Breast Surgical Specialist, LLC: Rachel Dultz MD

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• Lumpectomy

  A lumpectomy is a surgical procedure to remove malignant or other abnormal breast tissue with some healthy tissue around it. It is often also called a partial mastectomy, as we are only removing a part of the breast. In the majority of breast cancers, this can be accomplished with one surgery, however, sometimes this may require multiple operations. If you are a candidate for a lumpectomy, as many women are, the details will be explained by your surgeon. In the majority of times after a lumpectomy, you will require a short course of directed radiation therapy to reduce the likelihood of cancer from returning. Again, this will be more thoroughly explained by the surgeon. The Procedure Of Lumpectomy The procedure of a lumpectomy for cancer is most commonly performed as an outpatient procedure in the hospital. This means you go home the same day as the surgery. It can be done either under local anesthesia with IV sedation or under general anesthesia. The surgeon will discuss this with you when you are planning your surgery. A lumpectomy sometimes will require an additional procedure at the time of surgery, localizing cancer. This is done by a radiologist just prior to the surgery and will be discussed with the surgeon. Recovery For A Lumpectomy After a lumpectomy, the patient returns home after surgery the same day. She can resume normal activities in a short period of time, but the surgeon will discuss that in full detail during the postoperative office visit, which is usually the week after surgery. The following measures are commonly taken to assist in healing: Ice packs to the affected area Wearing the compression bra that the surgeon placed you in at the time of the operation Avoidance of strenuous activity until discussed with the surgeon Prescribed pain medicine Caring for the incisions Being aware of signs of infections Follow up appointment with the surgeon in 1-2 weeks Risks Of Lumpectomy There are a few risks associated with the lumpectomy including: Infection, signaled by redness or swelling at the surgical site, or fever Bleeding and bruising Allergic reaction Others These will be discussed in greater detail by the surgeon before and after surgery.

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• Mastectomy

  A mastectomy is a surgical procedure to remove all of the breast tissue in a patient with breast cancer or for a patient who has a very high risk of developing breast cancer in the future. Types Of Mastectomy There are several different mastectomy procedures designed to eradicate cancer but retain as much of the natural breast as possible. Some of the most commonly used techniques include: Simple Mastectomy This type of mastectomy involves removing all of the breast tissue, but leaving the lymph nodes. The lymph nodes are small structures that are under the arm, and help tell us if the cancer has spread or not. These are not removed with a simple mastectomy. Modified Radical Mastectomy This type of mastectomy involves removing all of the breast tissue and removing the lymph nodes under the arm or axilla. If you need this, the surgeon will discuss this with you. Preventive Mastectomy A preventive mastectomy is an elective surgery performed on women who have a high genetic or familial risk of breast cancer. Also called prophylactic mastectomy, it usually takes the form of a total or subcutaneous mastectomy, and can reduce the occurrence of breast cancer by 90 percent. Skin Sparing Mastectomy And Nipple Sparing Mastectomy These operations remove the breast tissue but leave the skin envelop and/or the nipple to create a more natural looking breast shape. At the same time the breast is removed, the plastic surgeon rebuilds or reconstructs the breast. Many women desire some type of restorative surgery after the mastectomy and this can usually be accomplished during the initial surgery to remove the breast. Dr. Dultz’s practice works with excellent plastic surgeons who can do this. If you are a candidate for this type of surgery and reconstruction, the surgeon will discuss this with you prior to surgery. A Nipple Sparing Mastectomy is a highly specialized procedure that Dr. Dultz and Dr. Crivello have been trained to do and they have been doing them successfully for years. Reconstruction And A Mastectomy Depending on the type of mastectomy procedure performed, a one to two-day hospital stay may be required. If a woman desires breast reconstruction and she is a good candidate for it (this will be discussed with her during her pre-operative office visit), she will then see a plastic surgeon that Dr. Dultz recommends. The goal of breast reconstruction is to restore the appearance of the breast and to eliminate the need for an external breast prosthesis. A prosthesis is a heavy piece of material that goes inside a special bra and is often quite heavy. Reconstruction can usually be performed at the same time as the mastectomy is performed, or sometimes at a later date. There are many different types of reconstruction options, and the board certified plastic surgeon will describe them in greater detail. Risks Of Mastectomy Certain risks are associated with mastectomy, and may include: Fluid-collection underneath the scar left by the incision Numbness of the skin along the incision site Mild to moderate tenderness in the area adjacent to the incision Heightened sensitivity to touch in the surgical area Delayed healing of the incision Increased risk of infection in the surgical area Formation of scar tissue If the patient has had reconstruction with her mastectomy, there are some additional risks which will be discussed by the plastic surgeon prior to the surgical procedure.

