Expert: Claes-Gustaf Nordquist, M.D. - 8/12/2006

Question
I am a 54 year old, postmenopausal, white female who recently underwent a lumpectomy with sentinel node biopsy.  The tumor margins were clear, but the sentinel node was positive.  

Final microscopic diagnosis - A) Sentinel lymph nodes, right axilla:  Two lymph nodes show evidence of metastatic tumor consistent with breast primary.  B) Right breast  mass, excision:  Infiltrating ductal carcinoma with lobular features.  Tumor measured 3 x 2 cm.  Tumor extends to the inked margin.  Tumor border is irregular and infiltrating.  Bloom Richardson score 8/9.  Tubules 3/3; nuclear pleomorphism 3/3; mitotic activity 2/3.  Microcalcifications present.  C)  Right breast margin facing tumor:  No evidence of residual tumor.  Margins are clear.

A post-op CT with contrast of the neck, chest and upper abdomen are clear at this time.  I have requested a PET fusion scan, but this has not yet been obtained.

Do I need to have a lymph node dissection if I am going to have radiation and chemotherapy?  What are my options?

Can a staged lymph node dissection be done, i.e., several sentinel node excisions until uninvolved nodes are reached?  

Are there any clinical trials; results from clinical trials, etc, regarding lymph node dissection versus non-lymph node dissection w/chemotherapy and radiation?

I am very concerned about lymphedema and the loss of the use of my arm and hand.  I am a very active individual and am not very careful with my limbs. I have been informed that extreme caution is to be exercised after a lymph node dissection, no scratches, cuts, injections, venipuncture, blood pressure cuffs, etc, on that arm.

I have also been informed that once lymphedema developes it cannot be reversed.

I am a Medical Transcriptionist and use my hands and arms everyday.

Any and all information is greatly appreciated.

I have a follow-up visit with my primary surgeon on Tuesday, August 14, 2006.  

Thank you.


Answer
In MY PERSONAL opinion I think it would be best with a mastectomy here with lymph node dissection followed by radiation therapy & chemo therapy & possibly (anti) hormonal therapy. Others may have a different opinion but this is mine, to be on the safe side as much as possible!
Though of course even with this more aggressive attitude no guarantees can be given. My opinion is based on many things mainly the size of the primary tumour and the fact that a lymph node biopsy was positive. That means that this tumour already is a stage 3 tumour at least and must be treated as such!