W. Lee Bourland, Jr, MD

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This questionnaire prepared by W. Lee Bourland, Jr. MD for General Surgery Associates of North Texas (GSANT), and is restricted for the use of GSANT members except with written consent from Dr. Bourland. 

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How to know if you're getting good advice about Breast Disease and Breast Cancer

Twenty Questions to ask about your Surgeon

During the past eighteen years in my medical practice, I’ve had a direct impact (I hope a positive impact) on 	breast cancer treatment for over a thousand women confronting this diagnosis. During this time span the DECISION 	MAKING process has become increasingly complex. Breast cancer is varied in its presentation and biological behavior, 	and while awareness of disease variability is a necessity for clinical practitioners, the array of choices in treatment 	can be confusing for the individual patient. Clear-cut decisions about crucial aspects of an individual woman’s 	care are difficult to discern, a situation that tactically leads to uncertainty. Information tends to sound less 	credible when it is qualified by statistical estimates not fully comprehensible to most patients or their families. 	I never really thought it was fair to drop a load of information on some bewildered patient and then dismiss them 	with the ultimatum to "call back next week with your decision".

As a surgeon, one of those difficult decisions that I influence in women with breast cancer is whether or not 	to remove regional lymph nodes in order to clinically "stage" a particular breast cancer. STAGING is 	the process of assigning a cancer at the time of its diagnosis to a numerical category that implies something about 	its future. Staging also allows more accurate comparisons of various treatment strategies among patients whose 	cancers have similar attributes. Staging is an attempt to place a rational reference device over the varied spectrum 	of breast cancer in order to make choices that we as patient and doctor can live with and confidently state: "Given 	my choices, I chose the best treatment plan for me as individual".

Staging criteria are somewhat varied but they usually include some measurement of tumor size and some assessment 	of whether or not the cancer has metastasized to regional lymph nodes i.e. tiny aggregates of immunologically active 	tissue through which the extra-cellular fluid of the body circulates as it leaves the breast. Most of this fluid 	is circulated through lymph nodes under the arm, a region of the body usually referred to as the "axilla"; 	hence the term axillary lymph nodes. Operative removal of these nodes is referred to as an axillary lymph node 	dissection (ALND). THIRTY-FORTY PERCENT of women with breast cancer will demonstrate REGIONAL NODE METASTASES. 	Detection of lymphatic cancer usually leads to some recommendation for systemic treatment (chemotherapy or hormone-antagonist) 	and places the cancer into a less favorable stage in terms of overall survival. Of course lots of breast cancer 	patients should use SYSTEMIC THERAPY (some would say almost all invasive cancers should be treated with anti-cancer 	drugs). I submit to you without further elaboration that knowledge regarding axillary node involvement is a useful 	piece of information to plug into the treatment scheme.

New data about how cancers spread within the network of axillary nodes combined with some time-tested technology 	has made the staging of the axilla an easier operation with fewer unpleasant and harmful side effects for the patient. 	This process has become known as a SENTINEL NODE BIOPSY (SLND). Here are the commonly asked questions about the 	procedure.

10 FAQs About Sentinel node Biopsy for Breast Cancer


 		The sentinel lymph node is the first node(s) in the body to come into contact with the cancer cells as they leave 		the organ of origination and start to spin off or spread into the rest of the body’s tissues. In the context of 		breast cancer the usual location for the sentinel node (SN) is under the arm, although for cancers on the inner 		or medial aspect of the breast, the SN may be inaccessible in nodes beneath the breast bone or sternum.

WHY IS THE SN IMPORTANT IN THE TREATMENT OF BREAST CANCER?


 		Testing for metastatic cancer cells in the SN allows accurate staging using information from a single lymph node 		or a small number of nodes. Since the risk for positive axillary nodes ranges from 0 to 40 percent, many women 		could undergo SLND (Sentinel lymph node dissection) rather than complete axillary lymph node dissection (ALND) 		and in the process gain accurate information about the rest of the lymph nodes in the network without enduring 		the trauma of ALND. In other words IF THE SN NODE(S) WERE FOUND NEGATIVE, one would not have to remove more or 		excessive numbers of lymph nodes to get all the information needed to accurately stage the axilla and the cancer.