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• Sentinel Lymph Node Biopsy

  A sentinel lymph node biopsy is a diagnostic surgical procedure performed to determine whether cancer has spread into the lymphatic system from its original site. The sentinel node is the first node to which cancer spreads after leaving its site of origin. In the case of breast cancer, the sentinel node is located under the arm. Reasons For A Sentinel Lymph Node Biopsy The most common reasons to perform a Sentinel Lymph Node biopsy are to help the surgeon stage the breast cancer and then help plan the subsequent treatment options for her. Procedure Of A Sentinel Lymph Node Biopsy During the surgery, dye is injected to illuminate the area and provide a map of the sentinel lymph node. Once identified, the sentinel node is removed and sent to the pathologist who will look at the node to determine if cancer has spread. This will routinely be performed after the surgery and the results take about one week. Soreness and bruising sometimes can result from the biopsy, but these symptoms usually subside in a few days. Complications Of A Sentinel Lymph Node Biopsy In addition to the risks of any surgical procedure, such as bleeding, infection and scarring, there are a few risks particular to this procedure itself. These include the following: Allergic reaction to the dye Temporary blue discoloration of the skin where the dye was injected Fluid accumulation or swelling at the side (edema) Numbness at the area of biopsy

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• BRCA 1 And BRCA 2 Gene Testing

  While the specific cause of breast cancer is often unknown, a certain number of women may be genetically predisposed to developing this disease. Women with the BRCA 1 or BRCA 2 gene mutation carry an inherited risk of developing breast cancer. These gene mutations likely occur in women with: A family history of breast or ovarian cancer Early diagnosis of breast cancer (before age 45) Another family member with BRCA gene mutation Women who carry the BRCA gene may have up to an 85 percent chance of developing breast cancer at some point in their lives. Hereditary factors usually account for only 5 to 10 percent of all breast cancer cases, but it is still important for women to undergo testing if they are considered at high risk of developing breast cancer. The BRCA genetic test involves a simple blood test that is performed in the doctor’s office through a vein in the arm. The drawn blood is sent to a lab for DNA analysis. It may take three to four weeks for results to be available. Patients with positive results will work with their doctor to develop an appropriate prevention plan. It is important for women who receive negative test results to realize that they still face the same risk of developing breast cancer as anyone else in the general population and should be screened on a regular basis. Genetic counseling can be beneficial both before and after testing for a BRCA gene. Your level of risk for the gene may be assessed by reviewing your personal and family medical history. Counseling can also help you determine how to handle the results of your test. With an increased risk of developing breast cancer in both breasts, women with the BRCA gene mutation often seek preventive care to reduce their chances of developing cancer. There are several surgical and nonsurgical treatment options available to protect even those women at the highest risk of developing cancer and maintain breast and overall health. We provide specialized care for these patients in the form of preventive and reconstructive options. Preventive Options Women who test positive for the BRCA 1 or BRCA 2 gene mutation should take special precautions to reduce their risk of breast cancer. It is vitally important to increase the frequency of cancer screenings to detect any lumps as soon as possible. Regular mammography, clinical breast examinations and sometimes other forms of imaging can help identify cancer in its earliest, most treatable stage. Precautionary measures may also include chemoprevention medication to kill cancerous cells as soon as they occur or preventive breast cancer surgery, known as a prophylactic mastectomy, which involves the surgical removal of the healthy breast tissue. Prophylactic mastectomy is performed using the same techniques as a treatment mastectomy procedure and may involve removal of the breast tissue, nipple, areola and lymph nodes, depending on the risk of cancer and the patient’s personal preference. This procedure often reduces a patient’s risk of developing breast cancer by as much as 90 percent. Reconstructive Options Many women with the BRCA gene who have cancer in one breast may choose to undergo a prophylactic mastectomy on the unaffected breast at the time of treatment. This eliminates the need for additional surgery and further reduces the risk of recurrence. Being tested for the mutation after a breast cancer diagnosis can help in making the decision for treatment. Taking into account each patient’s individual risk of recurrence prior to initial treatment and reconstruction is an important decision that should be discussed with your surgeon. Women who undergo a single mastectomy procedure and breast reconstruction, and then develop breast cancer in the other breast will be left with fewer reconstruction options for the second mastectomy procedure. If too much skin is taken from other areas of the body during the first procedure, there may not be enough available for a second procedure. Your surgeon will help determine the most effective treatment and prevention procedures for you, which may include implant, tissue-based or fat transfer reconstruction for one or both breasts. It is important to discuss all preventive and reconstructive treatment options with your doctor before making any final decisions. To learn more about prophylactic mastectomy, and to determine your risk for breast cancer, please call us today to schedule an appointment.

