Katiha, yes, the surgeon was following protocol. It is normal to not remove lymph nodes during an excisional (surgical) biopsy, and that is in effect the surgery your mother had. It's pretty much the same surgical procedure as a lumpectomy, but an excisional biopsy is done prior to a diagnosis of cancer, and the objective of the surgery is to remove the entire suspicious mass/area for pathological assessment so that a diagnosis can be made.

When I was diagnosed, I had a needle biopsy that uncovered a high risk condition, then an excisional biopsy in order to evaluate more of the suspicious tissue - that's when I was diagnosed. I did not have a Sentinel Node Biopsy done during the excisional biopsy and instead had it done when I later had a mastectomy.

Even if the surgeon realizes during the excisional biopsy surgery that the mass is cancer (most cancer is microscopic so it's not usually something the surgeon would know by looking), the SNB procedure requires injections of dye and/or isotopes into the breast prior to the start of surgery. So once in surgery, if the injections weren't done, the surgeon can't just go in an remove nodes because he might select nodes that are not the sentinel nodes, and that would not be effective. The sentinel nodes are the nodes that the dye/isotopes flow to first, and the way that lymph nodes are laid out, that's not something that would be obvious to the surgeon without the dye. The surgeon could remove all of the first level of nodes - then he's sure to get the sentinel nodes - but then he would be removing more nodes than necessary. That's undesirable because the more nodes removed, the greater the risk that the patient might develop lymphedema. The SNB procedure was developed specifically so that fewer nodes could be removed while still effectively checking the nodes for cancer.

All that to say it definitely would not have been appropriate for the surgeon to remove lymph nodes when doing surgery that was intended to remove a benign fibroadenoma.

So it appears that the surgery has followed protocol and the recommendations do as well. But a second opinion remains a good idea.

And since the HER2 has come back 2+ (I assume thats what you mean by HER2++... I previously read that to be HER2+ but I think I was misunderstanding), it means that the IHC test found the HER2 to be equivocal, in which case the FISH test must be done to determine if your mother is HER2+ or HER2-. If the doctors in Latvia didn't mention doing a FISH test, that is a problem and it's a good thing it will be done in Germany. As an FYI, the IHC test has a very large equivocal range for HER2, so it's very possible that the FISH test may came back HER2-. That's quite common.

However if your mother is HER2+ (or triple negative), with a 1.2cm tumor, if she is node negative, then the North American treatment protocol doesn't not recommend chemo prior to surgery. Chemo prior to surgery is recommended for HER2+ cancers that are larger than 2cm in size and/or node positive. That said, sometimes chemo is done first even for smaller HER2+ cancers.

While an MO who specializes in breast cancer would be better, since it was difficult to get the appointment, and with this doctor being the head of oncology, it's probably fine. He can bring in anyone else if necessary.

Interestingly, my MO, who specializes in breast cancer, is also a Hematologist.

Kate, sorry I missed your post on August 14th. I assume the doctor in Germany advised chemo, given that your mother's cancer is triple negative? What did her doctors at home say?

I can't offer any advice or information about the bilbiruben - it's not something I know anything about - but hopefully someone else will come by with information.