Breast and Melanoma Surgical Oncology in Rochester

Amy Degnim, M.D., General Surgery, Mayo Clinic: We are able to achieve really wonderful cosmetic results with this procedure.

Jeff Olson: Breast cancer surgeon, Dr. Amy Degnim says the first phase of this team procedure is nipple-sparing mastectomy, to remove cancerous breast tissue but if possible save all the skin including the nipple and areola.

Dr. Degnim: So that after a reconstruction the result looks as natural as possible.

Jeff Olson: The natural look is furthered during the second phase of the surgery: Pre-pectoral reconstruction.

Valerie Lemaine, M.D., Plastic Surgery, Mayo Clinic: Once we know that clear margins have been obtained, then I'm called into the operating room.

Jeff Olson: Plastic surgeon Dr. Valerie Lemaine says unlike traditional reconstruction with the implant behind the chest muscle, in a pre-pectoral procedure the implant goes in front.

Dr. Lemaine: The main advantage is the implant is positioned where the breast used to be anatomically. Also, when we do surgery without manipulating a muscle, there is definitely less pain.

Dr. Degnim: We want women to know that this is an option for many of them.

Jeff Olson: For the Mayo Clinic News Network, I'm Jeff Olson.

Judy C. Boughey, M.D., Breast/Melanoma Surgery, Mayo Clinic: When surgical resection of breast tissue occurs, pathological evaluation -- the review of the tissue under a microscope -- is a critical component to optimal patient care. While pathologic information can take days or weeks to obtain, at Mayo Clinic this tissue is evaluated by our pathologists while you are asleep in the operating room using an immediate frozen section method.

Frozen section analysis provides benefits on multiple levels. For patients undergoing excisional biopsy of benign breast lesions, it allows intraoperative confirmation that the tissue removed was benign. Importantly, for those cases where an unexpected malignancy is identified, this information can be given to the surgeon during the operation so that additional margins can be resected if necessary. This also means that the patients and her family can be informed by the surgeon about the pathologic findings on the day of surgery, and additional consultations or procedures planned, as needed.

For patients undergoing preventative or prophylactic mastectomy to decrease the long-term risk of breast cancer development, an unexpected cancer is identified in just a few percent of cases. In our practice, we routinely prepare for that possibility with the injection of a radioactive tracer in the breast that is undergoing preventative mastectomy. Once the breast is removed the pathologist evaluates the tissue. In cases where no cancer is identified, no lymph nodes are removed. If a hidden (or occult) cancer is identified, the surgeon proceeds with sentinel lymph node surgery. This preparation helps avoid the potential need for a second operation in the setting of a surprise finding of cancer.

This immediate and close collaboration between the breast surgeons and the pathologists for each individual minimizes the need for further operations and also decreases the waiting time for patients to find out the pathology from the surgical procedure.

Tina J. Hieken, M.D., Breast/Melanoma Surgery, Mayo Clinic: Hi, I'm Tina Hieken. I'm a surgical oncologist and an associate professor of surgery, and one of the breast surgeons here at Mayo Clinic in Rochester. Today I'd like to talk with you about lymph node surgery that's done for women with newly diagnosed breast cancer. Sometimes the lymph node surgery is the part of breast cancer treatment that women have the greatest fears and concerns about. One of the reasons that we evaluate lymph nodes for women with newly diagnosed breast cancer is to make sure that we stage the disease accurately, and that we provide you with the best treatment.

Our first step in our practice here in looking at lymph nodes is to do an axillary ultrasound. So we look at the lymph glands under the arm but we call the axillary lymph nodes using an ultrasound probe. For women who don't have lymph nodes that are enlarged that we can feel, most of the time when they have the lymph node ultrasound, the nodes will be normal but sometimes they will look abnormal. In those cases, we have you get a little needle biopsy of those lymph nodes so we know about them ahead of time. For those cases where the lymph nodes are normal -- and that's most women -- the next step is to discuss with you what we do from a surgical standpoint to manage the lymph nodes. For most women with normal lymph nodes under the arm and normal lymph nodes on the ultrasound, what we recommend to stage the lymph nodes and treat them is to do a sentinel lymph node biopsy. This involves getting an injection into the breast of a tracer done prior to surgery, and then at the time of operation, an injection of a blue dye that's done while you're asleep. This dual tracer method allows us to be really accurate. Those tracers actually trace out where cells might leave from the breast into the lymph glands if they were to travel from the primary breast tumor into the lymph nodes under the arm. Then in operation, we remove those lymph nodes -- usually we remove one or two or three; sometimes more -- and give them to the pathologist.

