Sentinel node biopsy Reconstruction

[Britanniagal]

I recently discovered a breast lump, which my gynnecologist removed (6 weeks ago). Pathology indicated malignancy ( invasive ductal, 2cm ER- )with the need for further excision.(subsequent ct and bone scans clear)

I got 2 opinions. One surgeon recommends mastectomy (the lump was close to the nipple) and axillary dissection  (she says sentinel node biopsy will no longer be reliable)
The  other gave me a choice of lumpectomy and SNB !!!

What are current thoughts as to accuracy of SNB after surical excision?

Is chemotherapy indicated?

Additionally I received conflicting advice re reconstruction.
I have very small breasts, will silicone implants give a pleasing result? tram has been suggested but that would probably include implants as well, and i am concerned about the additional surgery.
Does immediate reconstruction interfere with chemotherapy?
Is preopeative chemo an alternative?

[demi198]

A related discussion, Is this Secondary Breast Cancer? or What? was started.

[demi198]

A related discussion, secondary breast cancer was started.

[~Barb]

I just underwent a lumpectomy for infiltrating duct carcinoma-high grade, and a sentinel node  with axillary disection.
My sentinel node was clear of malignancy and 1 of the 6 lymphs disclosed 1 enlarged node shows diffuse replacement by metstatic tumor.
I am waiting on a 2nd opinion right now, but will be looking at 2 round of chemo now and possibly a mastectomy.
All I can say is that I am glad my surgeon took those 6 lymphs out along with the sentinel node disection. I am only 41 with no family history of BC and was considered very low risk.
I now am seeing that this doesn't mean didly when Brest Cancer rears its head.
Thank you for this forum.

[surgeon]

It's not certain: surgery on the breast can affect lymph flow throughout it, and therefore render a sentinal node biopsy inaccurate. It's not really possible to say to what extent that is true in any given situation. However, since most of the problems from lymph node surgery occur when the surgery is extended to the uppermost parts of the underarm, and since it's VERY rare to have lymph nodes involved in the upper areas with the lower areas being ok, removing the lower 1/3 of the node-bearing area will give an accurate sample, with little risk of sequellae.

[Britanniagal]

Thanks for the response, it is very much appreciated.
However, I am still not certain whether the sentinel test is rendered ineffective due to the prior excision.

[CCF-RN,MSN-JS]

Dear britanniagal, The main purpose for checking the lymph nodes is to decide about adjuvant treatment (Adjuvant treatment is treatment given after surgery to try to prevent or minimize the growth of microscopic deposits of tumor cells that might grow into a recurrent tumor). The standard of care is to check the lymph nodes by either axillary dissection or sentinel lymph node dissection (SLND). Particularly in an early stage cancer (stage I or II, with a tumor less than 2 centimeters), where there are no palpable (felt on physical exam) nodes in the armpit, a sentinel node biopsy may be done instead of a full axillary lymph node dissection. However, there is debate about the size of a tumor where it is felt to be "safe" to do only a SLND, so there may be some differing opinions.  An argument against sentinel lymph node biopsy is that is not foolproof; it could still provide a false negative. This happens in about 5% of cases; the sentinel node shows no cancer, and then cancer is found in other nodes at full dissection (although regular dissection can also miss some positive nodes.) Studies are now following women long-range to see if those who have had only sentinel biopsy where no cancer was found developed axillary recurrences later on in life. Currently the standard of care is for women who have a sentinel node that is found to contain cancer to go on to have a full dissection.

In terms of decision between lumpectomy and mastectomy certain factors are considered:
First, the size of the tumor relative to the size of the breast must be considered. If there is limited breast tissue, a lumpectomy with safe margins may leave a poor cosmetic result. In these cases, a physician may suggest mastectomy with reconstruction in order to provide for a better post-operative appearance.

Another consideration is if there is more than one tumor in the same breast.  In these cases, some surgeons may recommend a mastectomy in order to be certain that all of the cancer is removed and there are no additional undiscovered tumors remaining in the breast.

A third consideration is that a lumpectomy should always be followed by radiation therapy.  Radiation therapy is given every day for 5-6 weeks.  If, for some reason, it is impossible for a person to follow through with radiation therapy, a mastectomy may be recommended as an alternative.

Survival between lumpectomy with radiation and mastectomy is equivalent.  Therefore, the decision may boil down to the preference of the patient. Some people would prefer to "remove the breast" and others feel very strongly about preserving the breast whenever possible. Neither choice is wrong, theoretically. It is best to discuss your situation with an expert breast surgeon so that you can be confident in your decision.

Adjuvant chemotherapy will likely be recommended, and is usually considered when tumors are greater than 1cm in size.  Neoadjuvant treatment (chemotherapy before surgery) is usually considered when there is a tumor over about 3cm.

Regarding the cosmetic results of breast reconstruction these questions would best be directed to a plastic surgeon, who can advise you based on seeing your actual anatomy, and discuss with you the pros and cons of options.