The notion of a "routine medical procedure" masks an enormous complexity of details -- from the individuality of the patient to irregularities of circumstances and the many small decisions made by the physician, alone or together with the patient -- that all affect outcomes.
In the first of a series of occasional articles, the author follows a patient and a surgical procedure -- in this case a sentinel node dissection, an increasingly common, minimally invasive surgery for breast cancer that seeks to remove the tumor and a few nearby lymph nodes, where any spread cancer is likely to reside -- explaining the key actions while capturing some of the thoughts and emotions on both sides of the operating table.
The operation described took place a year ago. Many changes that have since transpired in the principals' lives were then unanticipated.
The doughy lump of Cathy Dill's breast, surrounded by a field of blue surgical drape, jiggled and shook as the nurse applied betadine prep to prevent infection. The mass buried deep inside, discovered on a mammogram eight weeks before, would be coming out in little more than an hour, along with a lymph node that would reveal a large measure of Dill's fate.
Surgeon Rick Brenner, wiry and earnest without being intense, now stood alongside her in pre-op, his receding hair a nondescript mousy brown in the places where it kept its color. He had put in a year as chief surgical resident at Georgetown University Medical Center, where he learned the relatively new technique of sentinel node dissection, a less invasive alternative to mastectomy that appears to offer equivalent results. After completing his residency training at Georgetown, he had spent the last three years in general surgical practice, working mostly out of Inova's Fair Oaks and Fairfax hospitals. Today's procedure was being performed at Fair Oaks.
Dill, a weathered-looking 51 with blonde and white hair, had a frank but good-natured look to her. Ditto for husband Karl, who watched straight-lipped, his arms folded. There was a green four-leafclover tattoo on his left forearm where his watch should be. Theirs was not a family that has had much luck, though. Her aunt had breast cancer. Nine of her father's 12 children had one form of cancer or another. Neither Cathy nor Karl expressed much emotion; both maintained a quiet, let's-get-past-this solidity. Being introduced to me, the doctor whom they had agreed to have observe the surgery, helped them pass the last few minutes before proceeding to the OR.
Cathy's story was straightforward. She'd had a normal mammogram in 1998. Then she'd been out of work and uninsured for a while. She got Blue Cross with her new job as a security dispatcher and scheduled a screening again in August 2001. The radiologist found something suspicious. A second mammogram confirmed what Dill feared. Her obstetrician referred her to Brenner, who arranged for her to have a needle biopsy, which revealed a low-grade invasive breast cancer. They would not know the size or classification of the tumor until after surgery, but if it fell into Stage I or II -- those most responsive to treatment -- her five-year survival odds, according to the American Cancer Society, would be between 100 percent and 75 percent. Dill herself had never felt the mass buried in her right breast.
What she was thinking about now, though, was her stomach: She was hungry. Because anesthesia is safest when administered on an empty stomach, Dill had been advised to have no food for 12 hours before surgery. Brenner kidded her about the steak she could have in post-op. Smiling, she told him not to even joke about it. Turning more serious, he delivered his final walk-through of what was about to take place. Cathy wore a good-student look. Karl sat stoically, concentrating: First she'll get wheeled into the OR, then sedation, then waking up in recovery. Nods all around. Okay?
Okay. Good: We're all okay.
When the anesthesiologist came to give her the first round of sedation a few minutes later, she offered up the arm with the IV, then said, "Wait! I want to remember kissing my husband before I go." And then all I could see of her was her being enveloped by the shamrock. For luck.
Voodoo and the Knife
In the OR, Dill complained of feeling chilly and then, anesthesia mask on, she was out. Brenner unbuttoned the gown, exposing her chest, and felt the side of her right breast for a solid minute or so, allowing his fingers to familiarize themselves with the lump. Earlier in the afternoon, the radiologist had injected a radioactive tracer fluid, or dye, into the mass and left a skinny wire in place to mark its location. With only one mass evident on the mammogram, Brenner had expected just one such marking, but the radiologist had placed two wires. The presence of a second wire bothered the surgeon. Brenner had also pre-marked her breast with a black felt-tip marker -- parallel to the rib line below her armpit -- to offer a distinct landmark for his scalpel. Once the blue drapes and brownish betadine had been applied, there would be no other obvious landmarks to guide the initial incision.
