Is node removal necessary for HER2+, ER/PR-?

Hi!

Is your friend planning to get radiation? Increasingly, radiation is being recommended instead of ALND. ALND is more associated with lymphadema than sentinel lymph node removal. So, doctors are recommending it less. I had ALND myself and had all 20 of my Levels 1 and 2 nodes removed. I did not get lymphadema but that's not true in every case.

Hi--There was a trial called the AMAROS Trial (After Mapping of the Axilla: Radiotherapy Or Surgery?). And the data showed that the distant metastasis and overall survival were essentially the same with both the removal and the radiation. The only thing that was significantly different was the lower quality of life with the lymphedema that you could get with the removal.

So that kind of explains the science behind doing radiation vs surgery. If it were me, I would ask the surgeon about this trial and ask why he feels he would still do the surgery. I think talking to him about this data would be a good conversation and you may get the insight that you're looking for. Good luck to your friend!

I would go with the Medical Oncologist on this one - in my opinion, extra node removal should be avoided when possible.

Lymphedema is not just about some swelling, it can cause serious problems and even infections. (I was recently hospitalized with a lymphedema related infection.) I don't say that to scare you, and of course that may never happen to your friend, but I think too often people say it's "just lymphedema" when lymphedema can really be huge problem even years down the road. I'd absolutely avoid removing any more lymph nodes if the MO gives you his/her blessing. Best wishes to you!

Hopefully not too late for me to chime in as I can offer a personal experience... I completely agree with what others have been saying re: the higher risk of a full axillary node dissection vs a sentinel node biopsy (the latter is what your friend had). There are several studies that have come out showing that the long-term survival for those who did just sentinel node biopsy was equal or even better in cases than those who did a full axillary node dissection, mostly due to the risks of the bigger surgery and bigger risk of lymphedema. Here are a couple of those studies:

https://www.hindawi.com/journals/ijbc/2014/513780/

https://www.breastcancer.org/research-news/outcome...

I was in a very similar situation just over 2.5 years ago. I was diagnosed with Stage II breast cancer and had 2 positive nodes. My surgeon wanted me to do a full axillary node dissection. After conducting my own research and finding these articles showing similar or even favorable long-term survival rates amongst those with positive nodes who did NOT do an axillary node dissection, and my surgeon and radiologist telling me that the risk of lymphedema with ALND was a whopping 50% while that risk with radiation was much smaller at 15%, I declined the full axillary node dissection. Even though I was getting pressure from my surgeon and radiologist, they had to respect my decision. I have no regrets.

Fast forward to when I completed radiation and spoke with my radiologist who declared me "healed" and told me he targeted my nodes during the radiation as well and he simply needed to know whether I did the ALND or not so that he could target his radiation therapy accordingly. He seemed to forget that he had supported the surgeon's reco at the time, and even told me months later that I made the right decision to not do the full axillary node dissection. And I got through radiation very well with minimal side effects so it felt good knowing I got the full radiation therapy, did not experience SEs, and still have my nodes.

Fast forward to 2.5 years later... I just received a clear mammogram! And I feel good every time I go swimming or play tennis - things that really require me to extend my arm - that I do not have any issues with lymphedema or reduced strength in my arm from missing nodes.

My advice to your friend is to do the research, read the studies that have come out recently, and make an informed decision based on her own personal risk/reward assessment. For me, the risk/reward balanced too far towards the risk with the 50% chance of lymphedema with a full axillary node dissection. But it felt balanced enough for me to go through radiation, and I also researched how to get through it with minimal SEs, and right now I'm still taking tamoxifen as SEs have been minimal there for me too, so again, risk/reward balance. I have no regrets declining the full axillary node dissection.

Hope that helps!

