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1...Can biopsy analysis be performed during the 10 - 20 hour
CONTACTS
SUBJECTS
Meeting Plastic Surgeon Evaluate Mastectomy Left Breast and Plastic S 5
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 17 E863, ref SDS 10 E863.
040502 -
040503 - The plastic surgeon helped clarify opportunities and risks for local
040504 - control to avoid IBC relapse with mastectomy and reconstruction of the
040505 - left breast. The lead surgeon set the purpose of meeting with an
040506 - agenda to guide discussions. ref SDS 0 8H5J The doctor reviewed plans
040507 - for skin biopsies to determine the area of very wide mastectomy for
040508 - clear margins. ref SDS 0 QS65 The plastic surgeon has a lot of
040509 - experience collaborating with the surgeon to treat IBC patients using
040510 - Kaiser's team care practice. ref SDS 0 243H The doctor expects that
040511 - immediate reconstruction to reduce risks of relapse by replacing
040512 - previously infected and radiated skin could require a 20 hour
040513 - operation. ref SDS 0 244K Examination during the meeting revealed
040514 - that tissue from the abdomen might be inadequate for reconstructing
040515 - the left breast due to prior surgery during the 1960s, and so tissue
040516 - may have to be taken from another area of the body. ref SDS 0 UJ6G
040517 - Research on the Internet found a small study on breast reconstruction
040518 - contemporaneous with mastectomy surgery for IBC patients, ref SDS 0
040519 - 269G; median disease-free survival was 19 months with median overall
040520 - survival of 44 months. ref SDS 0 ZW5X Due diligence has identified
040521 - five (5) major risks in case management for Millie's patient history,
040522 - and these present conflicting solutions. ref SDS 0 UZ7K The plastic
040523 - surgeon recommends conservative treatment measures, ref SDS 0 LA6G,
040524 - using a standard closure, and wait for findings from biopsy during
040525 - mastectomy to decide on reconstruction. ref SDS 0 245N The doctor
040526 - will submit a report to confirm understandings from the meeting today.
040527 -
040528 -
040529 -
040530 -
040531 -
040533 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Agenda Plastic Surgery Options Benefits and Risks
040902 -
040903 - Follow up ref SDS 17 WI6K.
040904 -
040905 - Meeting the plastic surgeon today was scheduled by the surgeon to
040906 - review planning on 050923 for a mastectomy, ref SDS 17 F144, proposed
040907 - by the primary care physician on 050913 to strengthen local control.
040908 - ref SDS 14 T646
040910 - ..
040911 - Agenda for meeting includes...
040912 -
040913 - 1. Scope of surgery........................ ref SDS 0 QS65
040914 - 2. Closing surgical wound.................. ref SDS 0 244K
040915 - 3. Problems during surgery................. ref SDS 0 246G
040916 - 4. Post-op risks........................... ref SDS 0 JT9N
040917 - 5. Planning to address risks............... ref SDS 0 UZ7K
040918 -
040919 -
040920 -
040921 -
040922 -
040923 -
040925 - ..
0410 -
0411 -
0412 - 1547
0413 -
041301 - The nurse came into the examination room and reported that the doctor
041302 - is trying to contact the surgeon to discuss the purpose of the meeting
041303 - today.
041305 - ..
041306 - The nurse received an extract of the record from meeting with the
041307 - surgeon on 050923 showing prior discussion on the scope of surgery,
041308 - for a very wide mastectomy. ref SDS 17 NT9G This submission
041309 - highlights Kaiser's requirements from the Healthwise Handbook for due
041310 - diligence on shared decisions about surgery, which can be addressed
041311 - during the meeting today. ref SDS 17 UL8K
041313 - ..
041314 - About 10 minutes later the plastic surgeon came into the examination
041315 - room and reported having been briefed by the surgeon. She brought
041316 - with her the patient submittal just given to the nurse, ref SDS 0
041317 - 7D7N, and thanked Millie for background to prepare for the meeting.
041318 - The plastic surgeon also brought a binder with photographs showing
041319 - mastectomy surgery closures, including plastic surgery solutions under
041320 - consideration today.
041322 - ..
041323 - This meeting lasted about an hour, with the doctor giving excellent
041324 - advice and explanations of options and risks.
041325 -
041326 -
041327 -
041328 -
0414 -
SUBJECTS
Experience IBC Surgical Closure for Very Wide Mastectomy
0603 -
060401 - ..
060402 - Contemporaneous Reconstructive Surgery Reduce Risk of IBC Relapse
060403 - Experience Treating IBC Surgical Closure for Very Wide Mastectomy
060404 - IBC Relapse Reduce Risk Very Wide Mastectomy Contemporneaous osure
060405 - Kaiser Surgical Team Very Experienced Close Collaboration Treat IBC
060406 -
060407 - Follow up ref SDS 17 NT9G.
