No Lymph Node Biopsy?

Hi agfischer:

MRI cannot exclude the possibility of lymph node involvement.

The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of breast cancer (Version 2.2016) provide the following general recommendation for locoregional treatment of clinical stage I invasive breast cancer:

Lumpectomy with surgical axillary staging (category 1) plus radiation

"An experienced SLN [sentinel node biopsy] team is mandatory for the use of SLN mapping and excision.(161,162) Women who have clinical stage I or II disease and do not have immediate access to an experienced SLN team should be referred to an experienced SLN team for the definitive surgical treatment of the breast and surgical ALN staging."

When invasive disease is found for the first time in a surgical procedure, a sentinel node biopsy is often done in a second procedure, even if quite small. Clinical guidelines provide information about what is done in the usual case. Here, I think they raise a significant question, requiring additional case-specific professional advice.

Therefore, please arrange for a second opinion at an independent institution regarding sentinel node biopsy, as well as possible further treatment (e.g., radiation therapy, endocrine therapy).

As part of the second opinion, in addition to consultation with a Breast Surgeon regarding sentinel node biopsy, you can seek a review of the pathology slides and all imaging to date, and consult with a Radiation Oncologist and Medical Oncologist (re endocrine therapy). The second opinion place will help you arrange for sending materials.

In addition, given your age at diagnosis (age ≤50 years) and family history, as part of your second opinion, please request a referral for genetic counseling for a professional genetic / familial risk assessment, consideration of whether you may be an appropriate candidate for genetic testing, and if so, the recommended scope of such testing, pros and cons. If you choose to proceed with genetic testing, the results of such genetic testing could further inform your treatment plan, and a different treatment plan might be recommended (i.e., other than lumpectomy plus radiation).

I recommend looking for a "Breast Surgeon" who specializes in the treatment of patients at risk of or with breast cancer as essentially all of their practice. Because several areas of expertise are indicated, the quality of the facility and depth of its staff is also important. 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...

Keep us posted.

BarredOwl

Hi agfischer:

Technically, it is the area of expertise of the breast surgeon. Given the guidelines, I think a second opinion is warranted. If the advice differed in some way, you would certainly want to know that. Be sure to ask the current surgeon for a list of the specific factors that support his view that SNB is not required in your case. This will permit you to probe these specific points in discussions with a second opinion breast surgeon, and gain an understanding of risk/benefit.

BarredOwl