Diagnoses/biopsy results

Btw, if you have any doubts about the advice you are receiving about axillary surgery, feel that you would like to consider or explore different surgical options, or simply would like an additional viewpoint and expert input, please do not hesitate to seek a second opinion at an independent institution. A review of imaging and pathology can be requested as well. It is quite common to seek a second opinion prior to surgery, and some people find they are more comfortable with the second team.

Look for hospitals with a comprehensive breast cancer center. For example, if you are reasonably near an NCI-designated cancer center, that may be a good option:

http://www.cancer.gov/research/nci-role/cancer-cen...

Others have recommended NCCN-member institutions:

http://www.nccn.org/members/network.aspx

BarredOwl

and we will all be in your pocket Monday.

Hi!

Seachain is right; everybody has a different number of lymph nodes. In an ALND, surgeons usually remove Levels 1 and 2 lymph nodes and leave Level 3 alone. I had all my Levels 1 and 2 nodes removed, which in my case, was 20 lymph nodes. I then had my node area radiated. You'd think I would have gotten lymphedema, but I did not. That, too, varies from woman to woman.

In your case, you could follow Seachain's path and ask your surgeon to minimize the number of nodes removed. That will reduce your chances of getting lymphadema. Best wishes!

Hi seq24:

You are information gathering now, and trying to understand, which is stressful. It sounds like he was trying to explain what level nodes he would remove and the extent of the axillary surgery. You can ask him to explain it again, to be sure you understand what he is recommending.

To prepare for further discussion, this information from NCCN guidelines may provide some helpful background. You may have to read it over several times carefully. (It is not a substitute for case-specific expert advice from a breast surgeon.)

The NCCN guidelines for breast cancer (Version 2.2016) state very generally:

"SLNB [sentinel lymph node biopsy] should be performed and is the preferred method of axillary lymph node staging if the patient is an appropriate SLNB candidate (See BINV-D)."

"However, not all women are candidates for SLN resection [sentinel node biopsy]. . . . In addition, potential candidates for SLN mapping and excision should have clinically negative ALNs at the time of diagnosis, or a negative core or FNA biopsy of any clinically suspicious ALN(s).

The panel recommends level I or II axillary dissection when 1) patients have clinically positive nodes at the time of diagnosis that is confirmed by FNA or core biopsy; or 2) sentinel nodes are not identified. For patients with clinically negative axillae who are undergoing mastectomy and for whom radiation therapy is planned, the panel notes that axillary radiation may replace axillary dissection level I/II for regional control of disease.

{ MY NOTE Above it says: level I OR II

Traditional level I and level II evaluation of ALN requires that at least 10 lymph nodes should be provided for pathologic evaluation to accurately stage the axilla.(173,174) ALN should be extended to include level III nodes only if gross disease is apparent in the level II or III nodes. In the absence of gross disease in level II nodes, lymph node dissection should include tissue inferior to the axillary vein from the latissimus dorsi muscle laterally to the medial border of the pectoralis minor muscle (level I/II)."

The information from the guidelines is rather top-line. Also, as a layperson with no medical training, I do not know how the above information would be applied to a specific patient, who may have certain clinical findings and a FNA or core biopsy of a lymph node that is deemed "positive" (or what specific lymph node biopsy findings are deemed "positive" for this purpose). This leads to questions like:

(1) What is the current standard of care regarding surgical axillary staging, in light of applicable consensus guidelines and possible recent clinical studies, in patients like me with my specific clinical and pathologic lymph node findings?

(2) Please review the main pathology findings from my lymph node biopsy. Is this amount of node involvement considered sufficiently "positive" to warrant axillary lymph node dissection (ALND) in my case? Are there any other alternatives that would be suitable in my case? Would the recommendation for ALND be the same whether I received lumpectomy plus radiation, mastectomy, or mastectomy plus radiation?

(3) If axillary dissection is recommended, what is the initial surgical plan regarding removal of Level I, Level II, or Level III nodes? Do any other findings, such as clinical or imaging findings about my lymph nodes, factor into this initial recommendation?

(4) Is it possible that this initial surgical plan will be modified during surgery to remove an additional level or levels of nodes? What criteria will be used to decide on removal of each additional level?

Please note that guidelines discuss what is typically done, and do not necessarily address all possible exceptions. Depending on the subject matter, there might be recent clinical studies that would support a slightly different approach (I have no idea in this case). In addition, in the appropriate case, physicians and patients may depart from what guidelines provide, based on clinical and pathologic findings and patient presentation. This is why you are seeking current, case-specific expert medical professional advice based on your clinical, imaging, and pathologic findings. It is also why it can be helpful to seek second opinion review and confirmation that the work-up has been sufficient, the interpretation of all imaging and pathology is correct, that the surgical advice incorporates all relevant clinical, imaging and pathology findings, and that another medical professional agrees and would recommend the same approach (or if not, that is important information to have).

Best,

BarredOwl

It's pretty clear he wants to do a full node dissection as that is what he is describing with his charming language . I am so pro full node dissection having had one and dealing with it fine...but he should be able to explain why he has chosen this path and it should be supported with scan information. It may be for example that several nodes seem affected to him and in this case he would be justified in taking an aggressive approach. While I completely understand why women here are advising less, if he has good reason and you end up getting a full node dissection report back and I will give you my lymphedema management advice! Now try to enjoy your weekend and avoid googling!

My surgeon is not in favour of axillary node clearance at all.

He said in the past it was standard practice but now he feels it just creates problems. He said most often the vast majority of cleared nodes came back negative and in some cases women were left with terrible problems with lymphodema. He said every day he feels more confident that the best practice is to monitor closely. In all of his patients he has treated this way in the past, only 2 have required further surgery for more cancerous nodes and their outcomes were no different to those women who didn't need further surgery.

Thinking of you seq24.

seq, - I have been reading and not posting much because others have been so much better at explaining and offering advice.

I think we were all equally afraid of chemo, and I know that I, for sure, shed some tears when I had my hair first cut short, and then buzzed off. BUT, - I did get an amazing wig, that was quite similar to my hair. I lost my hair about 10 days before my daughter's wedding but, with makeup and that wig, no one knew!

The drs have wonderful anti-nausea meds, too. If you arent feeling well they will make you better! I took Emend, which was a HUGE help!

Hang in there, - you WILL get through this!

Hugs from NYC

I bought one from the TWC - didn't want an expensive human hair one because in my mind it was going to be a temporary thing and didn't want to waste money. I ended up wearing it maybe 3 times as my chemo was in summer, that, combined with the every-freaking-half-an-hour hot flashes from the chemopause it pushed me in, made me wear only a silk scarf (that I got for free from one of the places that are on a thread on the chemo board somewhere).

Chemo is a crapshot and luck of the draw as it seems to be with most of what happens when it's about BC. Some people breeze through it and some get life-time side effects. I have neuropathy and fibro from it too, and I'm 6 years out.

seq, - I am not stronger than you, - we were all fearful, and sometimes tearful, but you will see, - the anxiety from the anticipation is often times worse than reality. You will get through this.

As for wigs, like muska, mine was 50/50 natural/synthetic. It was perfect, from a local store, was about $700 (insurance paid for 1/2).

Later on I did buy another, less expensive, wig that is short and more like the hair growing in : http://www.godivassecretwigs.com/petite-sheila-sho...

Someone on another board suggested that company and I found them to be very helpful and understanding.

There are very good meds to counteract any unpleasant side effects from chemo. Cross that bridge when you get to it.

I hope that your surgery is as easy as possible.

Take a deep breath and keep your chin up!