Low grade DCIS/Sentinel biopsy

Sentinel node biopsy (SNB) is done during a lumpectomy surgery. (And if by “excision” you mean the process by which your tumor was biopsied, you can get a lumpectomy/SNB as soon as you want and the surgeon has availability).

Before surgery, you get either a locator-wire or (more often now) a radioactive seed inserted into your tumor (guided by either MRI or ultrasound). Then you have blue dye &/or a radioactive tracer injected into your breast. Once you are under anesthesia, there is a nuclear-medicine tech who passes a Geiger counter over the breast—when it “chatters” that’s where the surgeon knows where to cut for the tumor (with further guidance from the imaging you’ve had thus far). Once (s)he is inside, the first lymph nodes that the tumor would drain to either also “light up” under Geiger counter or scanner, take up the blue dye, or both. (I didn’t have the blue dye). Those are the sentinel nodes, which are then removed for biopsy (sometimes additional nodes—stuck to them like grapes in a cluster—that don’t light up get removed too because it is impossible to remove just the sentinels and leave those behind). Then you are sutured closed—sometimes, if the nodes are close to the tumor, you might have only one incision. The whole procedure from anesthesia taking effect to closure takes less than 2 hrs., sometimes much less.

Breast cancer is scary. But the lumpectomy/SNB isn’t as scary as most of us fear.

hi I was diagnosed recently as well. I meet with breast surgeon Monday and my lumpectomy is Thursday -I think he is checking nodes during surgery-but will know Monday. I am terrified to

Hi LovesLiterature:

I agree with Beesie. Please be sure to obtain copies of the complete pathology reports from all biopsies and surgeries, to review the findings, confirm the diagnosis (pure DCIS with no evidence of invasion) and other important information such as grade(s), ER status, PR status, and margins (of the surgical excision sample).

I also agree that you should request a reasoned explanation of the basis for the recommendation of sentinel node biopsy "SNB") in your case. You may also wish to seek a second opinion, if unsure of what is best for you.

Additional Information:

To my knowledge as a layperson with no medical training, current US consensus practice guidelines from the National Comprehensive Cancer Network (NCCN) and American Society of Clinical Oncologists (ASCO) generally do not recommend SNB for a patient undergoing breast conserving therapy ("BCT", lumpectomy or wide-excision) for pure DCIS (any grade; no invasive disease present). In certain cases, it may be appropriate to depart from what the guidelines provide.

Under the NCCN guidelines for breast cancer (Version 2.2016), the lumpectomy options do not include sentinel node biopsy, except in the case of excision in an anatomic location (e.g., tail of the breast), which could compromise the performance of a future sentinel lymph node (SLN) procedure, in which case an SLN procedure may be considered:

Lumpectomy without lymph node surgery + whole breast radiation therapy (category 1)

OR

Lumpectomy without lymph node surgery without radiation therapy (category 2B)

The ASCO guideline does not recommend routine SNB for patients with DCIS undergoing lumpectomy either:

http://jco.ascopubs.org/content/32/13/1365.full

"For women with a minimally invasive biopsy showing [pure] DCIS who are being treated with BCS [lumpectomy], there is no evidence to support performing SNB (see Recommendation 4.3). Performing SNB places patients at risk for long-term complications including permanent lymphedema. SNB may be performed as a separate second procedure in the women in whom invasive cancer is found (reported in 10% to 20% of cases overall, approximately half of which are limited to microinvasive cancer). Exceptions may include [Note: these cases are not mandatory indications for SNB] cases where breast imaging or physical examination show an obvious mass characteristic of invasive cancer or a large area of calcification without a mass (eg, ≥ 5 cm) where the probability of finding invasive cancer on the resection specimen is high . . . These recommendations are primarily based on retrospective data. Therefore, the Update Committee does not endorse routine SNB for patients with DCIS undergoing BCS."

This 2012 abstract discusses apparent overuse use of the procedure in light of the guidelines, which have been in effect for some time, although some doctors and institutions have been slow to adapt their practice:

http://meetinglibrary.asco.org/content/100421-114

The abstract concludes: "SLNB can be performed as a second procedure for those treated with BCS and identified with invasive cancer, thereby avoiding unnecessary risk of significant morbidity. Breast programs should review their practices to curtail the use of unnecessary surgery for women with DCIS."

In other words, in the appropriate case, one can choose to have the lumpectomy for DCIS, obtain review of the final pathology, and if invasion is found, then undergo SNB in a second (later) procedure. If there is no invasion, the patient is able to avoid the SNB procedure and its accompanying risks, including the risk of lymphedema. Lymphedema can occur in some cases with SNB (estimates of incidence vary), the risk of it showing up is a life-long risk (it may appear years later), and once it appears, it is a life-long condition. Again, most lumpectomy patients can avoid SNB completely, or at least defer it until it is clearly medically indicated.

