my name is eleni tousimis, i'm the chief of breast surgery atmedstar georgetown university hospital. i mostly treat women with breast canceror women that present with palpable breast lumpsor breast disease. i came to medstar georgetownuniversity hospital because i knew here i'd be workingwith nationally recognized breast cancer surgeons,reconstructive surgeons, as well as medical oncologists. this is so important to have a comprehensiveapproach to your breast cancer care.
i decided i wanted to be a breast cancersurgeon because i knew i wanted to treat cancer patients. i was so fortunate to have the experienceof doing my fellowship in breast cancer treatment atmemorial sloan-kettering cancer center where i really saw first handhow breast cancer was so curable and treatable,especially if it was caught early and the impact you can haveon a woman's life in such a favorable way, and howbreast cancer treatment is not just the surgical treatment,but it's actually psychological,
social, it's also an impacton future fertility, the body image, reconstructive techniques,and involves so many different aspects that i found it very exciting and rewarding. it's also a field that's changingso dramatically, that the options in the futureare just endless. when someone is facedwith breast cancer it's very scary and it's where they can really step backand they consider things in their life that are most important to them. they learn not to get worried aboutthe small things
and they really come out on the other sideof breast cancer treatment with a whole new outlookand vision on life, which is usually more hopefulthan it was in the beginning and it's really for me, in my job,an amazing experience to meet a woman and takeher through the whole process and see her come out onthe other side of the treatment really a more hopeful and differentperson than they were when i first met them.and that's a beautiful thing. when a woman is diagnosedwith breast cancer
depending on the size of her breastand her tumor size, she has many different surgicaltreatment options. basically, these are divided downinto either lumpectomy or mastectomy. a lumpectomy means that we removethe tumor with the normal rim of breast tissue around it and take someadditional margins in order to prevent a future re-excision. a mastectomy means that we preservethe skin envelope of the breast, remove the breast from underneath,and then a plastic surgeon, at the same surgery would reconstructthe breast with either
some tissue from another part of the bodyor an implant reconstruction. the risk of local recurrence after alumpectomy is slightly higher than local recurrence after a mastectomy. it's approximately 7% chance the tumorrecurring in the same breast in 10 years versus about a 1%-2% of local recurrenceafter a mastectomy in 10 years. women commonly ask me, why is there anychance of the tumor coming back after i've had a mastectomy?which is a great question, because you wonder,if i have my breast removed, why should there be any chance thatit could come back?
and the answer is that it's not possiblefor any surgeon to remove 100% of the breast tissue.it actually sticks to the skin and even after a mastectomy there's a verythin layer of residual breast tissue underneath the remaining skin.so women who've had a mastectomy don't need mammography in the future,however, they would still return to their breast surgeon for examinationof their skin after their surgery. i usually do this every 6 monthsfor the first 5 years after a mastectomy, then every year thereafter. when a woman is deciding whetherto undergo a lumpectomy or mastectomy,
it's important to know that the survivalbetween the two techniques is the same. a lumpectomy is performed by removing the tumor and a normal rim of breast tissuearound it. at the same time, i remove additional tissuefrom that lumpectomy area in order to assure that the marginsare all clear. if the margins are not clear,then the patient would have to return to the operating roomfor an additional wider excision of more margin. by removing theadditional margins at the first surgery, this would decrease the chance of havingto go back for a future excision
of a wider margin. the sentinel lymph node is the gate keeper lymph node of all the lymph nodesunder the armpit. if a tumor in the breastwas to spread it would normally spreadto the sentinel node which is the first lymph nodeunder the armpit, before travelling to the otherlymph nodes. we have a way of finding thesentinel node during the surgery by injecting a dye into the breastright before the surgery.
the dye gets taken up by thelymphatic circulation in the breast, travels to that lymph node, and that's how i find it during the surgery. while the woman's asleep, i removethe lymph node and send it to the pathologist. if the lymph nodedoes not have any cancer in it, that means that none of the other lymph nodes have cancer in them either. lumpectomies are performed undera twilight sleep and basically, local anesthetic is used during the surgery, which lasts 8 hours after the surgery.so when the patient wakes up, she feels good and she goes homethe same day.
