Topic: Stupid question re. lymph nodes

Mar 16, 2013 12:27 AM gillyone wrote:

There are many of us around that had many nodes involved. If you have no nodes involved, those people think, great, it hasn't got to my nodes. But if you have node involvement, you think, great, my nodes caught it before it went any further.
Bottom line is, it's a crap shoot. Do the treatment and give it your best shot. That's all we can do. Most of us are fine!!

Mar 16, 2013 08:38 AM Beesie wrote:

I wonder if the surgeon is doing an axillary dissection along with your biopsy because either he or the hospital does not have the capability of doing an SNB.  The hospital that I was initially going to be treated at was planning to do an ALND on me because they didn't do SNBs at that facility.  (This was in the days before SNBs were commonplace). That was enough for me to change hospitals.

I didn't have a chance to reply to your previous answer to me in your other thread, but you said:

"I saw the surgeon the following Monday where he shared the radiologist's report. It read, " results highly suggestive of malignancy...given the mammographic appearance this is likely an invasive lobular carcinoma." The surgeon is doing a lumpectomy and an axillary lymph node dissection. He assured me he would not be removing more than a few lymph nodes, and that occasionally they can have pathology done right there, but typically it takes a few days. Does that make sense?"

Honestly, the answer is "No".  "Only removing a few nodes" is the definition of an SNB. If the surgeon is only removing a few nodes without the benefit of doing the full SNB process (i.e. the injections of the dye and/or isotopes), then there is a risk that he may not get the right nodes.  An SNB is a very precise and specific operation and the dye or isotopes is a critical part of the process.  Without doing the injection, the full first level of nodes, and usually some of the second level, should be removed.  That's a lot more nodes.  And that's an ALND.

Doing an ALND and not an SNB for any surgery these days, and particularly for a biopsy when cancer hasn't yet been diagnosed, does not make sense.  It sounds as though it is highly likely that you will be diagnosed - your image probably is a BIRADs 5 with about a 95% chance of finding cancer. But going into a biopsy, there is always a possibility, maybe just a small one, that cancer won't be found.  I've seen a lot of women over the years on this board who've had doctors who were absolutely certain that they had breast cancer, but it turned out that they didn't. 

Of course the more likely scenario, given what your surgeon has said, is that you will be diagnosed.  But there is no way to know if the cancer is in your nodes, and even if it is, that still doesn't mean that an ALND will be necessary.  An ALND is no longer a standard procedure when nodes are found to be positive; the decision on whether to do an ALDN is now part of the overall treatment plan decision that's made once the preliminary diagnosis is in.  If chemo is necessary, and particularly if rads will be also be given to the nodes, then an ALND is often not done.

So unfortunately, no, what your surgeon is telling you doesn't not seem to make sense.

Mar 16, 2013 09:03 AM fredntan wrote:

have you had MRI yet?  shouldn't she have one before they go cutting. IDK I'm not a doctor. My doctors after my first bx thought I was stage 1 or 2, didn't feel any lymph node . a mri was ordered at that point. you havn't had biopsy yet

I'm sorry I've been of no help to you. Iknow MRI's have a lot of false positives. mine showed 4 things. 1 of which was a false positive. hoqw come they are going straight to lumpectomy before bx?

Mar 16, 2013 04:45 PM lemon68 wrote:

I can share with you that before my SNB I had visible lymphnodes that could be easily seen. They were fairly certain of invasion. I had 2 out and both were negative. Told me my lymphnodes were the size of grapes, no idea what caused them to be so inflamed. I did have 2 isolate tumor cells near the sentinol node but they still call them negative. Until they get them out and send to pathology its all a guessing game. I would defintely ask why the ALND. My concern would be recovery and lymphodemia. The SNB is no picnic but I hear the ALND is far worse.

If you come back as ILC please visit us at Team ILC Warriors thread. I was just DX 01/04, I have learned so much for the loving women with much more experience than me. In regards to how scared you should be, I can only say from personal experience the whole thing scared me more than anything in my life, I am still scared. But something else in you will kick in a strength you didnt know you had and you will move forward. gillyone is right, its a crap shoot and we shoot all kinds of crap at it and hope, pray for the best outcome. The knowledge here on these boards is priceless. Please let us know how it goes for you, we are here for you.

((HUGS))

Mar 16, 2013 07:18 PM, edited Mar 16, 2013 07:20 PM by Beesie

Just to clarify my earlier post, I wasn't questioning the fact that the surgeon plans to remove nodes. That is unusual for an excisional biopsy, but I certainly understand in this situation why the node removal is being done, given that the surgeon is quite certain that cancer will be found and given the appearance of the node from imaging.

I am questioning why it's an ALND rather than an SNB as this first step.  Outfield, I agree that there remain today many situations where an ALND is recommended after a positive SNB; I was saying simply that an ALND is no longer automatically assumed in this situation, as it used to be even just a couple of years ago. So starting out with an ALND before there is a diagnosis of breast cancer or any confirmation of positive nodes is what to me is concerning.  If there is a diagnosis and if there are positive nodes, at that point a decision can be made on whether an ALND is advisable.

The other thing that worries me is the comment from the surgeon about not removing many nodes.  That suggests that he doesn't think that many nodes are affected, which of course is a good sign.  But if he's not injecting the dye or isotopes, how will he know which few nodes to remove? That's the other thing that raises a red flag for me. Either a surgeon does a proper SNB or a surgeon does a proper ALND, not something in-between. I realize that in doing an ALND, the surgeon can to some extent choose how many nodes to remove, but usually the entire first level is removed, along with at least a few nodes from the second level.  The actual number of nodes may vary, since our nodal systems are all unique. Here's an explanation from BC.org: How Many Nodes Removed?

Mar 16, 2013 11:54 PM Beesie wrote:

Outfield, I made an assumption about the lack of dye or isotope injections. 

The surgeon has said that he'll be doing an ALND. If the surgeon is planning to do the injections and planning to remove just "a few" lymph nodes, that's the textbook definition of an SNB.  So why wouldn't he call it an SNB then?  Since the injections are usually not part of the ALND process (they can be but usually aren't), I've assumed that the injections aren't planned and that's why he's saying he's doing an ALND.

Maybe this is all just miscommunication and he is planning to do an SNB.

Mar 19, 2013 03:27 PM Cowgirl13 wrote:

Vhlavaty, I'm wondering if you could postpone the surgery on Friday and get a second opinion.  If it were me, I would be uncomfortable with having my questions answered only a couple of days prior to surgery.  I need time to sit with new information and do not do well if I feel rushed.  There are definitly times where an ALND is required, however, there could be lifelong consequences re: lymphadema so I would go the SNB route first.  

Good luck.  I hope my opinions/suggestions have not made you uncomfortable.  

Liz