Cutting Edge Technology in Operation
Breast cancer surgery at Derriford Hospital has been radically improved by a £50,000 Digital X-Ray Machine, donated by local fundraisers. The Herald’s Health Reporter Diana Prince donned scrubs to see how it enables surgeons to instantly analyse removed tumours in the operating theatre, making procedures faster and safer.
It is 2pm in theatre eight and breast cancer patient Michelle Lewis is lying unconscious under general anaesthetic on the operating table.
Consultant breast surgeon Roger Watkins scrubs up in an adjacent room as the medical team checks monitors and prepares equipment.
Michelle arrived at Derriford Hospital at 7:30am that morning. She has already undergone an ultrasound to precisely locate the tumour in her right breast.
A cross is drawn on her skin to mark where the growth lies under the skin surface.
Her 10mm tumour, which she had not felt when checking her breasts at home, was unexpectedly revealed by a routine mammogram.
The 58-year old city teacher is about to undergo an operation called “wide local excision” It’s what layman would call a ‘lumpectomy’ says Mr Watkins.
It will involve extracting the tumour along with surrounding tissue rather than removing the whole breast in mastectomy.
The operation has been made safer and faster by a £50,000 machine donated by the Primrose Foundation and Derriford League of Friends. There was also a contribution from the Primrose Ward Fund.
The portable digital imaging machine, one of around 25 being used in hospitals across the country, enables surgeons to instantly x-ray removed tissue at the patient’s bedside.
The consultant can immediately see how much of it is cancerous and decide whether to remove more tissue.
Surgical teams used to wait at least 30 minutes while the sample was taken to the hospital’s Primrose breast care centre to be x-rayed.
It’s 2pm on Wednesday, August 27, and Mr Watkins and the five-strong theatre team are ready to start the procedure. It is one of around 150 breast operations the surgeon performs a year.
The first step will see several lymph nodes removed so they can be analysed by hospital pathologists over the following week. If they are cancerous, the disease has spread.
During the second stage of the operation, the main tumour will be removed and x-rayed in theatre. Mr Watkins injects blue dye into the Michelle’s breast and into her lymphatic channels.
He explains that it will stain the glands and help him see them. Earlier in the day she was also injected with an isotope – a low dose radioactive dye. It will help identify her lymph glands, which will be removed and analysed to see whether the cancer has spread.
Before cutting the skin near her right armpit, Mr Watkins uses a ‘gamma probe’ a stainless steel tube tipped with crystals which detects radiation from isotope which has collected in the lymph nodes.
When the probe detects a gland, the machine clicks and emits high-pitch whirs.
Mr Watkins makes a three-inch incision and, during the next 20 minutes finds and removed five lymph glands, which are placed in plastic containers to be taken to pathologists.
Now the surgeon moves on to the second part of the operation, making an incision over the top of Michelle’s breast with a scalpel.
Mr Watkins explains he aims to remove about 1cm of healthy tissue around the tumour. “I am trying to feel where the tumour is, but it is difficult as the tissue is so fibrous,” he says.
“I have a dilemma, because I want to get all the tumour out, but I don’t want to remove to much breast tissue, as it can lead to a poor cosmetic result.”
At 2.40pm he removes a lump of tissue slightly smaller than a tennis ball, marking it with small metal clips to indicate how it was positioned in the breast.
Minutes later it has been weighed and placed in the bottom compartment of the digital x-ray machine.
On top of the portable unit is a keyboard and flat-screen monitor. A few clicks of the mouse and, within 20 seconds, the digital x-ray image is on screen.
Mr Watkins points at a lighter blur in the centre of the picture which shows the tumour. He can magnify the image, change the contrast and measure the sample instantly.
“I am happy with what I’ve removed,” he says.
“This machine saves time. I can see results straight away and usually don’t have to wait for anyone else to confirm it.”
“If the machine shows the growth is close to the edge of what I’ve removed, I may take out some more tissue.”
That is not the case this time, and Mr Watkins returns to complete the operation. He stitches the breast tissue back together, saying Michelle should not notice a significant cosmetic change.
As specialist registrar Rami Ahmed finishes, sewing up the incisions in Michelle’s skin, it turns 3pm.
Mr Watkins says “Without the machine we would have been twiddling our thumbs now, waiting for the standard x-ray picture.”
The time an operation takes has been cut from around an hour and a half to an hour – meaning the patient spends much less time under anaesthetic.
Michelle will stay in hospital overnight.
Since it was donated six months ago, Mr Watkins says the unit has been used during more than 50 breast operations, around a third of “lumpectomies”.
“We use the machine when we can’t feel a tumour,” Mr Watkins says.
“Until tumours get to around 20 to 25mm in diameter you can’t feel then by hand. We remove tumours as small as 2 or 3mm.”
In total, about 400 breast operations are carried out each year at Derriford by the three consultant surgeons – Mr Watkins, Mr Cant, and Mr Drabble, and two other surgeons Miss Prance and Dr Hyett.
About half of these are mastectomies, which the machine would not be used for.
Michelle will wait for the results of the pathology report on the removed tissue and be seen in the Primrose clinic in two weeks time.
Later she will undergo radiotherapy treatment.
CASE STUDY - Michelle's Story
Cancer patient Michelle said she had almost cancelled the routine health check which turned out to reveal a tumour in her right breast.
The 58-year-old Plymouth teacher underwent surgery at Derriford Hospital last week to remove the growth.
She allowed The Herald to witness the procedure to highlight the work of Derriford’s Primrose Unit, telling her story to stress the important of regular breast checks.
Michelle, whose name has been changed to protect her identity, said she almost cancelled her June 12 mammogram appointment because she felt unwell.
A week after the x-ray, she received a letter asking her to attend a follow –up appointment because abnormalities had been discovered.
“It knocked me for six” she said. When I opened it I was totally confused – it said the mammogram had revealed two areas that needed to be more closely looked at, and I had to come into the Primrose Unit the next day.
“I can remember looking at it reading it several times and thinking “this is ridiculous, I don’t believe it.”
“I had only gone for a mammogram as a matter of routine – when you’re over 50 you go every three years.”
Michelle said that without the x-ray the lump wouldn’t have been found so fast as she regularly examines herself but did not feel it.
She said: “It would have been easy for me to cancel the appointment. And what then? If I’d waited another three years how far would it have gone?
“It’s a warning to others to just go and do it. Nobody likes having a mammogram, but it can save your life.”
The day after she received the letter, a radiologist told her she had an invasive slow-growing tumour and ordered further tests to examine a second abnormality.
“He said he was going to be absolutely straight with me,” said Michelle. “He indicated one of the areas of the x-ray, and said “this is a tumour, its sucking in material around it”.
“I immediately through about my family. I didn’t feel I could tell anyone. I kept thinking there must have been a mistake.
Results of a biopsy later revealed the second area was non cancerous and Michelle would not have to undergo a mastectomy.
She had an hour-long operation at Derriford last week to remove the tumour and will now undergo radiotherapy.
Michelle added that her care had been “amazing” at Derriford’s Primrose Unit, with a breast cancer nurse being assigned to her immediately she was diagnosed.
She said:”The staff really do understand that it’s a traumatic experience, and, with these people in charge, I think I could go through anything.”
Diana Prince, The Herald, Friday September 5th, 2008.
