LCIS- Sentinel node biopsy- To do or not to do?

I had the same situation at about your age.  BRCA neg, strong family history, LCIS on core bx.  I did the bilateral.  Really agonized over the sentinel node choice as I was afraid of lymphedema.  After bilateral excisional biopsies of anything that registered on MRI, with benign findings, I did the mx surgery without sentinel node bx.  No occult cancer was found, so that was the correct choice.  Very, very happy.

These days the trend is for less and less node removal.  Maybe biopsy the right side spot found on your MRI and make your final choice after that.  As I saw it, it was both my arms, the rest of my life.  I really did NOT want the sentinel and that's how we went at the end, no nodes out.  Remember, the node removal is only for staging and does not improve or extend survival in the case of invasive cancer.  You could be treated (and possibly avoid the aux dissection) if they find unexpected invasive.  There is a lot going on in this area of research.

I had a preventive mx for ADH and ALH. A 1.1cm IDC was found in the final pathology. No nodes were taken at the time of the MX surgery. Three weeks post mx, I had a SNB (apparently I needed the three weeks to heal from the mx). One node was taken in the SNB. I don't know how common this is, but in my case it could be done.

farmerlucydaisy, if the breast tissue was gone, how did they decide where to inject the dye? My understanding is that there are multiple pathways from within the breast to axillary nodes, so a dye injection in one spot would travel to one node, and a dye injection in another spot would take a different pathway.  I'd be very interested in a diagram or other explanation of how your surgeons knew they'd found 'the' sentinel node.  That approach would have saved me from lymphedema, because my path was 100% clear on my prophy bmx. Had I known an after-the-fact SNB was possible, I would have turned down the SNB during my surgery knowing that I wasn't risking the alternative of a broader node dissection if  the bmx path was not clear.

Very, very interesting.

Carol, we were posting at the same time, with similar questions. 

Your point about there being multiple pathways through the breast tissue to the nodes is an important one.  This is exactly the reason why usually there are several injections of dye or isotopes done prior to the SNB surgery, with the injections either surrounding the tumor area, or done all around the nipple.  I had 4 injections around my nipple and with each injection, the needle was intentionally aimed in a different direction.  After I had the injections, I had to lie (with my arm raised over my head) under this machine (can't remember what it's called) that was able to 'see' the isotopes as they travelled through my breast and into the nodes.  The image was displayed on a computer screen that I was able to see.  It was fascinating to watch the stream of isotopes from the four injections, each initially heading into a different part of my breast and then all of them turned and moved towards the nodes.  I could see that they all came together at the same node so I knew before my surgery that I had a very clear sentinel node.  Apparently the isotopes and dye then travelled through that one node into two more nodes - my surgeon removed 3 nodes that each were stained with the dye.  That all happened over about 20 minutes.  

I found the injections to be very painful (but at least it was quick) but the process was fascinating.  

farmerlucydaisy, usually the dye is injected into the breast before the breast is removed - that's what Angelina Jolie had done.  So once the breast is gone....well, that's usually why doctors say an SNB can't be done after a MX.

You obviously had an injection of dye - that's the important part - but where was the injection done?  In order words, where did the doctor stick the needle? 

A quick Google search brought this article up, about SNB after mastectomy, and it's very interesting.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909950/

The article describes one case where SNB was administered from close to a nodule that presented in a woman who had an earlier diagnosis of DCIS and who had had a total mastectomy. She had lymphoscintigraphy first, to see if a lymphatic pathway existed from the nodule (it did).  The authors do not generalize to say this is a procedure that should be done; they simply conclude that based on their experience, it seems that SNB is not contraindicated following mastectomy.

Thoughts?

Carol - Excellent research! Very interesting. Thanks!

farmerlucydaisy, good question.

Here's a blog post by David Gorski, who generates a lot of controversy in his posts about 'science based medicine' .  Gorski is a 'surgical oncologist, Professor of surgery at Wayne State University, and a surgical oncologist at the Barbara Ann Karmanos Cancer Institute, specializing in breast cancer surgery.' He endorsed Angelina Jolie's pbmx decision, but he is a skeptic on the approach her breast center took for the sentinel node biopsy.  Here's a link to the full post, followed by what he said about the SNB.

http://www.sciencebasedmedicine.org/angelina-jolie-radical-strategies-for-cancer-prevention-and-genetics-denialism/