There's been some recent studies that have suggested that for some women who undergo breast conserving treatment (a lumpectomy) along with the sentinel lymph node biopsy, especially women with small tumors, especially women whose tumors are estrogen receptor-positive and women who plan to have radiation to the whole breast after their lumpectomy that we don't need to take out more lymph nodes from under the arm if there is a very small amount of cancer in only one or two lymph nodes.

Usually we remove two or three sentinel lymph nodes at the time of operation; sometimes we only find one and sometimes we may remove five or six or more. Usually we have this information about the lymph node status at the time of operation and the pathologist lets us know not only the number of involved nodes but the size and the extent of the nodal involvement. Sometimes, however, we think that everything is fine on the day of operation and we receive that information only when the pathologists review the permanent sections where they look in greater detail at the lymph nodes that we've removed at operation. If they find only a little bit of cancer in one or two lymph nodes, it's unlikely that we would recommend that you come back and at a second operation have surgery to remove more lymph nodes from under the arm; however, sometimes they may find lymph nodes that are large in size, that have large size metastasis in them, or ... when the cancer has spread outside of the lymph nodes that may make us want to make a recommendation to do more surgery. We would discuss the risks and benefits of axillary lymph node dissection in a second operation with you and make a decision about how best to proceed.

When the pathologist finds only a few abnormal cells or small clusters of cells in the lymph node, then we might not want to take more lymph nodes out from under the arm. However, sometimes when the pathologist finds either a large size lymph node metastasis or multiple nodes, or lymph nodes with spread of the cancer outside of the capsule of the lymph node, we may wish to take more lymph nodes from under the arm. What happens if we do this? Well the complications that can occur with either a sentinel lymph node biopsy or a lymph node dissection are pretty similar. The most common complication is numbness under the arm in the inner upper arm after surgery that sometimes goes away but sometimes persists, and the most feared complication is swelling of the arm; that can be swelling in the hand, the forearm, the arm, or even in the tissues of the breast or the chest wall.

One recent study that looked at sentinel lymph node biopsy patients and patients who had a sentinel lymph node biopsy followed by an axillary lymph node dissection found that the percentage of women who had swelling of the arm or lymphedema three years after surgery was about 14% in the women who needed more lymph nodes taken out -- so a sentinel lymph node biopsy and an axillary dissection -- and about 7% in the women who had a sentinel lymph node biopsy alone. There are some things that we do from a technical standpoint to minimize the risk that you will develop lymphedema.

It's really encouraging that we have made so many advances in the surgical treatment of breast cancer over the last few years, and there's a lot of exciting areas of research and investigations to improve care. Here, we really focus hard on working together as a multidisciplinary team to formulate a bunch of treatment plans for patients. We're also here to help you sort through all these options and formulate a choice that's the best personal choice for you.

Jane Brandhagen: It was a shock, you know. I was already in my mind picking out wigs and thinking how much longer I'd have here. I was terrified.

Dennis Stoda: Jane Brandhagen was facing the news one in eight women will hear-- she had breast cancer. Her yearly mammogram had revealed a small tumor. She wanted to treat it very aggressively and wanted to wrap up her treatments as quickly as possible.

Jane Brandhagen: I could have gone with a full-out double mastectomy, and then I would be done.

Dennis Stoda: Mayo Clinic surgeon Dr. Tina Hieken says it's the main decision breast cancer patients have to make, to remove the entire breast in a mastectomy or have breast preserving surgery. Because Jane's cancer was caught early, Dr. Hieken says she was a good candidate for a new option which would also reduce her entire treatment to just a matter of days.

Tina J. Hieken, M.D., Breast/Melanoma Surgery, Mayo Clinic: So for those patients who have no evidence of disease in the lymph node and have small tumors that are completely removed with a lumpectomy, they leave the operating room with a catheter in place. It's an outpatient procedure.

Sean Park, M.D., Ph.D., Radiation Oncology, Mayo Clinic: So this is a breast model with the brachytherapy catheter device inserted into the lumpectomy cavity.

Dennis Stoda: Called brachytherapy, the catheter delivers the necessary follow-up radiation treatments internally in a fraction of the time of standard external radiation therapy.

