Axillary dissection - Purely academic?

[sara-jane]

Please could you answer this question in as much detail as you can: my sister, who is only 22 has just been diagnosed with stage 1 disease by biopsy and WLE.  The lesion  is about 2.3 cm and is aggressive (grade 3,her2neu+++).  The problem is that  she is adamant that she does not want any axillary procedure.  This is in view of a previous close friend whose life has been crippled by such surgery (has had to have amputation of her arm due to sarcoma caused by chronic lymph stasis and gross lymphedema).  My question is whether or not she has positive nodes, because the lesion is > 1cm the standard practice would be to recommend chemotherapy.  She has been told that she will require CMF chemotherapy and this will NOT  change if she has an axillary dissection and all the notes come back positive, or if all the nodes come back negative.  Upon reflection therefore, we really do not understand why an axillary procedure is needed when one already knows that they will need chemotherapy whatever the result.  Why do doctors insist on doing this in such a case?  Staging is purely "academic" in this case because as we understand it, her treatment will be exactly the same whatever the outcome of the dissection. more emphasis should be given to treatment and long-term morbidity.  Please could you explain, why an axillary procedure is still needed in a case such as this.

[CCF-RN,MSN-rf]

Dear sara-jane:  Lymph node dissection is done for 2 reasons, the more academic is for staging and prognosis.  The other reason is to determine treatment.  It seems that her doctors do not look at any options other than CMF.  I would ask, if they are considering strictly standard therapy, why they are not considering AC (adriamycin/cytoxan) if your sister has no cardiac history.  According to the (National Institute of Health, USA) NIH guidelines, AC has demonstrated a small but statistically significant improvement in survival compared with non anthracycline contanining regimens.  In addition, AC has a lower incidence of chemotherapy induced menopause in women both under and over 40 compared with CMF.  The only reason NOT to pursue AC is if your sister has a cardiac history.  The lymph node status may indicate the need for additional therapy, if they are positive. Clinical trials are in progress to address issues of adding taxol and herceptin (the monoclonal antibody for HER2 positive cancers) to HER2 positive and NODE positive patients.  In other words, if the nodes are positive, then this is NOT stage one and additional therapy might be recommended.  It is unfortunate that your sister is basing her opinion of lymph node dissection on this one individual.  Although lymphedema can occur, it is not with the frequency of the past.  Her friend's experience is certainly the exception - not the rule.  It would be important, however, to have a surgeon who is a breast specialist.  The more experience, the better the outcome, in general.  She might also consider another oncology opinion at a major cancer center with a breast oncologist.  In other words, a lymph node dissection is NOT just academic.

[Rubes2]

I have been struggling with this issue, too. I am 35, recently diagnosed with lobular carcinoma, 4.2 cm mass, ER/PR+, her2neu-. I am undergoing neoadjuvant chemo (FEC-100) based on the assumption that the nodes are positive. I will have surgery after 3 more (6 total) cycles of chemo, and have also been persistent in understanding why I should have the node dissection, particuarly since in my case the nodes could appear negative due to the effects of the chemo, even if they were postivie at the outset. Some answers that I have received include: it can serve as a local treatment, it may alter the radiation decsions made later, it may help in staging, and "it's not a cancer surgery otherwise." I feel better about some of these reason than others, but hoped my information might help your sister. I totally understand how little sense it seems to make. Good luck!!

[sara-jane]

I would be grateful if you could tell me on what basis you decided to have neoadjuvant chem. rather than "traditional" chemo. after the surgery - was the aim to try and shrink the tumor so that you could have more conservative surgery? and did they give you a choice of chemotherapy regimes or just recommend one for you, without discussion, as in my sister's case? Any personal input you can give would be greatly appreciated.
Thank you for your help and I hope your treatment goes well.

[Crystal85]

If I am reading this correctly, your sister is yet to have surgery to remove the tumor.  If this is the case, she may want to ask about sentinel node biopsy.  It is a less invasive procedure, but not every hospital is offering it as it is still being tested.  I have had the procedure on both sides and the effects are much less likely to be damaging.  Good luck! Crystal

[Rubes2]

Hi. It may be MUCH too late for you to see this comment...the website got "lost" in all the cancer reading I've been doing...

I decided to do chemo first primarily to get moving with treatment as quickly as possible. The reason I explored it at all was b/c of the size of the tumor, and hoping that I'd be able to have a lumpectomy. Now that I'm almost done with my treatment and planning surgery, I've decided to have a bilateral mastectomy anyway -- but at least I know the chemo will be behind me!

As for course of treatment, I went with my oncologist's suggestion. From what I'm reading in node-positive, premenopausal women FEC is really a superior treatment, with results from 12 - 25% better than those seen with FEC-50 and CMF, so there wasn't much of a decision. I'm young and healthy enough to get through the treatment (not easy, but not unbearable either) and I'm looking to use the biggest guns out there and fight this battle one! I also am probably done having children anyway, so I'm not concerned about menopausal issues...

Good luck to you and your sister!