mastectomies are performed undergeneral anesthesia. i use a local anesthetic during the mastectomy which lasts for 3 days so when the patient wakes up, shehas comfort for 3 days after the surgery. this decreases the amount of painmedication that she'll need after general anesthesia,and actually will improve her post-operative course and decreaseher length of stay in the hospital. the traditional radiation treatment aftera lumpectomy is a 6-week treatment which is monday through friday for about 5 minutes each day. this type of treatment actually treatsthe whole breast
and prevents the tumor from coming back in the future. we know that when a tumoroccurs in the breast, more than 90% of the timeit will reoccur in the same area where the original tumor was.so because of this, we found that instead of treatingthe entire breast with whole-breast radiation, that it's just as effective to treat thelocal area where the tumor was removed with targeted breast radiation. there are 2 forms of targeted breast radiation.
one is called intraoperative radiation therapy where a single dose of radiationtherapy is given during the surgery after the tumor has been removedand this one dose of radiation therapy can replace the 6 weeks of whole breast radiation. but one dose of intraoperativeradiation therapy just radiates the area within the lumpectomy bed and spares the rest of the breast tissue any radiation treatment. if a woman was to get a future breast cancersay 10 years from now, in the same breast but in a differentarea of the breast,
she could theoretically undergothe same procedure again and avoid a future mastectomy. so intraoperative radiation therapyis a single dose of radiation therapy that we give during the surgerythat can theoretically replace the 6 weeks of whole breast radiation. women that are candidates for thistype of radiation therapy are women with a small tumor, so the tumorhas to be less that 2cm in size, it has to be a favorable type of tumorwith estrogen receptors on it, and the women have to be overthe age of 50 years old.
all the margins around the tumorduring a lumpectomy have to be clear and the lymph node alsohas to be normal in order to undergo this typeof radiation therapy. the benefit ofintraoperative radiation therapy is that by giving one dose of radiationtherapy to the lumpectomy bed during the surgery and avoiding 6 weeksof whole breast radiation therapy, the woman has spared the restof her breast tissue from foregoing radiation therapywith its possible side effects. also, if she gets a future breast cancer,she can repeat the same procedure
and doesn't necessarily have toundergo a future mastectomy. it also has a logistical advantagewhere the woman does not have to go to a radiation facilityevery day for 6 weeks. instead, they get one dose while they'reasleep during the surgery and the radiation has been completed. it's not a painful procedure, becausethe woman's under anesthesia during the radiation treatment. this form of radiation therapy actuallybegan in england several years ago and was trialed in europe inmultiple countries.
the first publication proving that onedose of intraoperative radiation therapy was equal to the 6 weeks of radiation therapy, was published in the lansing journalin 2010. the patients who have undergoneintraoperative radiation therapy have been overwhelmingly enthusiasticbecause from the logistical standpoint now they've first of all avoided havingto go to a radiation place for 6 weeks and the second is, that they know thatthey're just treating the lumpectomy bed and they're sparing the rest of theirbreast tissue any unnecessary possible side-effects.
the most common side-effect i seefrom whole breast radiation is that some women can get a sunburn to the breast or some women can get breast changesexternally where the outside of the breast looks a little bit smaller than the other breast. however, with intraoperative radiation therapy, because of the localized treatment, you don't see these physical changesbecause the radiation is delivered only to one area. so thus farin our experience, we haven't seen any cosmetic changesor poor outcome for this 1 dose ofradiation therapy.
this treatment is not for everybody, we choose the patients selectively. they have to be older than the age of 50with small tumors less than 2cm in size with a favorable histology and no lymph node involvement. we do have a 5-day balloon catheter radiation treatment which is also a targeted radiation treatmentthat only treats the lumpectomy bed. it's performed a little bit differentlythan intraoperative radiation. instead of the one dose during the surgerywhile the patient's asleep, this is a 5-day treatment after the surgery. during the lumpectomy, a balloonis inserted into the lumpectomy bed.