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• Breast Exams

  Breast exams are physical and visual inspections of the breasts. They are an important part of a physical exam, performed by either an OBGYN or a Primary Care Physician. In addition, a doctor can teach a patient how to perform these exams at home every month in order to recognize any changes on their own breasts. Breast exams can be a very useful tool for the early diagnosis of breast cancer. During a breast exam, a doctor may ask the patient to place their arm in several positions to view and examine the breast from various angles. For the physical portion of the exam, the doctor will rotate his or her fingers around the entire breast, applying changing levels of pressure to feel areas near the surface as well as deeper within the breast. Both breasts will be examined. Women are encouraged to do self-breast examinations every month, about five days after their period begins. This is the time that the breast is the least tender and lumpy. If patients feel anything different or suspicious during the breast exam, they should consult their doctor immediately. In some cases, patients may be sent for a mammogram to further examine their breast.

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• Mammogram

  A mammogram is an X-ray examination of the breast. It is performed to detect breast cancer in its earliest stages, often before any signs or symptoms of the disease are present. Mammography allows doctors to detect small tumors that are easier to treat than larger, more developed tumors. And it can also detect small abnormal growths in the milk ducts of the breast, called ductal carcinoma in situ (DCIS). Early removal of these growths will remove the risk of future harm. Mammograms are an effective way to detect cancer early and can aid in the goal of successfully treating and beating the disease. Screening Mammograms Screening mammograms include two image views of each breast, typically when the patient has no breast complaints. For the most part, we start screening around the age of 40 (or earlier depending on family history). Screening mammograms typically happen once a year after the age of 40, although there are times when that recommendation may be altered. This can be discussed with your doctor. Diagnostic Mammograms Diagnostic mammograms are mammograms that include additional x-ray images of the breast after the screening mammogram has identified a problem. The problem could be a density or calcifications that are seen on the initial mammogram. The radiologist then requests additional films to help him/her decide whether the abnormality is worrisome enough to have a biopsy (tissue sampling). Sometimes the extra images prove to be a false alarm and nothing else needs to be done. There are other reasons for a diagnostic mammogram and this can be discussed with your physician. Both screening and diagnostic mammography can help diagnose breast diseases, lumps, cysts and benign and malignant tumors. Preparing For The Procedure Patients should not schedule a mammogram the week before they have their period, as the breasts are usually tender at this time. The doctor may ask the patient not to wear deodorant or lotion under the arms or on the breasts on the day of the mammogram. Otherwise, there is no special preparation needed for the procedure. The Mammogram Procedure During a mammogram, the breast is placed on a small platform and compressed with a paddle while it is exposed to a very low dose of radiation. Compression helps even out the thickness of the breast so that all breast tissue can be visualized, and it also holds the breast still to minimize blurring of the image caused by patient movement. Images of the breast tissue are produced and then displayed on a computer screen for the doctor to view. The patient may experience pressure on the breast from the compression, which may be uncomfortable if the breasts are sensitive. Most patients tolerate the mammogram procedure with no problem. Risks Of A Mammogram A mammogram is considered to be a safe procedure for most women, including those with breast implants. Patients should advise their doctors if they are pregnant or have any pre-existing medical conditions.