060408 -
060409 - The doctor initially indicated concurrence with planning on 050923 for
060410 - a "very wide mastectomy" guided by surgical biopsies, ref SDS 17 NT9G,
060411 - and in order to determine the diameter of skin for removing the area
060412 - previously radiated in 2002, and then later infected with IBC in 2003
060413 - - 2005, but now regressed since about 050727. ref SDS 10 YY7F The
060414 - doctor seemed aware from collaboration with the general surgeon that
060415 - the purpose of a very wide mastectomy is to remove previously infected
060416 - skin which may still contain microscopic cancer cells that risk
060417 - relapse, if left in place, and further to perform contemporaneous
060418 - reconstruction of the left breast with skin tissue from other
060419 - locations, e.g., hip, stomach, back, which are free of cancer cells,
060420 - thereby reducing risk of relapse, while also allowing additional
060421 - radiation treatments, if relapse should none-the-less occur, as
060422 - presented in Doctor Grissom's 2nd opinion received on 050920,
060423 - ref SDS 15 GT3M, and discussed with the general suregon in a meeting
060424 - on 050923. ref SDS 17 KF6I
060425 -
060426 - [...below, Doctor Smith proposes postponing reconstructive surgery
060427 - to reduce risks of relapse be postponed until after initial simple
060428 - mastectomy surgery is accomplished successfully. ref SDS 0 245N
060430 - ..
060431 - [On 051010 Doctor Grissom explains purpose of very wide mastectomy
060432 - with contemporaneous breast reconstruction for a patient presenting
060433 - with secondary IBC and no evidence of distant metastasis for 4
060434 - years is for local control that could yield a cure. ref SDS 22 GW5K
060436 - ..
060437 - The doctor appears approximately 40 years old, and described a long
060438 - working relationship of close collaboration treating patients with the
060439 - referring surgeon, commenting today something along the lines of being
060440 - the surgeon's "right hand man" for mastectomy operations. The doctor
060441 - further seemed to describe considerable experience and familiarity
060442 - performing reconstructive plastic surgery to treat IBC cases,
060443 - including closure of surgical wounds from "very wide mastectomy" being
060444 - considered in this case.
060446 - ..
060447 - Millie expressed confidence in Kaiser's team care practice of close
060448 - collaboration, described by the doctor. Significant experience of
060449 - surgeon working closely with plastic surgeon to treat IBC strengthens
060450 - chances of success performing a complex operation being considered at
060451 - this time. The primary care physician noted on 050329 that Millie's
060452 - surgeon is the most experienced in the Walnut Creek hospital for
060453 - treating breast cancer. ref SDS 9 IE8O Earlier on 050324, the surgeon
060454 - explained that IBC is a very rare condition, and noted that the
060455 - surgery department in Walnut Creek may see one patient a year
060456 - afflicted with IBC. The surgeon related having possibly treated an
060457 - IBC patient once in the past five (5) years. ref SDS 8 QJ35
060458 -
060459 -
060460 -
060461 -
0605 -
SUBJECTS
Primary Closure DIEP Flap or TRAM Breast Reconstruction Risk Fatigue
0703 -
070401 - ..
070402 - Contemporaneous Reconstructive Surgical Closure 20 Hour Operation
070403 - 20 Hours Risks Mistakes Contemporaneous Reconstructive Surgical Closure
070404 -
070405 - The doctor handed Millie a printed document on the DIEP flap plastic
070406 - surgery procedure that reflect her discussions with the general
070407 - surgeon on the scope of surgery in this case to reduce the chance of
070408 - relapse, per above. ref SDS 0 QS65
070410 - ..
070411 - There was no time devoted to read nor discuss this printed document
070412 - received during the meeting today.
070414 - ..
070415 - The doctor explained that a DIEP flap mastectomy closure is commonly
070416 - performed in Belgium and/or was developed in Belgium. There was also
070417 - some discussion of a TRAM closure for mastectomy surgery. At some
070418 - point the doctor showed a photograph from her binder to illustrate a
070419 - patient treated with either a DIEP or a TRAM, and the doctor noted
070420 - that a full breast reconstruction would occur with the method shown in
070421 - the picture.
070423 - ..
070424 - The doctor examined Millie below the belly button, and asked about a
070425 - surgical scar. Mil explained a prior gynocological procedure in the
070426 - early 1970s. The doctor advised that this prior surgery presents a
070427 - risk for performing plastic reconstructive surgery that tissue from
070428 - the stomach would be inadequate, and that this problem cannot be
070429 - determined until the operation is performed.
070431 - ..
070432 - There was no discussion of other options for obtaining reconstructive
070433 - tissue, e.g., from the back for a TRAM flap, cited on the Internet for
070434 - Imaginis...
070436 - ..
070437 - Transverse Rectus Abdominus Muscle (TRAM)
070439 - ..