WHAT ARE THE ADVANTAGES OF SLND OVER TRADITIONAL AXILLARY NODE DISSECTION (ALND)?

 
 		Many times in counseling patients I am asked by those who still have their wits about them: " Well lymph nodes 		must be there for a reason"? And they’re absolutely right. The lymphatics are a vital part of the micro-circulation. 		They serve as channels through which the base liquid of the body ( the extra-cellular fluid) is re-routed into 		the circulatory system. The lymph nodes serve to filter the liquids and to maintain the sterility through the actions 		of the immune system, elements of which are found in the nodes in abundance. Removal of critical numbers of lymph 		nodes interrupts the re-routing process and can lead to congestion of the tissues served by regional           lymphatics. 		Sentinel lymph node biopsy limits the disruption, and makes congestion of the arm or the breast, a condition called           LYMPHEDEMA, an unlikely event. In addition since the trauma of surgery is decreased, patients have fewer complaints 		of nerve injury or PARESTHESIA after SLND. Clinical lymphedema does not occur in everyone undergoing an axillary 		node dissection, but it occurs often enough to be a problem for many especially if they are athletic and active, 		and it is incurable and life-long.

WHO IS A CANDIDATE FOR SENTINEL LYMPH NODE BIOPSY? 


 		Women with a biopsy-proven invasive breast cancer should consider SLND as an alternative to a traditional ALND. 		Remember that non-invasive or in situ carcinomas seldom require ANY dissection of the axillary nodes since 		non-invasive cancers by their very definition have not invaded the spaces around the mammary duct and therefore 		lack access to the rest of the body.


 		Several circumstances disqualify patients for SLND and make traditional ALND a better choice. Patients who have 		obviously INVOLVED lymph nodes should have a complete axillary nodal dissection because it’s always a good policy 		to remove any cancer accessible to the surgeons. I’ve had problems accurately mapping the axilla in patients who 		have had large biopsies or "lumpectomies". Something about the surgical procedure itself disturbs the 		lymphatic circulation and interrupts the flow from the breast into the underarm and makes the precise identification 		of the "sentinel" node impossible. The LOCATION of the primary cancer may (inner aspect of breast or 		axillary tumor) interfere with nuclear isotope labeling or indicate a sentinel node in an inaccessible position 		like the intra-thoracic internal mammary nodes. Finally patients with LARGE tumors (>5 cm) should consider having 		chemotherapy first prior to any definitive treatment of the breast or the axilla because the disease is presumed 		to be systemic anyway for Stage III cancers.


 		Remember that the lymphatic system is part of the circulatory system and microscopic in proportion. In order to 		identify the precise anatomy of this system, some type of marker or brilliantly-colored dye has to be injected 		into the breast near the tumor site and followed as the component parts of this microvascular tree fill. Ultimately 		the lymph nodes under the arm pick up whatever tracer has been injected into the breast. At Presbyterian Hospital 		we employ first a RADIO-ISOTOPE which is injected into the breast a few hours before scheduled surgery in the Department 		of Nuclear Medicine AND secondly a neon-BLUE DYE which is used intra-operatively. I use both techniques currently 		to identify the first or first few nodes demonstrated in the axilla. Research has shown that when one or both techniques 		are successful, then we can be confident that the "sentinel" lymph node has been identified. It is common 		to identify more than one node by either it’s radio-active signal or by the characteristic blue coloration. 

IS ADDITIONAL TREATMENT NECESSARY AFTER SLND?


 		Generally speaking, YES, but further surgery may not be indicated depending on careful pathologic analysis of the 		lymphatic tissues submitted. Our pathologists at Presbyterian take the individual nodes and study them in great 		detail utilizing advanced biochemical and immunologic methods. If the SN contains even a tiny microscopic deposit 		of cancer (a micrometasis), then other nodes are potentially involved and a more extensive ALND is performed at 		a later date. On the other hand if the SN is NEGATIVE, the inference is that the REMAINING NODES are NEGATIVE ALSO 		and that the axilla has been successfully staged. Assuming that no further surgical treatment of the breast is 		necessary, patients then proceed to systemic chemotherapy or radiotherapy depending on which treatment is recommended.