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• Breast Ultrasound

  A breast ultrasound is a diagnostic imaging test used to examine the tissues inside the breast. By exposing the breasts to high-frequency sound waves, images of the breast tissue are created. These images are captured in real time and can show internal movement as well as blood flow within the blood vessels in the area. Purpose Of A Breast Ultrasound A breast ultrasound is commonly performed after breast abnormalities are found during a physical examination or mammogram. A breast ultrasound can be used to: Determine the cause of breast symptoms Diagnose a cyst or lump in the breast Monitor the size of a cyst Guide the placement of a needle for a biopsy or drainage procedure A breast ultrasound should not be performed in place of a mammogram but is a supplemental test to further screen for any potential problems. Benefits Of A Breast Ultrasound A breast ultrasound is a noninvasive procedure that involves no preparation or discomfort. It provides doctors with real-time images of the breast in order to help detect and diagnose abnormalities, offering a clear picture of soft tissues that do not show up on X-ray images. This procedure does not expose the patient to any iodizing radiation and is considered safe for nearly all patients. The Breast Ultrasound Procedure During the breast ultrasound procedure, gel is applied to the breast to help the transducer pick up sound waves as it is moved back and forth across the breast. The patient lies on her back with her arms raised above the head. As the transducer is moved across the breast, an image of the breast tissue appears on a computer monitor. The procedure takes about 15 to 30 minutes, depending on whether other procedures are being performed at the same time.

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• Breast MRI

  A breast MRI (magnetic-resonance imaging) is a noninvasive diagnostic imaging test that produces multiple cross-sectional images of the breast to help screen for breast cancer. This advanced procedure is capable of detecting certain abnormalities that may not be found by other imaging techniques. It is the only procedure to produce images of both hard and soft tissue. An MRI is often performed after a mammogram and may be helpful in staging breast cancer. The Purpose Of A Breast MRI There are many reasons to do a breast MRI. Some of the most common reasons include the following: An unclear mammogram or sonogram A very dense mammogram A strong family history of breast cancer An abnormal clinical breast exam that does not match other imaging studies The Benefits Of A Breast MRI A breast MRI is effective in detecting a wide range of breast-tissue abnormalities, including many that may be missed by a mammogram. A breast MRI might also be helpful in the following: Breast cancer diagnosis and staging Confirming abnormalities detected by other imaging exams Monitoring chemotherapy treatment Evaluating the status of breast implants An MRI is an effective diagnostic tool that does not involve any exposure to radiation. Unlike X-rays, radioisotopes, CT scans and other methods that use radiation, MRIs use radiofrequency waves, which detect differences in water concentration and distribution in body tissues. The procedure is safe for nearly all patients and is constantly being improved to make it more comfortable for patients with claustrophobia. The Breast MRI Procedure During a breast MRI, the patient lies facedown on a movable padded table; the breasts fit into hollow depressions that are connected to the MRI scanner through magnetic signals. A contrast dye may be injected into the body to help easily identify any abnormalities. The table then slides into the opening of the machine, and a magnetic field is created around the patient. A breast MRI takes about one hour to perform.

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• Core Needle Breast Biopsy

  A core needle breast biopsy is performed to evaluate breast abnormalities. Although similar to a fine-needle biopsy, a core needle biopsy removes tissue rather than just cells. Through microscopic analysis of this tissue, a determination can be made as to whether or not a malignancy is present. Reasons For Core Needle Breast Biopsy When an unexplained lump in breast tissue is found, or when an unusual mark or mass shows up on a mammogram or during an ultrasound exam, a core needle biopsy may be performed to determine whether the lump is benign or malignant. Each year, more than a million women in the United States undergo this procedure. Seventy to eighty percent of them find that the abnormalities palpated or viewed are benign. Still, because 20 to 30 percent of these biopsies result in the discovery of a malignancy, the procedure is worthwhile. Although it happens rarely, men, as well as women, may be diagnosed with breast cancer. Core Needle Breast Biopsy Procedure As with other breast biopsies, a core needle biopsy is usually administered by a radiologist or a surgeon. Core needle biopsy is a reliable way of determining whether or not a breast abnormality is cancerous. Core needle biopsies are minimally invasive, causing very little discomfort for most patients and leaving no disfigurement. A core needle biopsy is performed under local anesthesia. A core needle breast biopsy involves the following: Tissue Analysis The tissue sample is then sent to a pathology lab for evaluation. The lab issues a pathology report that includes details such as the abnormal tissue’s specific location, whether or not there is cancerous tissue present, and the chemical makeup of the tissue extracted. Recovery From A Core Needle Breast Biopsy Recovery from a core needle biopsy is rapid. The patient is advised to rest for the remainder of the day. Normal activities may be resumed the following day. There may be some bruising and discomfort, for which the following treatments are recommended: Ice pack application Rest Over-the-counter painkillers

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