070440 - http://imaginis.com/breasthealth/reconstruction.asp#types
070441 -
070442 - ...which says in part...
070443 -
070444 - The second main type of breast reconstruction, muscle flap
070445 - reconstruction, involves using a patient's own tissue to
070446 - rebuild the contour of the breast. Tissue may be taken from
070447 - the back, stomach, or buttocks. Muscle flap operations leave
070448 - scars both from where the tissue was taken and on the
070449 - reconstructed breast. In a free TRAM (Transverse Rectus
070450 - Abdominis Muscle) flap procedure, the surgeon transfers some
070451 - abdominal skin, fat, and a small piece of muscle under the
070452 - skin to the intended breast area. The tissue from abdomen is
070453 - usually enough to create a breast shape. If not, a saline
070454 - implant may also be inserted. In a back tissue (latissimus
070455 - dorsi) reconstructive flap, a surgeon transfers muscle and
070456 - skin from the patient's back to the intended breast area. This
070457 - creates a pocket where an implant is usually inserted.
070459 - ..
070460 - Muscle flap procedures take much longer than implant
070461 - operations, lasting about four to five hours, and patients
070462 - typically stay in the hospital three to four days, compared to
070463 - one day with the implant operation. Though the recovery is
070464 - slower, the breast usually looks and feels more natural to
070465 - most women.
070467 - ..
070468 - Another Internet location for....
070469 -
070470 - Breast Reconstruction with Tissue Flaps
070471 - By Houston, Texas Plastic Surgeon & Cosmetic Surgeon,
070472 - Dr Mark. Schusterman
070473 -
070474 - http://www.alwaysyouthful.com/tram-flap-tissue-flap-specialist.asp
070475 -
070476 - ...describes the DIEP flap procedure...
070477 -
070478 - Deep Interior Epigastric Perforator Flap (DIEP)
070480 - ..
070481 - For patients needing only a small amount of tissue to
070482 - reconstruct the breast mound or those needing bilateral
070483 - reconstruction, the DIEP Flap offers some advantages. The DIEP
070484 - Flap is a free flap of skin, blood vessels and fat only, and
070485 - no muscle. Like the Free TRAM Flap, tissue is harvested from
070486 - your lower abdomen, but only the overlying skin, fat and blood
070487 - vessels are removed. The rectus abdominus muscle is left
070488 - intact and in place.
070490 - ..
070491 - The record is not clear on whether primary closure of a "very wide
070492 - mastectomy" being considered in this case would require a "...small
070493 - amount of tissue..." for reconstruction, which seems to be described
070494 - for a DIEP flap in Doctor Schusterman's article.
070496 - ..
070497 - The doctor seemed to say today during the meeting at Kaiser that
070498 - surgery for a "very wide mastectomy" to treat an IBC patient on
070499 - relapse, and further that primary closure of the surgical wound with
070500 - concurrent reconstructive plastic surgery to achieve results shown in
070501 - the doctor's photograph, per above, ref SDS 0 245H, and for the
070502 - purpose of reducing the risk of relapse, per above, ref SDS 0 QS65,
070503 - would require a complex, 20 hour operation. She said this is a major
070504 - operation that entails a lot of risk for mistakes due fatigue and to
070505 - variables that require spontaneous adjustments during the operation.
070506 - This aligns generally with Doctor Grissom's 2nd opinion consultation
070507 - on 050912 that Millie's condition of IBC on relapse, with inflammation
070508 - having spread beyond the breast is very severe, and requires a major,
070509 - complex solution with a 10 hour surgery and contemporaneous
070510 - reconstruction to achieve near-to-long-term remission with hiatus from
070511 - chemotherapy to relieve debilitating side effects. ref SDS 13 V150
070512 - Other authorities describe a 4 - 6 hour operation, though none mention
070513 - the scope of a "very wide mastectomy," which may take longer for
070514 - closure.
070515 -
070516 -
070517 -
070518 -
070519 -
0706 -
SUBJECTS
Study Survival Disease-free 19 Months IBC Treated with Mastectomy Re
Research Criteria on Surgery for Mastectomy to Reduce Chance of Relap 1
1504 -
150501 - ..
150502 - Study Success IBC Treated with Mastectomy and Reconstructive Surgery
150503 -
150504 - Research on the Internet found a study that seems to show survival
150505 - statistics for IBC patients after mastectomy and reconstructive
150506 - surgery....
150507 -
150508 - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10703855&dopt=Abstract
150510 - ..
150511 - Esthetic reconstruction after mastectomy for inflammatory
150512 - breast cancer: is it worthwhile?
150514 - ..
150515 - Department of General and Oncologic Surgery, City of Hope
150516 - National Medical Center, Duarte, CA, USA.
150518 - ..
150519 - BACKGROUND: Because inflammatory breast cancer (IBC) has been
150520 - viewed as a malignancy with a poor likelihood of longterm
150521 - survival, few women have been offered esthetic reconstruction
150522 - after mastectomy for IBC. Recent advances in multimodality
150523 - therapy have improved the outcomes for women with this disease.