"Finally, more questionable is the use of a procedure known as prophylactic dye injection. During breast cancer surgery, we do a procedure known as sentinel lymph node (SLN) biopsy, which involves injecting (usually) two kinds of dye before surgery: A short-lived radiotracer and a blue dye, both of which are taken up by the lymphatics and head to the first draining lymph node (or lymph nodes) under the arm, known as the axillary lymph nodes. These nodes are removed and checked for cancer. In the old days (about 12 to 15 years ago), we used to remove all the lymph nodes under the arm in a procedure known as axillary dissection. These days, we get the same information (whether the axillary lymph nodes are involved or not) with much less morbidity using the sentinel lymph node procedure. When we do prophylactic mastectomies, however, we don’t know if there’s cancer there. There probably isn’t, although there might be. Consequently, we usually do sentinel lymph node biopsies, in case there is cancer in one of the breasts, because once the breast is gone we can no longer do that procedure, and SLN biopsy is pretty low risk. However, that is not acceptable at Pink Lotus, or so it would appear:

Whenever a breast contains cancer and the armpit lymph nodes cannot be felt on exam, we routinely perform a sentinel node biopsy, which is the removal of the first nodes that receive breast lymphatic drainage. By injecting blue dye into the breast, which then travels to the lymph node(s), we find out if cancer spread beyond the breast. Until now, the trend has been not to perform sentinel node biopsies in conjunction with prophylactic (preventive) mastectomies since the discovery of cancer in breasts removed prophylactically only ranges from 2-8%. Therefore, most women do not want to take the additional risks associated with a sentinel node biopsy, especially since they can have complications, such as pain, numbness, arm swelling (lymphedema), fluid buildup (seroma), limited arm movement, and infection. This dilemma has been resolved with a new technique that was pioneered at the Pink Lotus Breast Center, called Prophylactic Breast Dye Injection, or PBDI. PBDI allows the sentinel node to be identified, but not surgically removed, giving more control and peace of mind to women. I developed this technique while treating Angelina, and I hope other women will now benefit from it. It was at her friendly insistence that I wrote the rationale for it in our blog post, Prophylactic Breast Dye Injection.

If you peruse the rationale published by Dr. Funk, you’ll find that she invented this procedure in February 2013. I’ll actually give Dr. Funk credit. PBDI is actually not a bad idea. In fact, in concept, it’s a pretty good idea. However, by Dr. Funk’s own admission, it’s also a new idea thought up by her while treating Jolie that is completely unproven. (One wonders whether Jolie balked at bilateral SLN biopsy.) Hence, from my perspective it is irresponsible to promote PBDI in the context of Angelina Jolie’s surgery given that, also by Dr. Funk’s own admission, there is no evidence for the superiority (or even non-inferiority) of the procedure compared to standard sentinel lymph node biopsy. She even includes a disclaimer:

Disclaimer: We at the Pink Lotus Breast Center have started using the PBDI technique very recently. It is currently unknown which factors influence the precise length of time that the dye remains in the sentinel nodes. Further studies in that regard are needed.

In that case, Dr. Funk and colleagues should be doing preclinical trials in animals and clinical trials in humans to answer the question of what factors determine how long the dye persists in the sentinel nodes and why, not offering this procedure to, in essence, any woman undergoing prophylactic mastectomy."

So, Dr. Funk is either groundbreaking or irresponsible, depending on your viewpoint.  It sure would be wonderful if the procedure she invented could be demonstrated to work through legitimate trials and long-term follow-up.

Ncsord - I am so very happy for you! Yay - the big monkey (gorilla) is off (mostly off) your back!! As Carol says - happy healing. I'm a year out from the exchange and I rarely notice the implants - it is just the new normal.

Ladies, I realize this thread has not been active in a while but perhaps someone will see this and have an opinion. I have LCIS and am seriously contemplating PBMX. My surgeon has informed me that she would perform a SNB on the affected side. I'd really like to push back on this. I see the links to the studies in the earlier posts. My question is has anyone here gotten a lot of flack from their surgeon (along with a sound explanation as to why) if they have indicated they not want the SNB done? I would much rather have a 2nd procedure for SNB only if it's found to be necessary based on the pathology from the MX. Thx.

Hi Melissa. Did you read the studies that were posted on the earlier threads (one from '08 and one from '10)? They seem to describe in detail that SNB after MX is not contraindicated. It's been done, in some cases long after the MX had been performed (in the case of a suspected cancer recurrence). There may be differing opinions as to how reliable that is. I don't know. That's what I'd like to question my surgeon on.