Surgery was originally scheduled for 11:30 am but didn’t actually start until 1:15 pm; it took just a bit longer than two hours.

Ann’s surgeon, Dr. David P. Winchester, met with Nello and Ann’s sister, Sara, in the waiting room to review the results of the surgery. He said the surgery itself went well; there were no complications and blood loss was minimal.

Dr. Winchester found four lymph nodes that contained the radioactive marker injected the prior day. All four sentinel nodes were on the right side (even though the tumor was on the left). He removed two of them for frozen section pathology and one came back with metastatic disease. Based on this pathology report, Dr. Winchester performed an axillary lymph node dissection (ALND) on the right side. No nodes on the left-hand side picked up the marker or looked/felt suspicious so he left what remained of them intact.

Nello was not surprised that Dr. Winchester had found one metastatic sentinel lymph node on the right side. After all, Dr. Winchester had found two during the 2003 surgery when the breast tumor was less than 1 mm in size. This time the volume of the tumor was more than 100 times greater so why shouldn’t it have metastasized to the sentinel lymph nodes again?

Nevertheless, the ALND was a disappointment for two reasons:

• Lymphedema—swelling caused by the pooling of lymph—on Ann’s left arm was a side-effect of her 2003 surgery. Removing her sentinel nodes and the ALND probably caused it because whenever lymph nodes are removed, the chance of lymphedema increases. Lymphedema is a chronic condition that can be managed through massage and the use of compression garments but there is no cure. The swelling can be painful and disfiguring and puts the patient at risk for severe infection. The pooled lymph is an ideal medium for bacterial growth and the absence of lymph nodes leaves that area of the body less able to fight infection because the nodes are part of the immune system.
• Ann’s 2003 surgery left her with a lot of post-operative pain that Dr. Winchester attributed to the irritation and removal of nerves during the ALND. Dr. Winchester indicated that he performed the same procedure involving and removing the same nerves as during the prior surgery.

So, while not surprised, Nello was sad to learn of the right-hand ALND and fearful for what it might mean for Ann. Her surgical recovery might be very painful again. And, having both arms vulnerable to lymphedema might affect her quality of life.

Dr. Winchester indicated that Ann would be in the post-operative surgical recovery area for another hour. Nello and Sara made a few phone calls to friends and family to tell them the results of Ann’s surgery.

Soon, Ann’s gurney wheeled into her room and Nello and Sara were there to meet her. She was doing well and the nursing staff busily settled her into bed. Soon all the monitors and tubes were connected. Her intravenous line was moved from her arm to a leg, a lymphedema precaution. Finally, the staff taught her how to operate her bed controls and left her to rest. After sharing with Ann what Dr. Winchester had told Nello and Sara, the three of us had a short visit. Ann was also was not surprised that Dr. Winchester had found metastases in her lymph nodes and that he’d performed an ALND.

Ann was tired and it was time to leave so she could sleep.

Nello and Sara left for dinner at his favorite Thai restaurant in Glenview. Afterwards it was dark and getting quite late; it was time to pick up Alison from Nello’s parents. But, he and Sara just wanted to make sure that Ann was resting well. They drove back to the hospital and slowly opened the door to her room. It was dark but Nello could see that she was asleep and hear snoring that thundered over the background noise of monitor beeps and compression hose.

He was satisfied she’d be okay for the night.

Posted by Nello at April 8, 2010 9:11 PM

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