Sentinel Node Biopsy / Lumpectomy

I have been diagnosed with a 1.9 cm infiltrative ductal carcinoma in my left breast. I have had surgery to remove the lump which was ER/PR positive but the tumor extended to the margin so I am scheduled for a re-excison next week.  At the same time, my doctor will do a sentinel node biopsy to determine if the cancer has spread to the lymph nodes. I am told that if the sentinel node biopsy is negative then I will need radiation and hormone therapy and may not have to have chemo.  If the sentinel node is positive then we have a whole new ballgame to deal with.  I am 51 years old with no family history of breast cancer. I have had two prior surgeries to remove lumps in my right breast, one when I was 17 years old and one eleven years ago that both turned out to be benign.  I have never taken HRT but I did take birth control pills for several years. I did not breast feed my children. I am scared to death. My questions are as follows.

1. Is re-excision a common procedure when I had a dye/wire localization prior to my first surgery to locate the tumor. Is this not enough to assure complete removal of the tumor the first time.

2. Is the SNB painful. I will go to the nuclear med department prior to surgery for the radioactive/dye injections. I know I will be asleep for the actual biopsy but what about the injections and scanning prior to surgery? Is that part painful? I am scared to death of this procedure.

3. Is lumpectomy/radiation/hormone therapy enough.  Is it possible to need chemo even with a negative sentinel node and under what circumstances.

Thank you !!

[CCF-RN,MSN-rf]

Dear DeDe F:  1.  It is common to re-excision a lumpectomy.  Because the first procedure was a wire guided biopsy, doctors removed the suspicious area.  To the naked eye, one could not tell if there are any suspiciousl cells on the margin.  So, the pathology will come back positive and the only answer is to take another lumpectomy.  Although less common, it is possible that this margin could be positive too.  

2.  Sentinel node biopsy is not painful during the procedure.  Although the radioactive substance is administered in nuclear medicine - most women do not report this as being very painful), the dye is administered in surgery where you are asleep.  Like any surgery, you will likely have some post operative discomfort.  A bigger question is whether a sentinel lymph node biopsy is adequate.  Some institutions do sentinel lymph node biopsies only in very small tumors and prefer, due to the incidence of "skip" metastasis (where the first or second node is negative and the third node is positive) to do axillary node dissection.  In the case of sentinel lymph node biopsy, if the biopsy is positive, then many doctors would recommend axillary node dissection - so that the disease is fully staged.

3.  Whether or not chemotherapy is recommended is based on a variety of factors, of which some are unknown.  In each individual case, it is a discussion of risk versus benefit.  This discussion would be best once more information is known.

[surgeon]

1). You really can't tell with certainty at the original excision whether you get it all. It's not rare to need to do more after the entire specimen is processed. More often than not, you can get it the first time. But when it doesn't happen, it absolutely does not imply some sort of error.
2) the injections are no big deal: like having a routine IV started. Small needle *****. Piece of cake. You won't feel the actual stuff at all as it goes in or after. The surgery can hurt after, but since it's really just on and under the skin, there's usually not much pain at all. Sometimes some burning from small nerves that can get irritated. Typically very minor.
3) It's well-established that cure of breast cancer increases for women with positive nodes if they have chemotherapy. Those who might be advised to have it with negative nodes are those with very large aggressive-appearing tumors (doesn't sound like you), those who get it very young, etc. If your nodes are negative, it's not too likely you'd be advised to have "chemotherapy" but there are also data showing that even with ok nodes, taking hormone therapy is of benefit.

[DeDe F.]

Dear Doctor:
Thank you so much for your quick response. I know how very busy you must be and the fact that you take time out of your schedule and your life to assure women like me on this terrifying subject makes you a God send to us. You made me feel so much better about the SNB I can't even tell you.  I'm hoping to hear from other women that have had this procedure with their input also.  Thank you again for taking away at least some of my fears.

[ritavv]

I had a 1.6 invasive ductal carcinoma.  During my lumpectomy they did a quick look at the margins and the doctor excised more so that he had a 1cm clean margin all around.  The sentinel node biopsy was easy.  They used an ultrasound to inject the radioactive isotope.  It was then recommended that I move my arm around a lot.  They said they got better results that way.  There is a delay while you wait for the radioactive isotope to start draining to the nodes.  In my case they also used the blue dye but that was injected after I was asleep.  I had 3 nodes removed... all clean.  I got two opinions from oncologist.  One recommended chemo, radiation, and Tamoxifen.  Apparently, it is the standard to give chemo if the tumor is greater than 1 cm.  The other oncologist considered other factors.  My cancer was greater than 95% estrogen and progesterone positive and very slow growing and I was 50.  He felt I wouldn't get that much benefit from chemo.  Since then there have been studies that say hormonal treatment can be just as effective as chemo in post-menopausal women.  In the end, that is what I chose.  I am now 2.5 years out from diagnosis and doing okay.

