (Version 3_2015) state (emphasis added by me):

"Cytokeratin immunohistochemistry (IHC) may be used for equivocal cases on H&E. Routine cytokeratin IHC to define node involvement is not recommended in clinical decision making."

As part of the post-surgical pathology, my sentinel nodes were further evaluated by cytokeratin immunohistochemistry (three different immunostains), even though they were not equivocal by H&E. The good news is that on the right, where a 1.5 mm IDC was found, all four sentinel nodes were negative by this criterion as well.

On the left (DCIS only supposedly), they found a small cluster of "isolated tumor cells" ("ITCs") in the node (18 cells spanning 0.1 mm which stained for keratin 7 only (one of the three stains)). This is still considered node negative (N0), although it is more specifically indicated as "pN0(I+)" (I+ for positive by immunostaining).

Finding ITCs in a node is unusual even for invasive disease, and the literature is relatively limited. Some instances are believed to be artifacts (that would be nice).

Again, ITCs are considered node negative for the purpose of staging (N0). The guidelines include the following information on ITCs and sets forth N0 subclassifications based on IHC or RT-PCR evaluation (emphasis added by me):

"Note: Isolated tumor cell clusters (ITC) are defined as small clusters of cells not greater than 0.2 mm, or single tumor cells, or a cluster of fewer than 200 cells in a single histologic cross-section. ITCs may be detected by routine histology or by immunohistochemical (IHC) methods. Nodes containing only ITCs are excluded from the total positive node count for purposes of N classification but should be included in the total number of nodes evaluated.

pN0(i-) No regional lymph node metastasis histologically, negative IHC

pN0(I+) Malignant cells in regional lymph node(s) no greater than 0.2 mm (detected by H&E or IHC including ITC)

pN0(mol-) No regional lymph node metastases histologically, negative molecular findings (RT-PCR)

pN0(mol+) Positive molecular findings (RT-PCR),** but no regional lymph node metastases detected by histology or IHC

. . .Classification based solely on sentinel lymph node biopsy without subsequent axillary lymph node dissection is designated (sn) for "sentinel node," for example, pN0(sn)."

Again, my understanding (as a layperson) is that IHC evaluation of sentinel nodes does not appear to be recommended for DCIS, and may only be used in some cases of invasive disease. If IHC is done, ITCs are quite unusual and are deemed clinically node negative. So this is really for information only, in case someone sees this kind of designation on their pathology report.

[Edited to add: Be sure to discuss any finding of ITCs with your care team to obtain the most current information on how these are viewed clinically with respect to your treatment decisions.]

Please keep us posted!

BarredOwl

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Age 52 at diagnosis - Bilateral breast cancer - Stage IA IDC - BRCA negative;

Bilateral mastectomy and SNB without reconstruction 9/2013

Dx Right: ER+PR+ DCIS (5+ cm) with IDC (1.5 mm) and micro-invasion < 1 mm; Grade 2 (IDC); 0/4 nodes.

Dx Left: ER+PR+ DCIS (5+ cm); Grade 2 (majority) and grade 3; isolated tumor cells in 1/1 nodes (pN0I+(sn)).

Hi Chocomousse:

Saw your update elsewhere, and congratulations again on the negative nodes.

Looks like more good news regarding the additional assessment of no LVI or DLVI noted above. I believe that these assessments are looking for evidence of invasion of blood vessels and lymph channels in the tissue removed, as opposed to the lymph nodes themselves:

http://www.breastcancer.org/symptoms/diagnosis/vas...

In the TNM staging, I see the "(sn)" abbreviation meaning nodal status has been assessed by sentinel node biopsy, so I edited my post above to add the part from the NCCN guidelines that says:

". . . Classification based solely on sentinel lymph node biopsy without subsequent axillary lymph node dissection is designated (sn) for "sentinel node," for example, pN0(sn)."

From your "pN0(i-)(sn)" result, it looks like they did indeed conduct an IHC test, and the results were negative by this method as well. Sweet.

From our discussion in another thread, the NCCN guidelines also provide the size range for small "T1a" tumors as follows:

"T1a Tumor >1 mm but ≤5 mm in greatest dimension"

As usual, I am a patient/layperson, so please review the findings with your surgeon or oncologist (if they did not already mention it) to confirm the above.

BarredOwl

Thanks for the explanations.