Breast Cancer Management in a Small Rural Hospital

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Breast Cancer Management in a Small Rural Hospital

• Daniel J. Margo, M.D., FACS
• FRSAA

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• Medical School University of Minnesota
• Surgical Residency University of North Dakota
• - Grand Forks
• - Belcourt
• - Fargo
• - Fresno, California
• - Orlando, Florida
• An Ideal Program for the Development of Rural
  Surgeons

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• History of Sentinel Lymph Node Biopsy
• Options for Identification of the Sentinel Lymph
  Node
• Road Blocks to Sentinel Lymph Node Biopsy
  Technology at Smaller Facilities
• Experience of Sentinel Lymph Node Biopsy at the
  Deer River Hospital, Deer River, Minnesota
• Management of the Positive Sentinel Lymph Node
• Conclusion

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• SLN Biopsy for Melanoma
• SLN Biopsy for Breast Cancer
• 2002 University of Minnesota
• 2004 Deer River Hospital

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SLN Biopsy For Breast Cancer

• Blue Dye
• Technetium
• Both ?

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• Lymphazurin Blue
• - Peritumoral
• - 5 ccs U.S. Surgical
• (backorder)
• Technetium
• - 6 oclock, Intradermal, Subcuticular
• - 1 Millicurie in 1 cc.
• - 0.1 Micron Filter

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• Massage of Tissue
• 15 Minute Delay
• Ethicon Neoprobe
• First 10 With Completion LN Dissection

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Itasca County, Minnesota

• 42,000 People
• 3 Hospitals
• - 1 Large Hospital
• - 2 Small Hospitals
• (One of These is in Deer River ?, MN)
• The Blandin Foundation

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Deer River, Minnesota

• Population 903 People
• Elevation 1305 Feet
• Distance to Grand Forks 171 Miles
• Total 2379

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Deer River Hospital

• 20 Licensed Beds
• 1 Operating Room
• 0 Nuclear Medicine Laboratories
• 0 Pathology Departments

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How In The Heck Are We Going To Get Technetium?
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Cooperation

• A Partnership
• Shared Medical Technologies Incorporated
• Bemidji, Minnesota

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Technetium

• 1 Millicurie in 1 cc.
• 3 cc. Syringe
• 25 Gauge Needle
• Transport

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Surgery

• Dissection, Removal, Harvest of the Sentinel
  Lymph Node
• Packaging
• Transport

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Our Experience

• First 10 Cases
• - Sentinel Nodes
• 1 Node 3
• 2 Nodes 5
• 3 Nodes 2

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Our Experience

• First 10 Cases
• - Completion Dissection
• 6 Negative
• 2 Negative by HE
• Positive by Immunoperoxidase
• 2 Positive by HE
• (Completion Dissections Were (-) in All 6 From
  (-)
• (Completion Dissections Were () in 3 of the
  () Group

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Our Experience

• 2004 Through Present
• - Total Breast Cancer Patients (42)
• - WFMC (1) U of M (1)
• - Mastectomy (15)
• - Lumpectomy (25)
• - ID of Sentinel Node (37)
• - Sentinel Node Negative
  (24)
• - Sentinel Node Positive
  (13)

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Our Experience

• 2004 Through Present
• - Total Breast Cancer Patients (42)
• - Sentinel Node Positive
  (13)
• - Positive by HE (6)
• - Positive by
  Immunoperoxidase (7)
• - Mets by
  Immunoperoxidase (3)
• - Micrometastases (4)

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Our Experience

• 2004 Through Present
• - Total Breast Cancer Patients (42)
• - Infiltrating Ductal
  Carcinoma (36)
• - Lobular Carcinoma (2)
• - DCIS (2)

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Management of The Positive Sentinel Lymph Node

• Truly Positive Completion Dissection
• Micrometastases No Further Surgery
• What is the Correct Management of a Positive
  Lymph Node ?

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Conclusion

• While We Do Rural Surgery, Technology Continues
  to Advance
• When the Time is Right, We Must Explore the
  Opportunity to Bring These Technologies to Our
  Small Rural Communities
• With Cooperation and a Little Effort, These
  Techniques Can Be Appropriately Provided at Home

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