Week 1 - Getting Started

This week was the first week of the summer immersion program, and I have already learned a great deal. I first want to thank Belinda for working so hard to get us down here, and thank Mitch and Dr. Wang for taking care of us after we got here – I think that everything has ran fairly smoothly so far this year, and I for one am very grateful.

My physician is Dr. Eleni Tousimis. She is a breast cancer surgeon dealing primarily with early stage cancer. Most of the patients she sees have been referred to her after finding a lump in their breast or something abnormal during their yearly exam or mammogram. She has been absolutely amazing to work for, and she is very accommodating. I met with her for the first time on Tuesday, and she immediately invited me to come into the OR with her the next day to watch two lumpectomies. She also had already come up with some ideas on projects which she pitched to me (4 of them – wow!), which I will discuss in a little bit or in a later post. So I joined her in the OR on Wednesday morning. The first patient was an older lady who had a small area in her right breast which had minor calcifications and a tiny tumor (only a few millimeters). The whole process is very interesting. In the morning, the patient goes down to radiology, where they take an MRI and, using the MRI, insert a metal wire into the breast, with the tip of the wire at the tumor site. The wire helps the surgeon localize the tumor. Also at that time, the radiologist injects a radioactive dye that is used to localize the sentinel lymph nodes. During the surgery, Dr. Tousimis injects a second dye which is blue, which she can then use to visually identify the sentinel lymph nodes. A very commonly used tool here, sentinel lymph node biopsy is routinely done during lumpectomies to determine whether or not the cancer has spread. If they find evidence of cancer in the sentinel node, then the cancer has spread to the lymph system. However, if they don’t find cancer in any of the sentinel nodes, then it has not spread, since it is impossible for it to spread to any other lymph nodes without passing through the sentinel node first. So Dr. Tousimis removed the tumor and calcifications and sent it down to radiology, where they scanned it and reported back that the margins looked clean (which means there is a 95% probability that the cancer hasn’t spread – the final conclusion is made after the tissue is examined by a pathologist). This was an outpatient procedure, and the patient is under mild, general anesthesia during the process, so they are really just in a deep sleep. This was very interesting, as the patient occasionally moved her arm or leg during the process, and the resident would have to tell her very loudly to relax her limb. The patient wakes up quickly after the procedure. In fact, we talked to the first patient maybe 20-30 minutes after her procedure ended.

The second procedure that day was identical to the first, except for the fact that two tumors were removed instead of one, and at one tumor site a hematoma had formed after a prior biopsy. We met with the patient before the surgery, while she was having her MRI done, and it was so amazing to me the effect that Dr. Tousimis had on this patient. The patient was so anxious, and so nervous, and after only a few minutes of talking with the doctor, she visibly relaxed and looked more steady.

On Thursday I went into the clinic with Dr. Tousimis, and we met with patients for several hours. During these visits, Dr. Tousimis would perform a breast exam and then discuss what they had found and possible options they had. One consultation that I sat in on was between the doctor and a patient, who had come in with her husband. This patient’s sister had lung cancer, which was in remission. Twenty years after she had been diagnosed with the lung cancer, a tumor was found in her breast, which while not unheard of, is highly unusual. During treatment for this tumor, the sister underwent genetic testing and was found to have the BRCA2 gene. This patient was then immediately tested and found to have it. Because her chances of having cancer were so high, she immediately underwent all of the testing and scanning, and they found an extremely small tumor in her breast. However, because of the gene, the patient was opting to have a double mastectomy with immediate reconstruction, to improve her chances of staying cancer-free.

Finally, on Friday I went into the OR again to observe a double mastectomy. This procedure was very disturbing to me, but very fascinating. A plastic surgeon first removed the patient’s nipples and aureoles completely, and then Dr. Tousimis began at the exposed area, carefully cutting the breast tissue away from the skin, finally cutting the entire breast away from the muscle underneath and removing the tissue through the hole. After Dr. Tousimis was finished, the plastic surgeon would come back in, they would turn the patient over on her stomach, and the plastic surgeon would remove flaps of muscle and fat from the patient’s lower back to be implanted as new breasts. Additionally, because the patient did not have enough excess fat there, he would also be using silicone implants to help make the breasts look more natural. Then he would decide whether to reattach the nipples that were removed earlier, or to reconstruct the nipple with new skin flaps. The whole procedure would take 8-9 hours. Dr. Tousimis’ part was only about 2 hours. I am starting to get more comfortable in the OR, which is nice! And I have such great respect for all of the surgeons. For one, I'm amazed at how much time they spend on their feet on surgery days - it is incredibly tiring for me!