With BCT (lumpectomy), if clean margins are not obtained, a further procedure(s) may be needed anyway, so presumably the patient is willing to undergo a second procedure in general, and haw no contraindication for a second procedure (which entails another round of some type of anesthesia, etc.)

BarredOwl

[Edited to add: The above applies only to apparently pure DCIS treated by breast conserving therapy.]

[Oct 13, 2016 edit: The NCCN guidelines for breast cancer, with separate sections on DCIS, are available with free registration here:

https://www.nccn.org/store/login/login.aspx?ReturnURL=https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf

]

jenn, with invasive cancer, an SNB is an important part of the diagnostic progress, whether it turns out that one's nodes are clear or not. Invasive cancer can move into the nodes, and therefore it's critically important that this be checked, because nodal involvement, if found, will change the diagnosis and likely change the treatment plan. DCIS cells are confined to the milk ducts, and as such, DCIS cannot move into the nodes. This is why an SNB is not necessary for someone with DCIS.

I wanted to reiterate this point since any discussion on this topic that includes both those who have invasive cancer and those who have pure DCIS is bound to be confusing, particularly for those who have DCIS. DCIS is different from invasive cancer, and therefore the treatment protocols are different.

Hi LovesLiterature:

I am not certain what is meant by that comment, so it would be best to add it to your question list for your surgeon.

With apparently pure DCIS to be treated by mastectomy, the guidelines do include sentinel node biopsy ("SNB") on the DCIS side, which is typically done in the same surgery. This is because the SNB procedure relies upon intact lymph channels to identify the sentinel node(s). The radiotracer and/or blue dye is injected in the breast and flows through the lymph channels to locate the sentinel node(s) ("mapping"), which are thus identified for removal. The lymph channels are likely to be disrupted by mastectomy surgery.

With prophylactic mastectomy, SNB may not be required. Some considerations that may influence the recommendation received include, for example, whether you have had a recent breast MRI or not, or certain suspicious imaging findings (by any type of imaging) that have not been biopsied. Thus, if you are receiving a purely prophylactic mastectomy on one side, you may wish to discuss the pros and cons of SNB on the prophylactic side with your surgeon (including the possible outcomes and what would be done if invasive disease were to be found). Some surgeons may also have experience with a newer approach in which the sentinel nodes are mapped and marked, but are not removed during mastectomy surgery. Instead, the surgical pathology is examined, and the nodes are removed later only if invasive disease is found.

BarredOwl

Hi Beesie:

Your analysis makes sense to me. Follow-up questions would appear to be in order for both sides in LovesLiterature's situation to understand the basis for the recommendations, and possibly a second opinion.

BarredOwl

i had the same diagnosis low nuclear grade grade 0 DCIS I had a lumpectomy and snb biopsy , I was scared at at first alot of people told me not to get the snb,on these boards but I followed my surgeon, it was painless and my margins were clear, just discuss it with your surgeon. I glad he did it. dont worry you are under when it happens at least I was

i had the same diagnosis low nuclear grade grade 0 DCIS I had a lumpectomy and snb biopsy , I was scared at at first alot of people told me not to get the snb,on these boards but I followed my surgeon, it was painless and my margins were clear, just discuss it with your surgeon. I glad he did it. dont worry you are under when it happens at least I was

Let's be clear about this. The risk from an SNB is not what happens during the operation; the risk is what might happen in the years that follow, i.e. the development of lymphedema. Having an SNB sometimes results in a longer, more painful recovery with sharp pains and underarm / arm numbness (my numbness lasted 6 months), but that's a short-term issue. Lymphedema, should it develop, is a life long condition.

While lymphedema can develop immediately after surgery, or could possibly even develop many many years later (if you experience trauma to that arm), a recent study suggests that the period of greatest risk is years 2-3 after surgery. So unfortunately making it through surgery with no problems is not a sign that someone might not develop lymphedema.

Topic: New Study Lymphedema and Breast Cancer: When Is Risk Greatest? https://community.breastcancer.org/forum/64/topics...

Since all the leading experts and the ASCO and NCCN treatment guidelines say that an SNB is not recommended for someone having a lumpectomy for DCIS, personally I would not expose myself to the risk of lymphedema by choosing to have a medically unnecessary SNB, except in the case where my biopsy pathology and pre-surgery imaging indicated that it was almost certain that invasive cancer would be found during the lumpectomy. My objective with treatment is to reduce the risk from my breast cancer diagnosis, while exposing myself to the minimum number of new risks (some new risks being unavoidable with surgery, etc.).

My micro-invasion was found on the initial biopsy, which was why I had a SNB, but my surgeon specifically said that she would not have done one otherwise.