[heidiho]

Dear De De:
   I had procedures similar to yours: first, core biopsy, which came back positive, after which a left breast lumpectomy & sentinel node biopsy (& possible axillary dissection) were scheduled a few days thereafter.  Shortly before the surgery, the radiologist called & told me that "suspicious microcalcifications", too small to be a lump, were seen in my right breast as well, and that a wire localization would be done just before my scheduled left breast surgery, so that the surgeon could excise this area at the same time as the surgery.
   As you know, since you've already had the wire localization, this is no more painful than an ordinary needle injection, & most of the discomfort is with having your breasts compressed repeatedly while they are trying to get several views to make sure the needle is in the right spot.
   Well, if you've gone past that, trust me that the dye injection for the sentinel procedure will probably be even less cumbersome ... in fact, I barely felt the small needle injection, after which the tumor area was massaged to get the dye into the lymph area, which was totally painless. I know it's easy to tell someone who is terrified about the unknown not to worry, but don't worry.  It's much less hassle than the wire localization, you'll only feel a tiny pinprick (if anything at all) and you'll be asleep for the actual sentinel biopsy.  
Good luck... and "don't worry"!

[vermontgirl]

Prior to the injection of the dye/isotope, I suggest you ask the radiologist to inject some novacaine type stuff in the same area and allow it the necessary time to act.  Without it, the dye injection is tolerable but not very pleasant.

[bewilma]

I am 50 and have no history, family or self, of any kind of cancer. Heart attack and stroke runs in my family. No kids,no smoking, fit and active, eat low-fat, low-carb., HRT for 6 years, full hysterectomy in '97. I was devastated when diagnosed with medullary breast cancer. A tiny lump was found just under the skin. Dr's thought I had a 5% chance of cancer. Path report said otherwise. The lump was 1.7 cm
estrogen/progesterone both negative and HER-2 NEU overexpression 3+. Had a lumpectomy and the margins came clean, first try (prior lumpectomy 2/4 margins were not) Sentinal lymph node clean, until the path report revealed "single intracapsular micrometastasis of carcinoma 0.15mm greatest dimension"
______
My oncol recommended 4 chemo, 5 weeks radiation then 4 chemo
The chemo formula is: Taxotere, Epirubicin and Cytoxan
Note: I do have kidney disease cause by a severe kidney infection after the hsyterectomy.

I have read that this formula is extremely aggressive and I am not sure why this is called for with such a small tumor. I know that there is a higher risk of recurring cancer due to the estro/prog and HER-2 neu results. However, why would not radiation alone be sufficient? I had a PET scan prior to the lumpectomy and my body is totally clean of any other issues. More than 2 months after the diag. the cancer had not spread at all. Is this an overaggressive "preventative" treatment?
Your opinion please!!! Survival rate?
Thanks so much!!!
Bewilma

[bewilma]

Sorry, I am new to the site. Meant this to be a question rather than a comment.
Bewilma

[DeDe F.]

Hi Everyone, I'm back!  First of all I want to thank all of you for your comments and concerns.  This site is a great tool for all of us faced with probably one of the most frightful things that could happen to us in our lives. You helped me through my procedures just by being able to think about your comments and reasurring me that everything would be OK.  I'am now post-op for my second lumpectomy and sentinel node biopsy.  The sentinel node biopsy consisted of three injections that stung a little but were not really that bad.  As far as numbing the sites, the numbing injection would of felt just the same so what's the sense. I then had to be scanned in several different positions for the next three hours. Although they put me in some rather uncomfortable positions and it seems to take forever, this is not bad either. According to my Radiologist, this procedure can take anywhere from 30 mins to 3 hrs, and me being me, it took the whole 3 hrs for the radioactive solution to flow to my nodes.  I moved my arms around a lot during a break from the procedure and this seemed to help speed up the process (a tip I got from this site).  Two sentinel nodes were found and marked for removal.  Off to surgery and a much needed rest.  I had a wide re-excison using much of the same incision site as the first lumpectomy and a sentinel node biopsy.  My doctor removed both sentinel nodes along with a "cluster" of 4 nodes nearby(they were so close to the 2 sentinel nodes that he decided to go ahead and remove them as well). The initial frozen section report came back NEG but I am still waiting for the final report on the remaining nodes. I spent the night in the hospital (got a a lot more attention for my husband that way (smile) and I am  now recovering nicely. Although I am VERY bruised and sore, the sugery went well.  I seem to have more discomfort under my arm above the incison site than anywhere else.  I had the dain tubes removed yesterday so I think that may of shook it up a little.  My advise to anyone who is facing this is to do everthing exactly as your doctor suggests. Eventhough none of this is a picinc, there is not one single procedure that I have had so far that I would of risked my life to put off.  None of this is fun but this is just a temporary detour in our lives and support from our family/friends and sites like this where perfect stangers are here for us to help ease the path really do help.  Thank you all again for your help in getting me through this so far and don't worry, I'll be back again for help from you through the next phase of my treatment.  My heart and prayers goes out to all of you.

[DeDe F.]

Here I go again! I have just learned that my nodes were all negative (thank God) but the pathology states that the margins are considered "close" within 1mm.  My surgeon will speak with my radiation oncologist to determine if MORE surgery needs to be done and as I understand it the radiation oncologist will be the one to determine this.  Is it uncommon to have three surgeries to obtain clear margins and can another lumpectomy be done using the same incision or is radiation enough to kill these "close" to the margin cells. Since my nodes were negative will it be necessary to take more nodes. Since I am considered to have small breasts (B cup) is it even possible to have more taken out to get clear margins or will I need a more radical surgery.  Thank you again for your help.

[BigmommaTay]

A related discussion, Support and Prayers was started.