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Mar 16, 2013 03:55PM, edited Mar 16, 2013 05:57PM
There's a lot of truth in what Beesie wrote, but I'm going to disagree a little.
What you know now is that you have a very, very suspicious mass, and at least one highly abnormal lymph node.
The studies in which limiting node dissections to just a sentinal node removal even if the pathology was positive didn't change survival were looking at microscopic disease. That means the node looks normal when the surgeon takes it out, but when the pathologist examines it under the microscope there is cancer visible. ALND is still the standard of care if a node(s) is "grossly" (meaning you can see that it is abnormal with normal eyesight) abnormal.
A 4.5cm lymph node is never going to look normal when the surgeon looks at it. Normal lymph nodes are generally less than 1cm. So if your node is positive for cancer, you would not fall into the groups where limiting node dissection to the SNB despite a finding of cancer on microscopy has been studied.
The big unknown is whether or not you have cancer. There are a few other conditions that can cause very large lymph nodes. Most surgeons would not want to proceed with a surgery like an ALND without a "tissue diagnosis" because of the chance that you are the one out of a large number with your findings who does not have cancer. "Tissue diagnosis" means that the tissue has been examined under a microscope, the diagnosis confirmed.
I am guessing that one of these is what is going on:
1) Your surgeon is so sure that you have cancer that he is not describing any scenarios other than the ALND, although he does plan to send something up to pathology during the surgery.
2) Your surgeon and hospital for some reason do not have the capability to do microscopic examinations DURING your surgery. If this is the case, quickly get yourself somewhere else. If they don't have the capability to do SNB, then you have to wonder if they can examine the surgical margins of the lumpectomy in real time. If they can't, that opens the possibility of needing a second larger excision if the surgeon doesn't remove enough tissue. That's not a disaster, but why go through it. It also opens you up to the small possibility that you could undergo the damage of an ALND without needing one.
What a pathologist can determine during a surgery is fairly limited, because the longer the patient is in the OR the higher the risk of complications, and some of the fixing and staining of the tissues takes hours and hours. That's why you can't get a complete path report until a while after the surgery.
If you talk to the surgeon and things still don't sound right, find a second opinion.
Having cancer in the lymph nodes does change your prognosis and what treatments are recommended. I know from experience it can be very, very scary to find out cancer is in your nodes. Hang in there. Many women who have faced the situation you face now have done well.