Since I had not gotten a call from the Plastic Surgeon yesterday decided to call in his office and talk to his nurse G. I knew that he would not be in the office seeing patients on Thursday.
I was put on hold and then suddenly transerred to Dr.P .. I was pleasantly surprised he apologized for not calling me yesterday and said that he had a lengthy discussion with Dr. S the radiation oncologist who stook his ground saying that I did not need surgery but radiation. Dr. P said that they were taking my case again to the tumor board at the hospital today and he would join the call and call me on what the final decision was. Oh boy I feel like I have stepped into some kind of power struggle between my oncologist and radiation oncologist. I understand and respect their difference in opinions however they should get together to deliver a treatment plan to me as a Team !!! Bouncing me around is really not acceptable.
I AM ECSTATIC !!! Finally one of the doctors is taking responsibility to coordinate and it is not my oncologist, surgeon or radiation oncologist but my plastic surgeon !!
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At noon since it was raining scrapped the plan for riding outdoors and decided to hit the pool to see whether I could still float(have not been in the pool for about 6 months at least). Was able to get in about 500 yards (took at least 15 minutes with stops every 100 ) I suck.. but it seems workable.
Then went into the steam room for about 10 minutes, felt kind of good, will do the sequence like that from now on.
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At night did a short weights workout for about 30 minutes. And did the elliptical for 20 minutes. I was really tired, still not recovered I guess from the chemo last week.
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I was glued to the phone for the whole day waiting for a call from the PS, he called around 6 PM stating that he attended the call but the radiation oncologist had submitted my case to be addressed in the call 2 weeks from now !!! WHAT ?? They wanted to review my pathology slides ( oooppss. they are at Moffit need to bring back to Orlando ASAP ). He apologized that he could not provide any more insight. Somehow I got the vibes that his involvement in this was not welcomed. I am thinking more and more that I am caught between the fight of 2 major school of thoughts. The surgery principles regarding node management might be in a turning point within a couple of years just like my friend K who is also a surgeon stated.
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I am at the high end of the studies.. my Sentinel Nodes being positive at .2(micro), and >2mm(cutoff for macro), the studies not favoring ALND have tumor size 2cm ( mine is 2.5 cm).
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Axillary Node removal is going to be considered more of a staging tool then part of the treatment for cases where there are no clinical diagnosis of c(that is if they are not palpable or appear in the scans ) in the lymph nodes and the c in the sentinel node biopsy is microscopic(less than 2mm.. I have 1 that is 2mm just at the borderline ) I do believe that chemo and radiation actually will wipe out.. radiation acting like 'bleach' in doing a major cleanup. It might be an overkill to do the ALND.. hmm.. again..
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The direction seems to be going towards expanding the scope of the Sentinel Node Biopsy, by taking not only 1-2 but 4 or more nodes. ( which is my case 6 nodes ).However at this point there are not enough studies ( I only found 2 studies
Axillary Recurrence After Sentinel Node Biopsy

which says in the end :

The introduction of sentinel node biopsy (SNB) into breast cancer care marks a further progression in our understanding of this disease and has permitted a less extensive surgical option for many breast cancer patients.9–13 SNB allows the removal of fewer lymph nodes and has afforded a more targeted evaluation of the sentinel nodes, with decreased morbidity when compared with axillary dissection.6–8,14 The identification of histologically negative sentinel nodes indicates that an axillary dissection is unnecessary.7,9,12,15–17 The role of axillary dissection for patients with microscopic involvement of the sentinel nodes remains in question.

Thus far, 2 preliminary studies with 31 and 46 women with positive sentinel nodes and no further axillary surgery have recently been published. They showed no incidence of axillary recurrence after at least 2 years of follow-up. The extent of nonsentinel nodal involvement has been shown to decrease with smaller primary tumors and decreased axillary tumor burden. Thus, axillary dissection may have more limited utility with early-stage disease.