Hi all,

Although indeed the trend is towards removing less nodes in favor of radiation, the recommendation in certain cases (eg palpable swollen lymph nodes confirmed positive for cancer at diagnosis, which was my case) still remains ALND. From the AMAROS study someone referenced above:

Axillary lymph node dissection and axillary radiotherapy after a positive sentinel node provide excellent and comparable axillary control for patients with T1-2 primary breast cancer and no palpable lymphadenopathy. Axillary radiotherapy results in significantly less morbidity.

The NCNN guidelines Beesie posted above, if applied to your friend, if I read that correctly, given the four positive nodes found during surgery, point her straight to ALND. If I were in your friends feet, I would ask the surgeon why he recommends ALND (maybe those 4 nodes were bursting with cancer, showed extranodal extension, LVI, something else), that he/she points me to the relevant papers or guidelines in which the determination was based, and I would also probably ask for a second opinion, on top of trying to assess the lymphedema risk, to the extent possible, based on known risk factors. That is what I did in that situation, and in my case all routes (oncologist, surgeon #1, surgeon #2 at top cancer center, plus reading of research papers) pointed to the ALND recommendation as the best way to avoid recurrence. I also got radiation, on top of the ALND.

Lymphedema is indeed very serious and hard to predict, but also mysterious and there seems to be a mix of genetic and environmental factors at play. Some patients get one lymph node removed and get lymphedema right away, and some get all axillary level I and II nodes removed and don't get it.

In my case I had ALND as recommended, and fully accepted the possibility that I may get lymphedema -which so far I didn't get. I am on the thin side and also a swimmer, and my range of motion a few months after the surgery (but I did A LOT of physical therapy and stretching exercises) was as good as in the non-cancer side if not better -the extension is definitely better due to all the extra stretching on that side. I am three years out of that surgery and I have zero side effects from the ALND.

Just to throw another opinion out there, since it sounded like a consensus was forming on questioning that surgeon's call, while there may be good reasons for it. And also to offer hope that even with an ALND, she may not have that high a risk of lymphedema or other side effects.

Best of luck,

LaughingGull

Hi ,

Came across this forum today.

I posted in chemo forum about my situation and LeesaD and Mebo repliedwith good information.

I was treated with CTH for HER2, 6 rounds and had lumpectomy and SLN biopsy on May 13 th.

I had positive 2 lymph nodes on PET scan prior to chemo, unfortunately they were not biopsied and tagged in my local hospital. Now on SL biopsy I have micromestasis of 0.3 mm size in one of my lymph node. Breast tumor regressed. Since I have micrometastasis, my case is not considered as pCR.

Bessie posted NCCN guide lines, is very helpful, however in my case it is still not clear even though my MRI and US imaging just before surgery did not show enlarged lymph nodes. Waiting for tumor boards recommendation and Will post it.

Puzzled and anxious.

Thanks for all the above posts, they were all helpful.

chemo is a systemic treatment, meaning it goes throughout your entire body killing any fast growing cells it finds. with me, I had a node show up on ultrasound that looked suspicious, but biopsy was negative. They pulled the node during surgery (lumpectomy) though, and it reacted to the chemo like there had been cancer there, but there were no live cancer cells. They gave me whole breast radiation just to be safe to make sure any other cells that might have escaped the chemo were also dead.

From what I understand, with either surgery they will look at nodes, but try to leave as many as possible in place because of risks of lymphedema. I did see a studyrecently that seem to indicate lumpectomy with radiation has better outcomes than mastectomy — but it could be the same article you’re referring to.

Thanks Melbo. I suppose I will have to trust the staging process. I was leaning heavily towards mastectomy, but as I researched more, it seems the latest studies result in lumpectomy and radiation with some node removal having better progosis.

Kathabus, my thinking behind nodes preventing spread was if in the case of recurrence in the breast, the nodes will be there as a step to fight off or filter rogue cancer cells from spreading to normal tissue. On the other hand,, taking them out would remove a route for spread as well. There's so many factors to consider and trying to get the best outcome as a person who is non medically trained, and has no biological or chemical background is overwhelming when the decision is ultimitely placed on us.