150524 - The purpose of this review was to assess the results of
150525 - esthetic breast reconstruction in the population with IBC.
150527 - ..
150528 - STUDY DESIGN: Review of medical records at the City of Hope
150529 - National Medical Center for the 10-year period ending in May
150530 - 1997, revealed 23 women who underwent elective esthetic breast
150531 - reconstruction after mastectomy for IBC. The records of these
150532 - patients were reviewed retrospectively. Patients requiring
150533 - reconstruction for large surgical chest wall defects were not
150534 - included in the review.
150535 -
150537 - ..
150538 - 23 Patients Mastectomy 14 Immediate Reconstruction 18 TRAM
150539 - Median Survival 44 Months 6 Local Recurrence 10 Distant Failure
150540 - 30% No Recurrence After Mastectomy Immediate Reconstruction
150541 - 19 Months Median Disease Free After Mastectomy + Reconstruction
150542 -
150543 - RESULTS: Treatment for IBC included mastectomy in all
150544 - patients, chemotherapy in 22, and chest wall radiation therapy
150545 - in 14. Immediate reconstruction was performed at the time of
150546 - mastectomy (n = 14) or was delayed (n = 9). The types of
150547 - reconstruction included transverse rectus abdominis
150548 - musculocutaneous flap (n = 18), latissimus dorsi flap (n = 2),
150549 - or prosthetic mammary implant reconstruction (n = 3). Seven
150550 - women chose to undergo additional reconstruction procedures
150551 - (ie, nipple reconstruction) after their initial reconstruction.
150552 - With a median followup of 44 months for survivors, 16 patients
150553 - developed recurrence after reconstruction. Of these, 6 were
150554 - local recurrences and 10 were distant failures. Seven patients
150555 - are currently alive with no evidence of disease, 4 are
150556 - currently alive with disease, and 12 have died as a result of
150557 - breast cancer. The median disease-free survival after
150558 - reconstruction was 19 months. The median overall survival
150559 - after reconstruction for all patients was 22 months. The only
150560 - negative predictor of survival was a positive surgical margin
150561 - at mastectomy.
150563 - ..
150564 - CONCLUSIONS: The significant emotional and esthetic benefits
150565 - of breast reconstruction should be available to women with IBC.
150566 - In light of the improving prognosis of IBC with current
150567 - aggressive multimodality treatment, reconstructive procedures
150568 - should be offered as part of comprehensive therapy
150569 -
150570 -
150571 -
150572 -
150573 -
150574 -
1506 -
SUBJECTS
Planning Pre-op Identify Risks and Prepare for Adjustments Due Dilig
Local Control Conservative Treatment Planning Primary Care Physician
1704 -
170501 - ..
170502 - Planning Pre-op 5 Risks Require Prepare for Adjustments
170503 - Due Diligence Time Out Risks Performing Surgery Post-op Recovery
170504 - Risks of Pulmonary Emboli, Source Tissue Defective and Reexcision
170505 -
170506 - Five (5) major risks have been identified for conservative treatment
170507 - options to avoid risks of relapse. Conflicting solutions presented
170508 - for alternate treatment scenarios require due diligence to carefully
170509 - assess risks and benefits in choosing a course of action...
170511 - ..
170512 - 1. Local control - primary care physician cites risk of relapse
170513 - without mastectomy surgery during a "window of opportunity"
170514 - after IBC subsides with chemotherapy, shown by favorable
170515 - examinations and tests, reported on 050729. ref SDS 11 5B9K
170516 - Local control reduces risk of metastatic disease from spinning
170517 - of control, explained by primary care physician on 050913.
170518 - ref SDS 14 5T4J
170520 - ..
170521 - Balancing this risk is patient history showing local and
170522 - regional control improved with chemotherapy, reported on
170523 - 050727. ref SDS 10 YY7F
170524 -
170525 -
170526 -
1706 -
SUBJECTS
Planning Pre-op Identify Risks and Prepare for Adjustments Due Dilig
Surgical Wound Won't Heal Because IBC Still Active Despite PET and S
1904 -
190501 - ..
