axillary disection/positive sentinel node-when to consult oncologist?

[vfdirector]

I read with interest azdb's post on the subject of whether an axillary disection is necessary after a positive sentinel node biopsy.  I too have just had a sentinal node biopsy/lumpectomy.  The sentinal node itself was positive, with the largest metastatic focus measuring approx. 2mm.  the other 2 nodes removed were clear.  Also, the margins around my tumor that they removed were not as clear as they had hoped. In some instances it was only 3mm.  So the recommendation is for more surgery to try to get clearer margins, AND to remove ALL the nodes.  Some people are telling me to consult with an oncologist FIRST, before my 2nd surgery.  The surgeon tells me I'm most likely going to be given chemo AND radiation after the surgery.  In all the reading I've done, it's very clear that there are no definitive answers, and that if I seek a 2nd opinion, I may very well get one! It's a numbers game at this point. Or as my surgeon states "a risk/benefits analysis."  Is there any reason why I should consult with an anocologist FIRST, before my second surgery?  Would they recommend a different course of action? Or should I just go with the "standard of care," have all the nodes removed, and then take it from there?

[heidiho]

My case was pretty similar. I was scheduled for lumpectomy of a 3.0 cm. tumor with sentinel node biopsy, with the understanding that if anything at all was found in the sentinel node, a complete axillary node dissection would be done immediately along with the lumpectomy and axillary.
   As it turned out, only the sentinel node was positive (0.3mm)
so they did the dissection, with the other 10 nodes negative.
   Still, because of that one slightly pos. node, I had to undergo this additional surgery, with chemo therefore recommended at 4 AC's followed by 4 Taxols, followed by 6 weeks of rads, then followed by 5 years of Tamoxifen.
   At this point, I believe I'm getting optimal care; I'm starting my 3rd cycle of (dense-dose) AC tomorrow and hope to finish the whole chemo Rx by the end of September.
   I've done well on it so far ... only side effects so far were hair loss & a little fatigue; no N&V with daily Zofran tablet the first 3 days.  I'm also getting Neupogen shot 24 hours after each infusion, and blood work every week have been surprisingly good.

[CCF-RN,MSN-rf]

Dear vfdirector:  The criteria that define a negative margin are somewhat controversial.  Some feel that if there are no cancer cells in the margin, it is negative.  Others prefer to see a margin of a couple millimeters.  Sometimes the radiation oncologist who works with the surgeon will request a larger margin.  In other words, based on the information you provided, you may or may not need another surgery, depending on the situation.  Likewise, there is controversy regarding removing additional lymph nodes when the sentinel node is positive.  Some would argue that if a node is positive, you will get chemo anyway, so treatment would not change.  Others believe that checking more nodes gives the information necessary to determine accurate staging (this is what is done at Cleveland Clinic).  Seeing an oncologist at this point may provide you with additional information but the question at this point is still a surgical question.  Either way, both radiation and chemotherapy will likely be recommended.