 		The greatest risk is that the sentinel node will test negative and not accurately signal metastatic cancer within 		the underarm region or axilla. In the series reported in the world’s scientific literature, the percentage of false 		negatives is about two per cent at several institutions. The chief safeguard against a false negative result is 		the experience of personnel involved, their insistence on strict criteria for the identification of the sentinel 		nodes and their inclination to extend the procedure should the mapping techniques not meet strict criteria. The 		amount of radiation exposure with the isotope portion is negligible, and the blue dye is harmless other than giving 		the patient a Smurf-like hue for a few hours. There’s usually a bluish stain around the "lumpectomy" 		for a few weeks.


 		Theoretically the procedure should be quicker than a standard ALND, usually about 45 minutes. If the procedure 		includes additional breast surgery add another 30-45 minutes to the total. The overall time is shorter for thinner 		patients who don’t have a bulky underarm. I usually have the patients lightly anesthetized especially if they are 		having the tumor site re-excised at the same time. 

SHOULD SENTINEL LYMPH NODE BIOPSY BE CONSIDERED AN EXPERIMENTAL PROCEDURE?


 		At Presbyterian Hospital Dallas we are offering the procedure to selected individuals with proven breast cancer 		"off-protocol" or without an immediately following ALND. In my opinion the procedure has met the challenge 		of thorough clinical testing and should NOT be considered an experimental procedure. In the world’s scientific 		literature the false negative rate is about 2%. I think that figure which has been reported from various other 		institutions and continents is sufficiently low and the benefits so obvious that it is time to put theory into 		practice. My view is influenced by a personal experience treating over one thousand breast cancers and the consequences 		of that treatment including many women who suffered from incurable lymphedema after a totally negative           ALND.

Senitel Node site confirmed with Gamma Counter

Blue Stained Lymph Nodes removed through small incision

Breast incision closed after lymph node biopsy

Typical specimen sent to pathology for analysis

(click on each image to view larger version)

Improving Imaging Methods for Breast Cancer Detection and Diagnosis

During the past eighteen years in my medical practice, I’ve had a direct impact (I hope a positive impact) on breast cancer treatment for over a thousand women confronting this diagnosis. During this time span the DECISION MAKING process has become increasingly complex.

I saw a long time patient yesterday in the office.  Gloria drops in once a year for a checkup. She brought me a funny  birthday card and we teased each other about the effects of gravity and  aging. During her exam she detailed for me how much fun she and her  husband Francis are having running a small entrepreneurial business  (home remodeling). She is a perfectly healthy 55- year old woman with a  thriving business and an essentially normal bilateral mammogram. Her  breast exam is also normal except for a faint scar in the upper outer  breast and a second incision in the underarm region where I removed  lymph nodes in 1989. Gloria is a ten year survivor of breast cancer 

  and appears to be cured by her therapy including excision of the 1.5 cm  breast cancer followed by a series of radiation treatments administered  in our well-run but unsung Radiation Oncology center here at  Presbyterian Hospital of Dallas. 
         
         A small confession- I’ve taken most of the credit for Gloria’s  successful treatment. The surgical part was the easiest aspect of her  care. Breast conservation is a flawed strategy without follow-up  radiation directed at the entire breast, and I would be less than  gracious if I did not recognize the contribution of my colleagues in  radiation oncology. Without radiation, the cancer grows back in the  breast with terrifying frequency - 36% in the landmark NSABP B-06 trial.  Fifteen years ago when this trial was published in the New England  Journal, I was skeptical. My surgical training at Southwestern Medical  School in the late 70’s warned me that long term cures for breast cancer  were more assured with complete removal of the breast- the infamous  mastectomy. But I did know how to study a randomized, prospective trial  report and most importantly how to shoot holes in it. The NSABP in their  carefully conducted trial and long follow-up convinced me and most of  the surgeons in this country that we could offer the combination of  tumor excision and radiation in lieu of mastectomy for the treatment of  Stage I and II breast cancer. Since the publication of the NSABP  results, I’ve used their principles of breast conservation in the  successful treatment of over 1000 breast cancers at Presbyterian  Hospital of Dallas and the associated Margot Perot Hospital for Women  and Children. I see a lot of women who like Gloria are cancer-free years  after treatment (and dare we say it-cured).
         