190502 - 2. IBC risks surgical wound won't heal, despite favorable
190503 - examinations, and tests cited by the primary care physician on
190504 - 050729. ref SDS 11 5B9K Even if pending PET test, ordered by
190505 - primary care physician on 050913, ref SDS 14 T699, and
190506 - perimeter biopsies, ordered by the surgeon on 050923,
190507 - ref SDS 17 SZ6M, find no evidence of disease, there remains a
190508 - risk of relapse while off chemotherapy during surgery and
190509 - recovery, noted by the surgeon on 050727, ref SDS 10 R34I, and
190510 - restated during the meeting on 050923. ref SDS 17 KF6I This
190511 - risk may reflect persistent CA 15-3 cancer marker above normal
190512 - the past few months, reported by primary care physician on
190513 - 050913. ref SDS 14 GJ5M Return of IBC could prevent healing a
190514 - surgical wound, cited by Doctor Bailey in a 2nd opinion
190515 - reported on 050922, ref SDS 16 XD8P, and demonstrated by the
190516 - punch biopsy that took a year to heal due to IBC, reported on
190517 - 050107. ref SDS 7 IS5N
190518 -
190519 - [On 051007 doctor's notes from meeting confirm risk that
190520 - surgical wound may not heal due to IBC. ref SDS 20 KO64
190522 - ..
190523 - Balancing this risk is patient history showing that when
190524 - chemotherapy reduced IBC, the biopsy wound healed quickly,
190525 - reported by the surgeon on 050727. ref SDS 10 WI6K
190527 - ..
190528 - Very wide mastectomy with contemporaneous and immediate reconstructive
190529 - surgery reduce risk of losing local control from IBC relapse...
190530 -
190531 - Doctor Grissom and Doctor Bailey indicate that risk of cancer
190532 - relapse can be reduced by performing a very wide mastectomy
190533 - along with pre-op biopsies to avoid cutting through skin
190534 - infected with IBC, reported on 050922. ref SDS 16 XD8P
190535 - Replacing skin previously infected with IBC by using
190536 - contemporaneous reconstructive plastic surgery further reduces
190537 - risk of relapse, and, also, enables radiation, for standard
190538 - treatment of IBC in the event risks of recurrence materialize
190539 - following mastectomy, and as noted by the surgeon during the
190540 - meeting on 040429, ref SDS 4 SD7F, also, recommended by
190541 - Kaiser's Tumor Board, reported on 040517. ref SDS 5 F77M
190543 - ..
190544 - Below, the plastic surgeon today cites concern about clear
190545 - margins failure requiring reexcision, which can be reduced with
190546 - contemporaneous biopsy for verifying clear margins. ref SDS 0
190547 - 2491
190548 -
190549 -
190550 -
1906 -
SUBJECTS
Planning Pre-op Identify Risks and Prepare for Adjustments Due Dilig
Coumadin Suspended Risk Pulmonary Emboli PE Risks Death During Surge
2104 -
210501 - ..
210502 - Coumadin Suspended Pulmonary Emboli PE Risks Death During Surgery
210503 - Plastic Surgeon Coumadin Treatments Stopped Risks PE During Surgery
210504 - Pulmonary Emboli PE Risks Death During Surgery When Coumadin Suspended
210505 -
210506 - Three (3) new risks of contemporaneous (immediate) reconstructive
210507 - plastic surgery were presented today by the doctor...
210508 -
210509 - 3. Millie is being treated with Coumadin for pulmonary emboli (PE)
210510 - -- a 20 hour operation risks bleeding problems which could
210511 - cascade out of control. This risk was cited by Doctor Bailey
210512 - in a 2nd opinion received on 050922. ref SDS 16 6Z5Q
210513 -
210514 - [On 051021 Millie has mastectomy surgery; nurse draws blood
210515 - to evaluate pulmonary emboli risk related to treatment with
210516 - Coumadin. ref SDS 26 QW4I
210518 - ..
210519 - Primary care physician planned on 050729 to prescribe an
210520 - alternate medication to replace Coumadin so that bleeding is
210521 - controlled during the surgical period. ref SDS 11 WE9H
210523 - ..
210524 - Millie reviewed patient history showing minimal evidence of
210525 - pulmonary emboli, reported on 041104. ref SDS 6 4Y9G There is
210526 - a single report of PE among a great many tests before and after
210527 - the one and only positive test on 041103. Family history of
210528 - PE-type problems supports caution, as proposed by the doctor
210529 - today. Millie has reported bleeding from fingers, toes, and
210530 - nose, as side effects of chemotherapy. The medical team has
210531 - not been concerned nor made adjustments to Coumadin treatments
210532 - in order to avoid risks of pulmonary emboli, including
210533 - bleeding. This bleeding appears to coagulate normally while on
210534 - Coumadin, suggesting that while risk should not be ignored, in
210535 - this case the occurrence of bleeding may be manageable based on
210536 - patient history.
210538 - ..
210539 - If complications of PE should occur during surgery, can this be
210540 - addressed by the surgical team, or would it require having a
210541 - specially trained surgeon standing by for such eventuality?
210542 -
210543 -
210544 -
2106 -
SUBJECTS
Planning Pre-op Identify Risks and Prepare for Adjustments Due Dilig
Stomach Tissue Inadequate for Breast Reconstruction Due to Prior Sur
2604 -
260501 - ..