Brenner's fingers continued massaging at the side of her breast as a nurse wheeled around an instrument cart carrying a syringe with 5cc of a navy blue liquid. This was the living agent of the procedure, a dye that, once inside Dill's body, would be naturally detected as a foreign substance and transported by the breast's lymphatic vessels to the closest lymph node, where it would come under attack from her body's host defenses. Brenner injected the dye under Dill's skin close to the entry point of the needle and then proceeded, once again, to knead the segment of breast. "A little voodoo. If you rub the dye in for a full five minutes, it makes for better uptake in the node." He paused and explained a little further. "Well, not quite voodoo. They did studies to compare uptake of the dye after one minute, two minutes and five minutes. Five minutes won." Despite the offhand nod to superstition, very little that Brenner does is not backed up by medical research.
By the time he finished, it seemed he had been jiggling the breast for hours.
It was time to wash, another five- to 10-minute surgical ritual.
As we scrubbed, Brenner explained that he had two primary goals: remove the tumor in its entirety, and remove any and all lymph nodes to which it might have sent metastatic seedlings. In slow-growing, low-grade malignancies such as Dill's appeared to be, this ought to be curative. All the malignant tissue in the breast would be out of her body by the end of the procedure, limiting the need for further treatment to radiation alone -- to eliminate subclinical cancer cells that may not have started growing. If, however, he found the tumor growing beyond its shell, or capsule, or if the lymph nodes that picked up the injected dye were found to be tumor-laden, then she faced some combination of chemo, mastectomy, radiation and a far worse prognosis.
While we were scrubbing, the surgical nurse carefully placed sterile drapes and painted the breast with more betadine. When we got back, no more of Dill was visible than a brown, round lump in a field of blue drapes and gown. The nurse, a furrow across her face, was examining the mass, mimicking Brenner's motions of a few minutes ago.
We were helped into our sterile gowns and gloves, a scalpel appeared in the surgeon's hands, and the skin fell away.
Brenner began with the lymphatic chain in Dill's armpit; the nodes resembled largish pearls spaced along the strand of connecting lymph vessels flowing from the breast. He needed to identify the lymph node that picked up the dye first and strongest so he could dissect it and send it off to the pathologist for analysis. That node, the one likeliest to be infested with any cancerous cells, is known as the "sentinel" node. A cancer would spread along the closest lymphatic channel into the first node it hit, much as a commuter takes a convenient local road onto the same highway entrance each day.
The sentinel node was marked two ways: by the radioactive tracer in the wires placed by the radiologist, and by the blue dye Brenner had just injected. The job was to find and remove a blue, radioactive node. If it tested negative for cancer, Dill would fall into the best of prognostic categories. The tumor to be removed next would then likely represent a fulfillment of the surgeon's dictum: Remove the disease from the patient. She would in effect be cured.
In Search of a Tumor
Brenner tracked through the subcutaneous tissue, using a blunt spreader, an instrument resembling a small spatula, and a scissors to snip away at small fibrous bands, penetrating deeper toward the lymphatic chain of nodes with each move. In perhaps five minutes he had the node he was looking for, a rubbery, bean-sized object whose dark discoloration distinguished it from its neighbors. A small Geiger counter sat by Dill's left side, waiting for Brenner to probe the area. He placed the probe on the blue object and the machine screamed away.
Bingo. The sentinel node. He rolled it around in his fingers, assured now that he had found what he was looking for, and seemed to like what he felt. "It feels nice and soft," he said, a hopeful sign that it had not yet undergone a malignant transformation. Then he snipped it out. A pathologist appeared in a moment to take away the node. But as Brenner explored the region, he found a second blue node next to the first, also largish and also moderately radioactive. He rolled that around in his fingers, too, and furrowed his brow. "Label this 'Node B.' " His optimism seemed to fade a little.
It was time to go after the tumor. After a 20-second discussion with the OR nurse, Brenner decided to extend his first incision instead of making a second cut, tracking the blue thread of a lymphatic channel toward the cancer itself.
He lengthened his cut to just beyond where his wire pierced the skin, griping about the second wire, the reason for which he had not yet been able to decipher: He didn't know if the radiologist had encountered a second "primary" tumor, or had merely hedged his bets by placing a second wire into one mass. But Wire Two sat much closer to the armpit, and the tumor Brenner was now carving out did not include it. A second mass would be a far worse matter for Dill, and Brenner's continued fretting over this unexpected wrinkle reflected his rising concern for his patient.
Removing the lymph nodes had taken 15 minutes or so. It took another 15 or 20 for dissection of the tumor. Brenner worked clockwise, completing a lemon-shaped incision, ending back up at the armpit where he had started, occasionally using an instrument shaped like a Bulky pen, the Bovie cauterizer, to control bleeding from small veins with a small electric zap. As he worked, he periodically dropped his fingers along the breast to tease out any feeling about the mass beneath.