One hundred fifty-eight (68%) sentinel node–positive patients underwent completion axillary dissection (Table 4). The mean age for this patient population was 57 years, the mean tumor size was 2.4 cm, the mean and median number of sentinel nodes were 1.8 and 1, respectively, the median number of additional nodes harvested during axillary dissection was 12, and the mean follow-up was 28.6 months. Seventy-six (48%) of these patients had additional axillary disease, with an average total number of 3.7 (median, 2) positive nodes. Thus, an average of 1.9 additional positive nodes were yielded through completion axillary dissection. The median size of nodal metastasis for patients undergoing axillary dissection was 7 mm; the mean size was 8.4 mm (Table 5). Of the patients managed with breast-conserving surgery, 85% received radiotherapy. Eighty-one percent received systemic therapy. No sentinel node–positive patient who underwent completion axillary dissection has had an axillary recurrence.
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The remaining 73 (32%) sentinel node–positive patients were managed with observation alone (Table 4). The mean follow-up for this patient population was 27.6 months, with a mean age of 59 years. The mean tumor size for these observed patients was 1.9 cm, the mean number of positive sentinel nodes was 1.2 (median, 1), and the median number of nonsentinel nodes harvested was 0. The median size of nodal metastasis for patients managed with observation alone was 1 mm (median, 2.7 mm; Table 5). Tumor size and pathologic grade distribution for this patient population was reflective of the larger sentinel node–positive patient population (Table 3). In this group, 58 (79%) of the observed sentinel node–positive patients were ER positive, and 15 (21%) were ER negative. Of the patients managed with breast-conserving surgery, 92% underwent radiotherapy. Eighty-five percent received adjuvant systemic therapy. No patient in the sentinel node– positive observation group has had an axillary recurrence (odds ratio, .37; P = .725). Management with axillary dissection or observation had no influence on recurrence in node-positive patients (P = .578).

Background: Sentinel node biopsy (SNB) has evolved as the standard of care in the surgical staging of breast cancer. This technique is accurate for surgical staging of axillary nodal disease. We hypothesized that axillary recurrence after SNB is rare and that SNB may provide regional control in patients with microscopic nodal involvement.

Methods: With institutional review board approval, SNB was performed with peritumoral injection of 99mTc-labeled sulfur colloid. From 1996 to 2003, 1167 patients were entered into a prospective cancer database after surgical therapy; 916 patients consented to long-term follow-up. Fifty-two patients (5.7%) did not map successfully and were excluded, leading to a study population of 864 patients. The median follow-up was 27.4 months (range, 1–98 months).

Results: The median number of sentinel nodes harvested was 2, and 633 (73%) patients had negative sentinel nodes. Thirty (4.7%) of those sentinel node–negative patients underwent completion axillary dissection, whereas 592 (94%) patients were followed up with observation. A total of 231 (27%) had positive sentinel nodes: 158 (68%) of these patients underwent completion axillary dissection, and 73 (32%) were managed with observation alone. Two (.32%) patients who were sentinel node negative had an axillary recurrence; one of these patients had undergone completion axillary dissection. No patient in the observed sentinel node–positive group had an axillary recurrence (odds ratio, .37; P = .725).

Conclusions: On the basis of a median follow-up of 27.4 months, axillary recurrence after SNB is extraordinarily rare regardless of nodal involvement, thus indicating that this technique provides an accurate measure of axillary disease and may impart regional control for patients with node-positive disease.



2nd one:

Is Axillary Dissection Obsolete for the Management of Breast Cancer?