Dr. Park: Treatments are done over five week days, twice a day, approximately six hours apart for a total of 10 treatments.

Dennis Stoda: Brachytherapy itself is not new, but patients routinely have to wait two to four weeks for a second surgery to implant the catheter, because that can't happen until a pathology report comes back saying it's OK to proceed. So Dr. Park and Dr. Hieken designed a treatment regimen to eliminate the waiting time by using a single surgery. First, special dyes are injected to identify any cancer cells that may have spread beyond the tumor site or to the lymph nodes under the arm. That allows a pathologist to immediately screen the lymph nodes and a safe margin of tissue removed from around the tumor while the patient is still under anesthesia. Once the all-clear is given, the surgery continues with a second incision to insert the brachytherapy catheter and expand it, filling the lumpectomy cavity. The very next day, the patient's radiation plan is mapped out during a simulation. The following morning, the brachytherapy begins using a computer-controlled robotic machine which manipulates a single radioactive seed smaller than a grain of rice within the implanted catheter.

Dr. Park: The radioactive seed will travel through the cable into the patient, into the catheter, and stop at different locations that we program it to for a different amount of time, and that shapes the radiation dose.

Dennis Stoda: Unlike externally-delivered radiation, Dr. Park says brachytherapy is delivered more precisely to the target area without passing through healthy tissue.

Dr. Park: Meaning the breast tissue, the chest wall, lung tissue, for left-sided cancer patients, importantly, the heart tissue.

Dennis Stoda: It's hoped the expedited brachytherapy option encourages more women to receive the full benefit of their recommended post-surgery radiation, particularly those living far from a treatment center.

Dr. Hieken: So with standard therapy, they're driving a couple hundred miles round trip each day for three, four, or six weeks. The actual rate of completing the radiation may be as low as 60% or 70%.

Dennis Stoda: Jane says she leaped at the chance to be part of a pilot study that completed her brachytherapy in just three sessions.

Jane Brandhagen: So from Monday to Friday, five days, that was surgery and radiation all in five days, which I think is amazing.

Dennis Stoda: Jane and other patients in the study will continue to be followed for five years to verify that their long-term health and survival is just as good as those receiving standard radiation procedures. For the Mayo Clinic News Network, I'm Dennis Stoda.

Tina J. Hieken, M.D., Breast/Melanoma Surgery, Mayo Clinic: There are several approaches a woman can choose from to decrease your risk of future breast cancer.

Surgery to remove both breasts is one approach to breast cancer risk reduction. Generally, surgical risk reduction is most appropriate for women at the highest risk for breast cancer, those with a known dangerous genetic mutation or women with a very strong family history of breast cancer. Surgery to remove both breasts is estimated to reduce the risk of subsequent breast cancer by 90 to 95 percent. This means that for a woman whose estimated lifetime risk of breast cancer is 40%, the chance that she will be diagnosed with breast cancer in her lifetime after bilateral risk reducing mastectomies is reduced to around 2 to 4%.

There are three main types of bilateral risk reducing operations that can be performed. Total mastectomy is generally done without reconstruction. This operation involves removal of the nipple areolar complex and the skin overlying the breast, so that after complete removal of the underlying breast tissue, the incision can be closed in a smooth flat line. This attention to closure is important so that a woman can wear a prosthesis comfortably inside, a specially design bra or swimsuit if she desires.

A second type of risk reducing mastectomy, a skin-sparing mastectomy. In this operation, the nipple areolar complex is removed, but an envelope of the overlying breast skin is preserved while all of the underlying breast tissue is removed. This permits breast reconstruction to be initiated at the same operation.

The third type of risk reducing mastectomy as nipple-sparing mastectomy. In this operation, the skin of the breast including the nipple areolar complex is preserved, the underlying breast tissue is completely removed and breast reconstruction is initiated at the same operation. In suitable women, the incision for a nipple-sparing mastectomy can be placed as a hidden scar on the under surface or side of the breast. This creates the most natural appearing reconstructed breast.

At Mayo Clinic, our multi-disciplinary and high-volume practice includes highly skilled breast oncologic surgeons and reconstructive plastic surgeons. Our team has special expertise in these advanced procedures. We work together as a team with women who want breast reconstruction following mastectomy. Based on a woman's individual circumstances and her preferences, our team designs an optimal plan for surgical risk reduction. Our goal is to provide maximal cancer risk reduction with the very best possible aesthetic outcomes for each woman.