In an unassuming, surgically uninteresting procedure, he was cutting through a wedge of fatty breast tissue to isolate and encase a deadly, transformed tissue, watching all the while for any tendrils of wildly growing tumor. The end product: a lump of tissue roughly the size of a Big Mac, half-blue from the dye, the remainder a ruddy-orange color of drying fat, a cancer buried somewhere within a generous margin of (hopefully) healthy tissue. Brenner deposited it on a specimen tray above Dill's belly, to be sent to pathology.
Midway through this dissection, the pathologist called back with good news: no cancer cells in the first lymph node. With luck, now, Dill's entire cancer now lay on the table, outside her body. Once again Brenner's fingers explored the excised lump to learn if the size would also be in her favor: a tumor smaller than two centimeters suggested a much better outcome than a larger tumor. He couldn't really tell, but liked her chances.
He returned to Dill's side for the final job of tracing the end of the second wire. It was, he discovered upon a few minutes of careful further dissection, deposited in a suspicious intra-mammary lymph node the radiologist had discovered, and marked for Brenner's attention. It also lit up the Geiger counter to a moderate degree. Not good. Maybe. Another item added to his sense that the day's surgery might not wholly cure his patient.
The pathologist would take the tumor, and all three nodes, to perform more detailed analyses. His final report in a few days would either confirm the preliminary good news or revise it downward.
Going on Faith
It was time to close the skin wound. This required another few minutes of basic surgical care: coarse (for sutures) subcutaneous stitches, then a finer thread to bring the skin together. Cosmetically, the wound left a largish cavity that, depending on the Dills' wishes, might ultimately require a plastic surgeon to restore a semblance of the original shape and symmetry. Their decision wouldn't be dependent on their financial resources: In the late 1990s, Congress mandated complete insurance coverage for all breast cancer cosmetic reconstruction -- both on the involved breast as well as the other side.
Total OR time had been about 60 minutes, and the sentinel node biopsy and tumor resection -- or lumpectomy -- Brenner had performed had been about as exciting, surgically, as house painting. To a surgeon, the procedure lacked the drama of a transplant or intricacy of a vascular procedure.
But it was not without its controversial aspects. The more traditional approach to Dill's case would have been mastectomy (surgical removal of the entire breast) and a radical lymphatic (node and lymph vessel) dissection. Both involve greater post-operative pain as well as the likelihood of a second surgery for breast reconstruction.
The risk of the sentinel node dissection was that a small chance remained, maybe 5 percent or less in controlled studies, that either the breast or another lymph node not removed might still harbor cancerous cells.
Even if the cancer never recurred, the leap of faith in opting for the less-invasive procedure would require far greater vigilance on Cathy Dill's part. More mammograms, rechecks, always living in the shadow. Another patient and another surgeon might have looked at the same set of data -- initial biopsy results, family history -- and together decided on the more aggressive surgical approach in hopes of lowering the possibility of a recurrence.
Somewhere along the line, doctor and patient had made a judgment call to accept these tradeoffs.
We found Dill's husband coming out of the restroom.
"Went well," Brenner said. "Even a little faster than we expected."
"Good, good," Karl Dill said, eyes still maintaining a steely watchfulness.
"And the lymph node was negative."
A broad smile. "Damn, that's great." He was grinning and finally softened for the first time.
The next visit was a week away, when he would know the pathologist's findings. Karl would take Cathy home tonight after she awakened in the recovery room, Brenner had already left her a prescription for a painkiller.
"Top shelf," he had told her.
A year later, Cathy Dill is in remission. Her final pathology report showed an intermediate-grade tumor, not the low-grade tumor that was diagnosed initially. As a result, she received months of chemotherapy before undergoing radiation treatment. As Brenner puts it, "Chemo lowers the risk of systemic (general) recurrence, and radiation lowers the risk of local recurrence."
But the real benchmark is five-year survival, and that seems, to Cathy, a long way off. The last year has been a harsh one, for more reasons than just the wearing course of chemo and radiation: Her mother was diagnosed with breast cancer (Brenner operated on her, too), and Karl passed away suddenly and unexpectedly. As a memento, she got a four-leafclover tattoo for herself: "It just reminds me of how worried he was for me and how much he loved me. It really makes me feel good at times that I need it most."
J.B. Orenstein is an emergency room physician at Shady Grove Adventist Hospital in Rockville and Inova Fairfax Hospital.