DeKalb Clinic Specialties

A FIRST AT KCH: RECONSTRUCTION AFTER MASTECTOMY
When Rosemarie Brumley received the bad news last summer that she had breast cancer, she had two options: five weeks of daily radiation or a modified radical mastectomy. Because aggressive cancer cells were evident, a mastectomy was highly recommended by her physician, Dr. Rogér Maillefer, a surgeon at DeKalb Clinic.

Brumley, a licensed practical nurse employed at Sycamore's North Elementary School, understood what she was facing and agreed with Dr. Maillefer. She wanted to make sure the cancer would be gone. "It was a peace of mind thing," said Brumley, who was back at school Sept. 13, following surgery Aug. 5. Dr. Maillefer also recommended what he considers the standard of care for mastectomy - breast reconstruction.

He teamed with Dr. Richard Kopolovic, a community-based board-certified plastic surgeon, to perform Kishwaukee Community Hospital's first breast reconstruction surgery using autologous (patient's own) abdominal tissue. Brad Copple, KCH administrator, credits the recruiting efforts of both the hospital and physicians for making this "first" happen. "We have been successful in recruiting physicians into clinical areas not represented in our community and have looked to them to help expand the medical services available here," Copple said. Dr. Kopolovic, who practices in Sycamore and the western suburbs, has done many breast reconstructions at hospitals to the east. Dr. Maillefer also was trained in this surgical procedure.

Brumley, 62, who has no family history of breast cancer, said she's "a walking advertisement for the importance of getting an annual mammogram." She had no obvious "lump," but comparing her mammographies from previous years, Dr. Maillefer noticed subtle changes in the calcification pattern. He performed a stereotactic core needle biopsy at KCH, where a very tiny, minimally invasive incision is made without much discomfort for the woman.

"The hospital's stereotactic core needle mammogram suite is state of the art, a Cadillac," Dr. Maillefer said. "When I came here, I was amazed. Kish has more technology than any of the three teaching hospitals where I trained." Brumley's biopsy showed ductal carcinoma in-situ, early cancer. A quadrantectomy (removal of a breast quarter) showed invasive cancer. She then required an axillary dissection of lymph nodes to determine how advanced the cancer was.

"Because cells of the tumor were fairly aggressive, I recommended a mastectomy to prevent local recurrence. Then we talked about immediate versus delayed reconstruction or no reconstruction at all," Dr. Maillefer said. Dr. Kopolovic said, "Immediate reconstruction is preferred because studies show women experience less post-operative depression if they have the reconstruction at the same time as the mastectomy.

"They're already dealing with the cancer. With immediate breast reconstruction, they don't have to deal with a prosthesis, too. They walk out of the hospital wearing their usual attire, and don't have to feel awkward because one side of their chest is flat," he said. There are two types of breast reconstruction, depending on body type. Latissimus dorsi flap reconstruction takes muscle from the back and brings it forward. Transverse rectus abdominous muscle (TRAM) flap reconstruction takes muscle from the abdomen with its associated fat and skin.

The TRAM procedure was best suited for Brumley. Tissue from below the belly button was rotated and tunneled into the area where the breast had been. A second surgery will rebuild the nipple and reduce the other breast. "After cancer surgery, this operation gives a woman the option to improve her image," Dr. Kopolovic said.

"Another benefit of using the body's own tissue is that weight gain or loss affects the reconstructed breast as it does the normal breast," he said.

Dr. Kopolovic and Dr. Maillefer used the most current technique, the skin-sparing mastectomy. With cooperation between the general and plastic surgeons, as much of the breast skin as possible is saved. The scar is minimal and is usually around the areola, the darker area around the nipple. With this technique, a woman can wear a bikini top and a scar will not be visible.

Brumley will have her second surgery in December. In an outpatient procedure, Dr. Kopolovic will reconstruct the nipple on the mastectomy side and improve the symmetry of the two breasts. The initial surgery is extensive and requires the expertise of a plastic surgeon, Dr. Maillefer said. The mastectomy itself takes about 60-90 minutes. The reconstruction takes much longer. Altogether, Brumley was in surgery eight hours, which is not unusual.

The incision for the reconstruction was from one side of her waistline to the other. There was significant pain at first from all the muscle that was involved, she said. But a benefit she can brag about now is a flatter stomach. "I got a tummy tuck," Brumley boasted. She did have a post-operative complication that occurs in 20 percent of the cases. Some of the grafted skin died and had to be removed. But for Brumley that was only a minor setback.

"I feel really blessed that this was caught early and that I could have the surgery here so my family and my minister could be with me a lot," she said. "I can't say enough about the doctors and the nurses. I could call them any time, and they would call me back right away. I feel really good, and I'm no longer afraid of the disease."

Brumley also saw Dr. Rabia Parveez, an oncologist practicing at the Illinois Regional Cancer Center in DeKalb, who recommended she go on Tamoxifen for five years. Tamoxifen is an anti-estrogen drug that has been shown to prevent recurrence of breast cancer.

By law, the Women's Health and Cancer Rights Act of 1998 requires insurance companies to cover breast reconstruction after mastectomy, including surgery and reconstruction of the other breast to produce a symmetrical appearance. Prostheses and physical complications related to any stage of the mastectomy also are covered.

Dr. Maillefer, meanwhile, and several other community-based surgeons on the KCH medical staff, are teaming up to study an even more cutting edge treatment for breast cancer, sentinel node biopsy. In that procedure, the first lymph node is removed because that is where the cancer spreads first. This procedure may determine the need for further therapy.

"We're exploring the opportunity for entering into a national study. Within three to five years, sentinel node biopsy may be the standard of care. Very few community hospitals offer this, but we'd like to move toward it," the doctor said.