260502 - IBC Relapse Requires Intact Tissue for Treatment
260503 - Mastectomy IBC Relapse Chemotherapy Reduced Effectiveness
260504 - Stomach Tissue Inadequate Harvest for Breast Reconstruction
260505 - Blood Vessels Mastectomy Reduces Chemotherapy Effectiveness
260506 -
260508 - ..
260509 - 4. Millie's prior surgery in the stomach area where tissue would
260510 - be used for reconstructive surgery, may have reduced or
260511 - completely eliminated blood vessels required to deliver
260512 - chemotherapy treatment on the one hand, and, also, nutrients
260513 - from the body's natural immune system to the breast skin. This
260514 - would reduce effectiveness of treatment and therefore slow, or
260515 - even prevent recovery in the event of IBC relapse. The doctor
260516 - feels that this risk can only be evaluated during the course of
260517 - reconstruction, and so presents a significant risk of failure
260518 - for contemporaneous and immediate reconstructive surgery.
260520 - ..
260521 - During the operation, can tissue be used from another location,
260522 - say for the example the back, to avoid this issue of depleted
260523 - blood vessels in previously altered tissue in the abdomen?
260524 -
260525 - [On 051007 received Doctor Smith's report on the meeting
260526 - today; the doctor discusses prior surgical procedures on
260527 - the abdomen, but does not cite this condition for risks of
260528 - missing blood vessels that slow recovery from IBC relapse,
260529 - as discussed today, ref SDS 20 KO49; prior abdomenal
260530 - surgery is mentioned among other reasons for postponing
260531 - aggressive breast replacement surgery, but no rationale is
260532 - presented for this risk. ref SDS 20 635M
260534 - ..
260535 - [On 051007 primary care physician orders standard
260536 - mastectomy to remove breast mass with blood vessels needed
260537 - for delivering treatment and nutrients to the breast skin,
260538 - which impacts risk of relapse and effectiveness of
260539 - treatment. ref SDS 20 P64J
260541 - ..
260542 - [On 051011 Doctor Bailey comments that risks of mastectomy
260543 - are compounded for secondary IBC patients, because, where
260544 - there is no evident tumor to remove within the breast,
260545 - benefits of palliation are reduced by removing breast mass
260546 - with blood vessels needed to treat relapse of cancer.
260547 - ref SDS 23 G65S
260549 - ..
260550 - [On 051012 opportunities and risks of mastectomy surgery
260551 - following Kaiser's requirements for Time Out to perform due
260552 - diligence, ref SDS 24 IH4P; risk of slow recovery from IBC
260553 - relapse due to loss of blood vessels for delivering
260554 - chemotherapy treatment cited. ref SDS 24 IC37
260556 - ..
260557 - [On 051027 surgeon reports having stretched skin and tissue
260558 - sufficiently for standard closure of a wider than normal
260559 - mastectomy, and this maintains sufficient blood vessel and
260560 - related body mass for delivering nutrients and treatment,
260561 - if necessary, for normal healing of the surgical wound, and
260562 - in the event of IBC relapse. ref SDS 27 QY8K
260564 - ..
260565 - [On 060922 analysis of slow recovery with the same
260566 - chemotherapy treatment following IBC relapse on 060623,
260567 - ref SDS 28 9E6L, cites Doctor Smith's anlaysis on the
260568 - impact of diminished capacity for blood vessels.
260569 - ref SDS 28 ML3I
260570 -
260571 -
260572 -
260573 -
2606 -
SUBJECTS
Planning Pre-op Identify Risks and Prepare for Adjustments Due Dilig
Clear Margins Fail Reexcision Prevents Immediate Contemporaneous Rec
2804 -
280501 - ..
280502 - Clear Margins Biopsy During Surgery Very Wide Mastectomy
280503 -
280504 -
280505 - 5. Clear margins may not be achieved with initial surgery, even
280506 - with a "very wide mastectomy" based on pre-op biopsies. This
280507 - determination will be made based on post-op biopsy of removed
280508 - breast tissue, and reported about a week later. This could
280509 - require reexcision, as occurred with the original surgery on
280510 - 020327. ref SDS 2 0001 The doctor seemed to indicate that
280511 - performing contemporaneous reconstructive plastic surgery with
280512 - a DIEP flap, or a TRAM eliminates or reduces ability to perform
280513 - reexcision, if clear margins are not achieved. The doctor
280514 - commented that pre-op diagnostics with surgical biopsies helps
280515 - reduce this risk, but does not eliminate the issue.
280517 - ..
280518 - This risk seems closely related to risk of relapse that could
280519 - extend and prevent healing the surgical wound, per above.
280520 - ref SDS 0 9W4I
280521 -
280522 - [On 051007 doctor's notes from meeting confirm risk that
280523 - surgical wound may not heal due to IBC. ref SDS 20 KO64
280525 - ..
280526 - [On 051027 surgeon reported post op biopsy found clear
280527 - margins. ref SDS 27 JN3L
280529 - ..