once the margins have been cleared by pathology, then the radiation oncologist deliversradiation therapy through the balloon twice a day for 5 days. this is alsotargeted radiation that is only radiating the areaaround the lumpectomy bed. once the radiation is completed,the balloon is deflated and the balloon is removed in the radiationoncologist's office. after a woman's been treated forbreast cancer, i follow all my patients every 6 monthsfor 5 years. the reason for this is that if the tumorwas to reoccur
the risk of the reoccurrence is the highest in the first 5 years. after 5 years she graduatesto a yearly follow-up. traditionally, we've preformed the skin sparing mastectomy which means that the surgeon sparesall the skin and removes the nipple and the ringaround the nipple. in the past 5-10 years we've been savingthe nipple and the ring around the nipple which is called "nipple-sparing mastectomy". cosmetically, this is much superiorto the skin sparing techniques of the past. basically, the reason that we used to removethe nipple and the ring around the nipple is
that there's actually breast tissue insideof the nipple. so by retaining the nipple there's a riskthat you could get a future breast cancer in that tissue. however, the studieshave shown that this risk is very low so from a cancer standpoint we feelthat it's safe to retain the nipple as long as the cancer is notnear the nipple area and we also biopsy the tissueunderneath the nipple during the surgery to assure that there's no cancer cellsin that space. if there's no cancer cells in that biopsyunder the nipple, then we feel as thought it's safe to save the nipple.
here at medstar georgetown university hospital we have an extensive experience withperforming nipple-sparing mastectomies. we either perform the mastectomy through the bra line which has a superior cosmesis, butdepending on the location of the tumor we actually might position the scareither around the nipple area to get better access to the tumor,or on the side of the breast. so we approach each patient differentlydepending on their breast size and their tumor size, and we actuallyapproach each patient as a team together with the reconstructive surgeon
to come up with the best treatmentoption for the patient. a nurse navigator is a specially trainednurse in breast cancer oncology who's really the point person inthe multi-disciplinary team. so if the patient needs any socialservices, any extra support, nutritional advice, any questions aboutsurgical treatment, they can really make contact with that personto help guide them through the process. here at medstar georgetown university hospital we have a very well establishednurse navigator system. when a patient comes into the breast cancercenter they meet the nurse navigator
and she basically provides them withmultiple resources that every breast cancer patient needs.this would include nutritional support, support groups, as well as physical therapy,and also, when the patient is having the surgery, the day of surgery -a patient navigator actually greets the patient in the morning,stays with the patient for the entire day, through the entire surgical process,to make sure that they find their way through the hospital,get to the services that they need and feel comforted and reassuredduring the surgery. when a woman is faced with breast cancerit's not just the breast cancer surgeon
that's involved in their treatment, it's actually a multi-disciplinary approach.there's multiple doctors that are involved in the care of a breast cancer patient. the nurse navigator is really the pivotal person, the point person, to really help coordinate all the careof the patient. it's very important when you're decidingon your breast surgeon, first of all that you know your breastcancer surgeon is specially trained. nowadays, breast cancer treatmentis so specific and there're so many different treatmentoptions that it's very important to know
that your breast cancer surgeon is trainedin all these different treatment options so you can have all of these optionsavailable to you. when you're interviewing your breastsurgeon and meeting them, it's important that you feel as thoughyour breast cancer surgeon is compassionate, connected with youand sensitive to all of your needs. if you feel like you have this connectionwith your surgeon, you're going to have a better experienceand ultimately you're going to do better. men who are diagnosed with breast canceris very rare, but i have had an extensive experience treating men with breast cancer.
