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Is it important how many lymph nodes removed?

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windwalker27
windwalker27 Member Posts: 54
edited August 2022 in Stage III Breast Cancer

Hello everyone,

My surgeon removed only 5 lymph nodes. And 4 of them turned out to be cancer-positive. I see that many people had 10-40 lymph nodes removed. Here’s my question: is it important only for the staging or the survival is better when cancerous nodes are removed? Thank you

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  • meow13
    meow13 Member Posts: 1,363
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    My understanding is they can do a sentinel node biopsy then take more if needed. They actually take out a section and it varies person to person on how many nodes are in the section. One person I recall had something like 4 out of 40 nodes positive, which really surprised me so many nodes. I had 0 out of 2 positive if I remember.


    Found this article

    https://pubmed.ncbi.nlm.nih.gov/23578295/


  • meow13
    meow13 Member Posts: 1,363
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    Well I guess I don't know about leaving potential cancerous nodes in place and radiating the area in long term outcomes.

  • windwalker27
    windwalker27 Member Posts: 54
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    Thank you, Meow. I am having an appointment with my surgeon in a couple of hours. I will ask her and post here for people to read

  • specialk
    specialk Member Posts: 9,233
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    windwalker - to your original question - the total of nodes removed, and the method, can be hard to discern from the way signature lines are designed on this site. In my original surgery - bi-lateral mastectomy with bi-lateral SNB - I had two nodes removed from the non-cancer side, and one from the cancer side. That is what lit up with the tracer and dye. The two nodes on the non-cancer side were normal, and the one on the cancer side was declared clear in the OR, but later found to contain 20 IST (isolated tumor cells) in the lab. Those would have been too small to visualize during surgery, and often the look at the SNB is cursory or looking for gross disease at the time of surgery. Because I had Her2+ cancer my surgeon and medical oncologist insisted that I have complete axillary clearance (ALND) surgery, which happened five weeks later. I had an additional 11 nodes removed in that clearance, and one contained quite a lot of cancer. This is unusual to have almost no cancer in the sentinel and a lot in a node further up the chain. My signature line shows 2 of 14 nodes positive, but unless you are reading closely, it may appear that was what was collected in the SNB, but it actually represents bi-lateral SNB + ALND. That total is actually quite low considering levels 1 & 2 have been completely removed from the cancer side. All of us have differing numbers of nodes - some have a lot, and others like me have very few. At the time of my surgery there was a shift away from ALND in cases of IST or micro-mets in the SNB, and instead doing radiation - this was to limit the risk of lymphedema. Information showed that odds were if your SNB contained IST or micro-mets, it was unlikely there was more cancer - but for a small percentage that is untrue. It would have been a mistake for me because of the size of the cancer further up - but I did initially resist the surgery. In terms of how many nodes are removed in a SNB, that varies from person to person. The nodes are encased in a fatty pad, and this is what takes up the tracer of dye. That is removed entirely, and the number of nodes contained within can be one, or many. Some surgeons, upon seeing gross disease in the first fatty pad, will continue to remove until they see normal appearing nodes - a de facto full or partial ALND done at the time of initial surgery. Were your positive nodes seen on any imaging prior to surgery? I would ask your surgeon if ALND is warranted or if he/she thinks that chemo and radiation will be sufficient in eradicating any issues. Wishing you the best.

  • threetree
    threetree Member Posts: 1,422
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    I had a large tumor - close to 6 cm and it had already on its own, started to cause lymphedema in my left arm, so my surgeon only did a sentinel node biopsy after injecting the dye while I was "under" for the mastectomy (I was completely freaked out about having the procedure with just a local). He took 1 or 2 sentinel nodes (reports about the number seem to vary) and there was no cancer. I told him I'd read that a sentinel node biopsy is 89% accurate and he said that yes, that is the statistic. This surgeon worked (retired now) for a major university teaching hospital and had had years of experience.

    The oncologist I see works for a local cancer center that is affiliated with the university. She however, was highly disappointed that the surgeon did not do an ALND (he was trying to prevent worsening lymphedema) and noted that all of the surgeons at the cancer center would have done the ALND and that they too, also thought my surgeon had been wrong in what he did. I personally had no problem with it, as there were no other signs from scans, etc. of any spread to lymph nodes or elsewhere and I was very worried about the ALND and worse lymphedema. Both the surgeon and I decided that radiation, that I was going to have to have anyway, should take care of anything missed in the nodes.

    Due to the controversy, my surgeon told me at my mastectomy follow up, that we could do an axillary ultrasound and then if anything in that looked suspicious, he could proceed further and do an ALND. He also told me there is something called a "reverse sentinel node biopsy" where they begin down in your forearm, I believe, with the dye and go "backwards" essentially, looking for any bad nodes. He said that that too, could avoid some of the complications of an actual ALND. Long story short, none of that happened, I just went with the sentinel node results, got the expected radiation, and so far, so good. It has been 4 years now since my initial diagnosis and I have had no problems. I am personally fine with what the surgeon did and offered to do if I continued to have concerns.

    My oncologist continues to be "upset" over the fact that a full ALND was never done, and sometimes brings it up in a snarky way, about how we'll just never know about my actual node status, since an ALND was never done.

    The surgeon, who was in his early 60's told me of how back in the day, when he first got into "the business" they would take as many as 50 and 60 nodes and that some huge percentage (way over 50%?) would develop lymphedema. Then he said a method was developed where they could take more like 20 nodes and the lymphedema development was dramatically reduced to less than 20%, I think he said. He said that they had continued that way for years and years, but that recently he was starting to see that the younger doctors were back to taking a massive amount of nodes, and he was convinced that it was unnecessary. The younger doctors just seem to want that data, that actual specific count of what was found in each node, or they remain highly suspicious that you have cancer in the remaining nodes. My surgeon on the other hand was of the "more than likely we got it all" sort of mind, and believed that the danger of lymphedema outweighed the benefit of knowing those exact numbers and fine data.

    Both my oncologist and her surgical comrades at the cancer center (highly affiliated with the university that the surgeon worked for) are all in their 30's and 40's primarily, so maybe there is a generational issue here. I'll never know. I do know that all of the staff at the hospital told me that there was no question whose opinion they would go with in a controversy, and they were hands down on the side of the surgeon (many staff at the hospital had their own surgeries done by this same surgeon). Again, to this day, I have no problems with the fact that I only had the sentinel node taken and have no regrets in that regard. The lymphedema originally caused by the tumor has remained mild to moderate and very stable.

  • windwalker27
    windwalker27 Member Posts: 54
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    Thank you guys for your wisdom. My surgeon says we will wait after the chemo to do the dissection. I think it’s a good decision - I don’t want to delay chemo

  • windwalker27
    windwalker27 Member Posts: 54
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    I want to faint after reading my pathology report