280530 - Can biopsy analysis be performed during the 10 - 20 hour
280531 - operation, so that clear margins are assessed and verified
280532 - during primary surgery, rather than after the fact?
280534 - ..
280535 - Research found that this practice increases risk of failure.
280536 - Evidently at one time contemproaneous biopsy analysis was
280537 - performed, and experience showed a large percentage, e.g.,
280538 - 23%, of the cases were incorrectly performed, so this
280539 - practice is now discouraged.
280540 -
280541 -
280542 -
280543 -
280544 -
280545 -
2806 -
SUBJECTS
Planning Pre-op Identify Risks and Prepare for Adjustments Due Dilig
Conservative Treatment Enables Recovery Options Avoid Solve Problems
3004 -
300501 - ..
300502 - Conservative Treatment Enables Recovery Options Avoid Solve Problems
300503 -
300504 - The doctor explained a personal preference for treating IBC patients
300505 - with conservative measures. She prefers to maintain options to
300506 - recover from risks of mistakes during surgery and post-surgery
300507 - problems.
300509 - ..
300510 - Patient history in this case shows "conservative measures" occur in
300511 - many, and conflicting forms.
300513 - ..
300514 - The primary care physician proposes conservative measures using
300515 - mastectomy to maintain local control that hopefully reduces chance of
300516 - relapse, and by extension somewhat reduces the chance of distant
300517 - metastasis, keeping in mind biopsy on 020312 was out of capsule
300518 - reported on 020321. ref SDS 1 4U8X
300520 - ..
300521 - Doctor Benz and Doctor Bailey recommend conservative measures with
300522 - chemotherapy treatment to avoid altogether risks of surgery causing
300523 - relapse problems. This measure seems to greatly reduce chances of
300524 - disease free survival without chemotherapy, i.e., remission, though
300525 - possibly not, and so requires additional analysis.
300527 - ..
300528 - Doctor Grissom proposes conservative measure to reduce risks of IBC
300529 - relapse by using a very wide mastectomy and reconstructive surgery.
300530 - If IBC does not relapse, then chances of distant metastasis seem
300531 - reduced, though continuing due to original findings out of capsule
300532 - from the biopsy on 020308, and reported later on 020321.
300534 - ..
300535 - Millie explained having asked for the meeting today in order to hear
300536 - about risks and planning to be prepared for problems. She asked if
300537 - the surgical team prepares a due diligence checklist of problems and
300538 - solutions? Are pre-op planning meetings conducted to review
300539 - particularities of the patient, and develop a work plan with staffing
300540 - and a flow chart, like a CPM schedule, showing work that people will
300541 - perform in a 10 or 20 hour operation presented today?
300543 - ..
300544 - The doctor seemed to say that Kaiser supports pre-op planning to
300545 - identify risks tailored to the patient profile, so that everyone is
300546 - prepared to adjust in the event of problems during the operation, and
300547 - post-op recovery.
300548 -
300549 -
300550 -
300551 -
3006 -
SUBJECTS
Planning Pre-op Identify Risks and Prepare for Adjustments Due Dilig
Post-op Problems Standard Closure More Options for Adjustments Docto
3204 -
320501 - ..
320502 - Postpone Breast Reconstruction to Avoid Risks of Complex Surgery
320503 - Post-op Problems Standard Closure More Options for Adjustments
320504 - Standard Closure Very Wide Mastectomy Preserves Reconstruction Option
320505 -
320506 - The doctor proposed that breast reconstruction using a DIEP flap or
320507 - TRAM to reduce the risk of relapse, reviewed above, ref SDS 0 QS65, be
320508 - postponed for the initial mastectomy, and instead try to close the
320509 - very wide mastectomy with a "standard closure" procedure to avoid high
320510 - risks of a long, complex surgery described today, per above.
320511 - ref SDS 0 246G
320512 -
320513 - [On 051007 doctor's notes confirm understanding that plastic
320514 - surgeon recommends postponing breast reconstruction to reduce
320515 - risks of complex surger. ref SDS 21 KO58
320517 - ..
320518 - The doctor presented a photograph which she said shows closure for a
320519 - "standard mastectomy" on the left breast. This picture indicated an
320520 - approximate 2" - 3" long horizontal sutured incision about an inch or
320521 - so below the breast line connection to the chest; it was angled
320522 - slightly upward, and closed the prior location of a left breast after
320523 - removal. The picture was remarkable for no signs of skin stretched to
320524 - close removal of an area of skin. It was not clear how this result
320525 - could be achieved for a large area of skin removal in the case of a
320526 - very wide mastectomy, required to reduce the risk of relapse by
320527 - removing microscopic cancer cells, discussed with the general surgeon
320528 - on 050923. ref SDS 17 E863 Doctor Smith did not present pictures
320529 - showing a standard closure for a very wide mastectomy discussed, also,
320530 - discussed with the doctor today, per above. ref SDS 0 QS65
320532 - ..