each year in the united states,approximately 1,600 men are diagnosed with breast cancer.unfortunately, it's so rare, that the man doesn't normally think thathe would actually have breast cancer when he feels a lump behind the breast,and their physician a lot of times doesn't think that it could be breast cancer. so a lot of times, when a manpresents with breast cancer, they present at a later stage with a larger tumor because it's gone diagnosed. normally when a man presents with breast cancer
he presents with a palpable mastunderneath his nipple. because the man's breast isthe size of about a silver dollar which is centered on the nipple.so it normally doesn't present on the side or where the breast bone is, it normallypresents right behind the nipple. because the man's breast is so small,he's not a candidate for a lumpectomy. and the standard treatment for a manwith breast cancer is to undergo a mastectomy with a sentinel lymph node biopsy. so a man with breast cancer wouldundergo a mastectomy which involves removing the entire nippleand ring around the nipple
as well as checking the sentinel lymph nodeunder his armpit. most of these tumors are estrogen receptor positive so he would be a candidate fortamoxifen therapy after mastectomy. stage for stage, when you comparemen to women with breast cancer, there's no survival difference.however, because most men who present with breast cancer arepresenting with larger tumors at a later stage, their outcomeis less favorable. at medstar georgetown university hospitalwe have a very well established and robust genetics program.at any day of the week
a patient is able to have genetic testingfor the breast/ovarian cancer gene. this is very important for select patientswho have a strong family history of breast or ovarian cancer. genetic testing is covered by insurance. obviously each insurance company isdifferent and we have each patient check with a geneticist to confirmthat their insurance covers this test. genetic testing is very importantfor select patients who have a very strong family history of breastor ovarian cancer because if a woman carries the genefor breast cancer
she basically has an 85% lifetime riskof getting breast cancer. and if she has the gene, she hasa 30%-50% chance of getting ovarian cancer. ovarian cancer screening is very difficult, so this is the cancer that we're actuallymore concerned about. it's harder to follow than breast cancer screening. so usually, when women have the breast and ovarian cancer gene we recommend that they prophylactically have their ovaries removed by the age of 40.
prophylactic mastectomy is a reasonableoption for women who have the breast cancer gene. women who carry the gene have an 85% lifetime riskof developing breast cancer. so because the risk is so high theydo have options of how to be followed. one would be a prophylactic mastectomywhich would reduce the risk of getting a future breast cancer by over 95%. or they could be followed closely,which would include breast surveillance with yearly breast mri and mammography as well as a clinical breast examevery 6 months
with a specially trained breast surgeon. the surgical treatment options forprophylactic mastectomy have improved dramatically over the last 5-10 years. most women who are undergoingthis procedure who have no evidence of cancer in their breast are opting to undergo nipple-sparing mastectomy if their breast size is a candidate for this. very large-breasted women are notgood candidates for nipple-sparing mastectomy.
having comfort through your breast cancertreatment is very important, because breast cancer treatment is not just one surgery and you're done. it basically can involve a 6-monthtreatment process. between the surgery, the reconstruction,possible chemotherapy and possible radiation therapy, the treatment process can go overa 6-month period. that's a very long period of time.it's very important to have a good support systemboth at home and both in your medical community at the breast center, where you feel
as though all of your needs and your care is being addressed. so it's very important that you finda place where you feel comfortable and you feel that you can approacheveryone, ask your questions, get your answersand feel good about your care. anesthetic techniques for breast cancersurgery is very important. because by providing the patient withthe best possible anesthesia you ensure that their post-operativeexperience is a favorable one. they will have a shorter hospital staywith less pain and faster recovery. some of the different anesthetic optionsthat we offer is
for all lumpectomy patients -they undergo twilight sleep which is basically just like takinga deep nap with no breathing-tube and during the surgery i perform a local nerve-block that numbs-up the local areafor up to 8 hours after the surgery. so when the patient wakes up,she feels good, has no pain and goes home the same day. most of the patients don't even requireany pain medication once they're at home. for women undergoing mastectomy,in addition to the general anesthesia i perform a local block to the mastectomyarea with a new local anesthetic
that lasts up to 3 days after the surgery. this has been shown to decrease the post-operative pain, the amount of pain medicationthat a patient will require, decreases their hospital stay and makes their post-operative recovery more favorable. with most cancers, the earlierthat a patient is diagnosed, the smaller the tumor, the bettertheir chance for cure. nowadays, with the close surveillance, screening mammographyand breast self-examination
as well as best sonography and breast mri, we're catching tumors much earlierand smaller than we were in the past. so this area of cancer treatmentis very hopeful. because women are diagnosed much earlier, the treatments have become less invasive,so preserving the shape of the woman and also offering very goodsurvival and outcomes.
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