The operation that can make breast cancer surgery less painful

Today I have a health piece in the Daily Mail. Here is the link:
http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=453402&in_page_id=1774

It is about a new procedure used to treat women with breast cancer. It's a procedure which is now being used more and more widely - which can only be a good thing.

Here is the piece......

Breast cancer surgery usually involves removing the lump and up to 30 of the lymph nodes under the arm — often causing painful chronic swelling.

With a new technique, only one or two lymph nodes have to be removed — an operation which is set to become more widely available now that 80 per cent of the UK's breast surgeons have signed up for training.

Victoria Yeates, 49, was one of the first to undergo the procedure.

Here, the law lecturer, who lives in Cardiff with her husband Philip, 55, tells SARAH EBNER her story.

The patient

When I discovered a tiny lump in my right breast, I was very blase about it. I'd had another one ten years before which had just disappeared on its own accord.

When I felt the new lump, I thought it would be the same.

It was my sister, who is a pharmacist, who persuaded me to get it investigated. I went to the GP several weeks later and was referred to the University Hospital of Wales.

I was so relaxed about it that when the appointment coincided with a holiday to Egypt, I went to Egypt instead. I feel terrible about that now.

Two weeks later, under the care of Robert Mansel, professor of surgery at the University of Wales College of Medicine in Cardiff, I had a mammogram that came back normal.

I then had an ultrasound scan and was surprised when the radiographer said: "Oh dear, there's definitely abnormal tissue here."

They did a needle biopsy, in which a small piece of suspicious tissue was taken to be sent for analysis, and when I returned to the hospital a week later to find out the results, I knew it was bad news because I was accompanied by one of the breast care nurses.

Still, I felt very calm when they told me the lump was cancerous. My husband Philip, who had come with me, was ashen though. He went through hell.

I was told I had a small tumour which was not aggressive, and that a mastectomy (in which the whole breast is removed) would not be necessary.

They advised a lumpectomy — where only the cancerous tissue and a small area around it are removed — and then radiotherapy (they didn't know yet if I would need chemotherapy).

I came away feeling quite optimistic, but reality dawned over the next week.

I might face a disfiguring procedure and I learned that during the operation they would need to remove all of my lymph nodes in case the cancer had spread.

I was concerned about this and spoke to my breast nurse, who suggested discussing the options with Professor Mansel.

He said that of all tumours, mine was the best type to have — it was slow-growing and small.

He said he was working on a trial involving a technique called sentinel node biopsy, which might reduce the after-effects of having my lymph nodes removed.

The lymph nodes are part of the lymphatic system which draws lymph — fluid — from tissues all over the body back into the bloodstream.

If cancerous cells get into the lymph nodes, it can spread through the body.

Professor Mansel explained that 70 per cent of women with breast cancer have their lymph nodes removed unnecessarily, when they don't have cancer in them, and that lymph node removal can result in a serious complication called lymphoedema — chronic swelling — especially in the arms because lymph is no longer able to drain away.

This feels painful, and it is very hard to move the arm normally.

With sentinel node biopsy, only one or two nodes are removed. If no cancer is found, the rest of the lymph nodes can be retained.

Professor Mansel said the aim of the procedure was to check the first node the cancer would spread to — which is called the sentinel or guard node.

If there is no cancer present, it won't have gone to the other glands, so there is no point taking them out.

It made so much sense, and after meeting Professor Mansel, I went away feeling uplifted but also nervous that I wouldn't be selected for the trial.

I was attending an outpatient appointment in preparation for admission when the nurse told me I'd been selected.

On May 13, 2002, the night before the operation, I was seen by Professor Mansel and his registrar, who explained what would happen during the surgery.

When I was wheeled into theatre, I felt totally calm. The operation lasted two hours, during which time they took out the cancerous lump, removed the lymph nodes and put in a temporary drain.

When I came round, I felt marvellous. There was a tiny scar from where they had taken out the sentinel nodes and a neat line where the lump had been removed.

The side of my breast was a bit caved in because they had to take some tissue out, and I have since had two reconstructive operations.

I had full mobility in my arm afterwards and no swelling.

Ten days later, I went to get my test results and was told that the cancer hadn't gone to the sentinel nodes so I didn't need another operation. It was very good news.

I didn't need chemotherapy, although I did have radiotherapy to make sure no stray cancer cells remained.

I now have a mammogram every year. I consider myself very lucky to have benefited from this medical advance.

The surgeon

Professor Robert Mansel of University Hospital, Cardiff, says:

Sentinel node biopsy allows women who are undergoing breast surgery to have only one or two lymph nodes removed from under their arm, rather than the conventional 20 to 30.

The nodes are then checked in the laboratory for the presence of cancer cells.

If cancer gets into the lymphatic system, there is an increased risk of it spreading to the rest of the body.

Experts had thought that cancer cells spread to all lymph nodes equally — but in fact the cancer moves in a predictable pattern, going from node to node, starting with the sentinel.

If the sentinel node is found to have cancerous cells, then there is a possibility it may have spread to other lymph nodes.

In this case, the patient has to return to theatre for the remaining nodes to be removed.

But if there is no cancer in the sentinel node, then there will be no cancer in the others — and no need for further surgery.

The new technique not only reduces recovery time but also cuts down the number of patients who suffer long-term damage to their arms after the operation.

Removing all of the lymph glands can cause very painful after-effects, such as lymphoedema, where the arm swells up and feels heavy.

This affects around 20 per cent of women having full removal of the nodes and is incurable.

With the new technique, arm swelling is reduced by 80 per cent and numbness and tingling by 80 to 85 per cent.

I'm passionate about this procedure, which is now the standard operation in the U.S. and most of Europe.

I'd like to see it rolled out across the whole of the NHS because it has so many benefits for patients compared to conventional surgery.

When I first met Victoria, I was sure her tumour was non-aggressive and that she would be a good candidate for this operation.

A few hours before her operation, I injected a drop of fluid containing a tiny amount of a radioactive isotope into the skin at the edge of Victoria's areola (the area around the nipple).

The radioactivity travels from the skin to the lymph nodes, reaching the sentinel node first.

During the operation, the radioactivity guides me to this node.

Once in theatre, Victoria was given a general anaesthetic.

We also injected a blue dye under the skin around her breast.

Very occasionally, though not in Victoria's case, the radioactivity doesn't go to the lymph node, so we can then use the dye to guide us instead.

With Victoria asleep, we used the radioactive probe to find the sentinel node.

The probe is like a steel pen, and you point it at the area under the arm.

The nearer the probe gets to the sentinel node, the louder the noise it makes, until it sounds like a scream.

I made a small incision to let the probe in, and moved it around to find the exact position of the nodes.

The radioactivity had gone to five nodes, which I removed, before closing up the wound. (The nodes were sent off for tests — which later came back clear.)

I then made a two-inch incision on the breast to take out the tumour and a margin of tissue.

Once I was satisfied that all cancerous tissue had been removed, I stitched Victoria up.

Victoria recovered remarkably well. She was very positive about the whole thing and was up and about as if nothing had been done.

That's the great thing about this operation. It uses only small incisions and there's very little pain afterwards.