320533 - The doctor indicated that a standard closure can be accomplished by
320534 - the surgeon for a very wide mastectomy, and this method would preserve
320535 - options for plastic surgery to later use a DIEP flap or TRAM after
320536 - biopsy of removed tissue determines clear margins and reexcision is
320537 - performed, if needed. Standard closure reduces the risk from bleeding
320538 - associated with pulmonary emboli. Additionally, if plastic surgery
320539 - reconstruction is performed outside the pressures of primary surgery,
320540 - then problems of inadequate tissue (see point 2, ref SDS 0 248I) are
320541 - markedly less critical. This part of the discussion seemed less clear
320542 - with references to skin grafts from the thigh as an alternative
320543 - strategy. The overall impression was a preference for a standard
320544 - closure, and deferred consideration of reconstructive surgery, rather
320545 - than contemporaneous plastic surgery closure.
320546 -
320547 - [On 051019 prepared letter asking Kaiser to take Time Out for
320548 - performing due diligence requirements presenting risks and
320549 - benefits, ref SDS 25 DY5P, on the scope of mastectomy surgery in
320550 - this case. ref SDS 25 DZ56
320552 - ..
320553 - [On 051021 surgeon reported performing a very wide mastectomy and
320554 - that a standard closure was accomplished. ref SDS 26 8K6N
320556 - ..
320557 - The doctor seemed to further suggest that standard closure offers more
320558 - latitude for recovery in the event of post-opt problems from IBC
320559 - relapse that prevents healing of mastectomy surgery.
320561 - ..
320562 - If standard closure can be performed for a very wide mastectomy, then
320563 - deferring reconstructive plastic surgery for a week to verify clear
320564 - margins might be a conservative step that maintains benefits proposed
320565 - by Doctor Grissom and Doctor Bailey to preserve post-op radiation
320566 - treatment, discussed recently on 050923 in connection with meeting the
320567 - surgeon. ref SDS 17 4G4F Deferring reconstructing the breast,
320568 - however, risks closing the wound with tissue known to have been
320569 - previously infected with IBC, thus increasing risk the wound will not
320570 - heal.
320571 -
320572 - [On 051007 plastic surgeon report recommends postponing breast
320573 - reconstruction to verify successful recovery from wide mastcomy.
320574 - ref SDS 20 635M
320576 - ..
320577 - A conservative measure would be to include biopsy analysis during the
320578 - 10 - 20 hour operation, so that clear margins can be assessed and
320579 - verified during primary surgery, rather than after the fact, if this
320580 - can be accomplished, so that reconstruction can proceed immediately.
320581 -
320582 -
320583 -
320584 -
320585 -
3206 -
SUBJECTS
Written Report on Meeting Will Be Distributed to Patient Confirming
Surgeon Commended Strong Commitment to Millie's Case Working Extra H
3404 -
340501 - ..
340502 - Written Report Confirm Understandings Medical Planning from Meeting
340503 - Meeting Notes Written Report Confirm Understandings Medical Planning
340504 -
340505 - The doctor will submit a written report to confirm understandings from
340506 - the meeting today, that complements the surgeon's report for the
340507 - meeting on 050923, and received on 050927. ref SDS 18 0001 The doctor
340508 - can address issues of shared responsibility on surgery listed in
340509 - Kaiser's Healthwise Handbook, and cited in the record on 050923 which
340510 - was submitted for the meeting today, per above. ref SDS 0 7D7N
340511 -
340512 - [On 051006 Chantel, the advise nurse in Plastic Surgery
340513 - department, found that Doctor Smith had dictated a report, but the
340514 - dictation had not been trascribed; Chantel will expedite
340515 - trascribing and proof reading by the doctor in time to support
340516 - patient meeting with the oncologist on 051007. ref SDS 19 0001
340518 - ..
340519 - [On 051007 received Doctor Smith's report during meeting with
340520 - primary care physician. ref SDS 20 MW6F
340522 - ..
340523 - Millie thanked the doctor for an effective meeting that presents new
340524 - issues for consideration of a surgical solution. The doctor commented
340525 - that the surgeon has strong feelings for Millie's case, and she
340526 - praised the surgeon for commitment to patients as people, rather than
340527 - mere professional tasks.
340529 - ..
340530 - These feelings may eminate from work on 040419 when the surgeon
340531 - performed an unscheduled biopsy procedure that discovered IBC,
340532 - eventually leading to the meeting today. ref SDS 3 789F Previously,
340533 - on 050329 the surgeon won praise the primary care physician in the
340534 - Oncology Department for being a top breast surgeon. ref SDS 9 YV95
340535 - This has been evident from work throughout patient history in this
340536 - case, listed on 050812. ref SDS 12 TW6H
340537 -
340538 -
340539 -
340540 -
340541 -
340542 -
340543 -
340544 -
3406 -