3rd one:

How Much Is Enough? The Continuing Debate on the Axillary Lymph Node Dissection in Breast Cancer


( I do not have clinically positive lymph node disease)

Currently, it is accepted that ALND(axillary node dissection) is indicated when a patient presents with clinically positive axillary lymph node disease. As stated above, there is also agreement that no further ALND is indicated when the SLNB shows no disease. The major point of debate now is what to do with positive SLN in patients with otherwise clinically negative regional disease in early breast cancer. Studies have shown that the SLN is the only positive lymph node in 38% to 67% of cases when completion ALND was followed.7 This reflects dramatically changed presentation over the last decade of breast cancer with decreasing primary tumor size and lymph node positivity in patients with invasive breast cancer.8 Unfortunately, there is no proven method other than ALND that can identify the group with additional axillary nodal disease.

There is no clear indication that ALND provides a survival benefit. In the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04, ALND did not show survival benefit in patients without clinical evidence of axillary adenopathy. With 25 years of follow-up, no significant survival differences have emerged.9 Proponents of ALND argue that B-04 did not have enough patients in the trial to see a survival benefit. A meta­analysis of six trials evaluating the impact of ALND on breast cancer survival showed an average survival benefit of 5% with ALND (95% CI=1.7-8.0%, probability of survival benefit >99.5%).10 It warrants mention that these patients received no adjuvant therapy and that tumor size was larger in these studies than the tumor size we see now. This exemplifies a common problem in evaluating the issues surrounding breast cancer treatment. The problem is that only a small benefit can be seen many years after the studies are started, and that demonstration of the benefit requires large numbers of patients as in a meta-analysis.11 Thus, the data may no longer be applicable because of improved survival from other new treatment modalities.

4th one:

There is currently a large national clinical trial called Z0011, which is evaluating exactly that question. In this trial some patients are chosen (randomized) to receive a full axillary lymph node dissection if their sentinel lymph node is positive. Some patients are chosen to not undergo any further lymph node dissection, and they are carefully watched. All of these patients will receive chemotherapy. The two groups of patients will be compared to see if there is a benefit to doing the full axillary dissection if the sentinel lymph node is positive. Or, alternatively, they will be compared to see if there is a detriment to not doing a full axillary dissection if the sentinel lymph node is positive. This is still experimental, and should only be done under controlled circumstances after being enrolled in this trial by a participating breast cancer surgeon. Doing a full axillary lymph node dissection if the sentinel lymph node is positive is still considered “the standard of care” with which all patients should be treated. To do otherwise, risks under treating your breast cancer.

5th one:

Preliminary Outcome Analysis in Patients With Breast Cancer and a Positive Sentinel Lymph Node Who Declined Axillary Dissection

Limited information is available regarding the outcome of patients with positive sentinel node resection and observation after adjuvant therapy. The data presented in this study suggest that SLN biopsy without axillary dissection may be an acceptable alternative to completion axillary dissection. However, longer follow-up and prospective randomized studies are needed to delineate appropriate criteria for patient selection and confirm the safety of this approach. Patients should be encouraged to enroll in ACOSOG Z0011, which randomizes to completion dissection or no further surgery. On the basis of the preliminary results of this study, the latter approach is both ethical and justifiable.

6th one:
Axillary Dissection Is Not Required for All Patients With Breast Cancer and Positive Sentinel Nodes

7th one: a smaller trial but interesting results:

Sentinel node biopsy should be supplemented by axillary sampling in patients with small breast cancers

For patients with a positive sentinel node, the finding of additional positive nodes in the axillary sample strongly indicated the likelihood of further positive nodes in the axilla, therefore, justifying an axillary clearance. If the SNB was positive and the ANS(axillary node sampling-getting a few more after SN) negative, the likelihood of further malignant nodes being revealed by an axillary clearance was much lower (1/12, 8%) but with only this limited evidence we still feel that this figure justifies proceeding to ANC.

8th one:
Is Axillary Dissection Obsolete for the Management of Breast Cancer?

9th one:
[P-3] Micrometastases in the sentinel node: take it or leave it? -well I have macrometastases.

10th one:

Clinical practice guidelines for the care and treatment of breast cancer: 16. Locoregional post-mastectomy radiotherapy