         What I’ve learned from my twenty year experience treating breast  cancer is to sit up and take notice when dedicated and committed  experts from other disciplines like radiation oncology tell me there’s a  better way to treat a terrible disease like breast cancer. Early in my  career, I was exposed to the huge MD Anderson Cancer Center experience  with breast conservation through my colleague Dr Don Schwarz. Don had  been a part of the radiation therapy department at MDAH when he and Dr.  Eleanor Montague and others worked out the most efficacious and least  harmful means of using the power of the ionizing radiation to prevent  the re-growth of breast cancer following surgical excision. The  successful formula for today’s treatment of both invasive and in-situ  breast cancer calls for surgical excision of the malignant disease  combined with radiation therapy to the affected breast for several weeks  following. 
         
         And that combination works in 90+% of properly selected cases.  Radiation is not without side-effects, but for the most part these are  short term. The breast often swells particularly if it’s a C cup or  larger; it often looks sunburned in limited areas toward the end of  treatment and the skin may blister and peel in the areas most affected. A  few patients complain of breast sensitivity afterwards and the skin is  often tanned and leathery for a period of time that may last months ( or  years in a small fraction).  In the fair-skinned, the blood vessels 

  of the skin may break down (spider veins). An infrequently mentioned  plus is that breast conservation as a concept obviates the necessity of  breast reconstruction. 
  Long term problems with modern radiotherapy are mercifully rare.  The  worst complication, of course, is local re-occurrence in the breast, an  outcome that is exceptionally uncommon when well-known principles  governing patient selection are observed. 
         
         The biggest inconvenience with primary radiotherapy of the  breast is the investment in time to achieve the desired curative effect.  At the Presbyterian Radiation Oncology Center (Dr. Schwarz’ outfit),  the treatments take place over a period of 5-6 weeks. Computer-generated  calculations of radiation exposure are made for each individual. Safety  and accuracy are assured by taking into account the variability in  shape and size of the breast for each individual patient. In the actual  treatment, powerful (and expensive) linear accelerator generates a  precisely directed beam that is         focused specifically on the breast sparing other non-breast  tissues.   Ultimately the tumor scar, the most likely site of  re-occurrence, receives an intense boost. The boost effect leaves the  skin of the breast more deeply pigmented and the “boosted” sector of the  breast a little more sensitive. On mammography the scar within the  breast is a prominent feature for several years because of the combined  effect of lumpectomy and radiation. I don’t worry about local  re-occurrence unless I see some ominous change in the mammogram or by  examination. Inadequate margins and multi-centric tumors are the most  common causes of re-occurrence. Arm swelling or lymphedema occurs in  8-10% of cases treated by axillary node dissection and/ or radiotherapy.  The advent of sentinel node biopsy for node-negative cancers reduces  the risk for lymphedema significantly. 
         
  My own personal experience over the past twenty years with breast  cancer has demonstrated that a breast conserving strategy employing  meticulous surgery, reliable  pathology, and careful radiotherapy is a very effective combination in  the treatment of primary breast cancer. My thanks to Dr. Schwarz and his  colleagues for providing state-of-the-art technology that works. I’ll  tell Gloria to send him a birthday card next year. 
         
         		Dr Bourland is a surgeon specializing in the treatment of  breast cancer. He is director of Margot Perot Center Breast Consultants  in Dallas          

I saw a long time patient yesterday in the office. Gloria drops in once a year for a checkup. She brought me a funny birthday card and we teased each other about the effects of gravity and aging. During her exam she detailed for me how much fun she and her husband Francis are having running a small entrepreneurial business (home remodeling).

Author | W. Lee Bourland, Jr, MD

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