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Mar 23, 2021 06:42PM
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,
ACx4, THPx4, HP (to complete 1y); Nerlynx (1y); AI (expected 10y), Surgery: BMX + ALND, Reconstruction, Oophorectomy. Radiation.
10/26/2017, IDC, Right, 3cm, Stage IIB, Grade 3, 2/6 nodes, ER+/PR+, HER2+ (IHC)