I had a mastectomy for a 4 cm invasive Ductal CA on a 40 years old lady with sentinel node biopsy.Unfortunately frozen section instrument got a problem and we closed the wound without formal axillary dissection.Now I knew that 3 of 4 sentinel node was positive.Is it essential to do a formal axillary dissection in this patient?
It is best to undertake an axillary node dissection. Especially considering her age and size of the tumour this would be in her best interest.
Having 3 pos. Lymph Nodes axillary dissections has to be recommended to the patients!
- Certainly you should go back and perform a complete axillary dissection.
- If you don't for any reason, then axilla should be irradiated along with the thoracic wall, as this patient has already an indication for post-mastectomy radiotherapy due to tumor size.
Dear Bijan,
certainly there is an indication for complete axillary dissection, since 4 and more nodes involved would implicate dose-dense chemotherapy. Thus, it has clearly therapeutic relevance to know the exact extent of axillary node involvement.
All the Best
Rainer
Under the circumstances I would do an axillary dissection in the first place due to tumor size.
Frozen section for sentinel nodes has a high rate of false results. Instead of complete axillary dissection for this young lady, you may prefer a limited axillary sampling for palpable lymph nodes reaching a total number of 12. Complete axillary resection can cause permanent sequelas
Dear Hedef,
you are right that there may be some morbidity by complete axillary dissection, as it is also for sampling and even sentinel node. However in this situation to do some kind of sampling is definitely the wrong way: if you are worried about additional morbidity of further axillary dissection you should leave it with the sentinel information and decide whether you want to accept potentially unnecessary higher morbidity from dose-dense chemotherapy or perhaps reduction of survival probability by not doing dose-dense in spite of potentially more than 4 nodes involved. On the other hand a sampling which is not complete is still uncertain about the total number of involved nodes and also with respect of morbidity. Thus, I would strongly recommend not to choose this option.
Yours
Rainer
Dear Every one
Thank you for yuor ansewrs.I did axillary dissection for the patient this afternoon.Now I am wonder about the therapeutic effect for axillary disection! I thought it has just an diagnostic value.Am I wrong?
Dear Bijan,
no, you are right. But the diagnostic result will tell you whether you will perform dose dense or regular chemotherapy, which in fact makes a difference in toxicity and chance for survival for patients with 4 involved nodes and more. Thus, e.g. if you do some kind of "sampling" , detecting only 3 involved nodes, you may fail to detect the forth one - leaving it in.Thus the patient would be undertreated by avoiding dose dense chemotherapy due to inadequate/insufficient diagnostics.
That is what I meant - either sentinel or systematic axillary node dissection - there is no place for anything (undefined) in between from the logical point of view.
The Best for you and your patient.
Rainer.
Non senttnel lymp node positivity is high, and axillary dissection is indicated.
Nomograms (Ondokuz Mayıs Nomogram of our instituion, http://tip.omu.edu.tr/bc_nomogram.ondokuzmayis/?h=ok), that will caculate the possibility of non SLN posititivity could be useful.
Best rregaards,
Bekir
Dear Dr Bijan.
Salam hale shoma khube? I fully agree with most of the excellent opinions of the other responders which is to perform full axillary dissection given the fact that she has a 4 cm tumour plus 3-4 positive sentinel lymph nodes. I agree that adjuvant chemotherapy is in order. Additionally adjuvant radiation may be considered not because the lymph nodes are positive but especially so if associated with extranodal extension. I think the benefits of the axillary dissection far outweighs the complications of the surgery, i particular, post-op lymphoedema. I'm sure attention to this problem can well be addressed by local means and thorough referral to rehabilitation medicine.
I hope all goes well for you and your patient
Merci and Khodafez!
ROWEN T. YOLO, MD
- Badges
- Science topic
- Similar topics
- Biological Science
- Anatomy
- Tissue