NEW TECHNIQUES IN THE DIAGNOSIS AND MANAGEMENT OF BREAST DISEASE

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NEW TECHNIQUES IN THE DIAGNOSIS AND MANAGEMENT OF BREAST DISEASE: ETHICON ENDO - SURGERY KECK SCHOOL OF MEDICINE, UNIVERSITY OF SOUTHERN CALIFORNIA LOS ANGELES, CA November 14, 2006 00:00:06 ANNOUNCER: This program is made possible through an educational grant from Ethicon Endo - Surgery. During the next hour in this live webcast from the Keck School of Medicine at the University of Southern California in Los Angeles, Drs. Melvin Silverstein and Beth DuPree will demonstrate a presentation of new techniques i n the diagnosis and management of breast disease.

This includes new approaches of breast - conserving surgery and oncoplastic procedures. The techniques presented use the Mammotome Biopsy System and Harmonic technology for reconstruction of the breast and us e for the axillary dissection. During the program, viewers may ask the physicians questions by clicking the MDirectAccess button on the computer screen.

This live webcast originates from the Keck School of Medicine at the University of Southern California in Los Angeles, where you will learn how the Mammotome Biopsy System works to diagnose breast abnormalities without the need for open surgery. See how new technologies combined with clinical investigations are helping physicians diagnose and treat breast d isease. 00:01:19 MELVIN J.

SILVERSTEIN, MD, ... more. less.

FACS: Hi, I 9m Dr. Melvin Silverstein. We 9re live at the Keck School of Medicine on the USC Health Science campus. I 9m sitting here with Dr. Beth DuPree, who is the medical director of the comprehensive breast cen ter at Bucks County 3 00:01:38 BETH DUPREE, MD, FACS: Pennsylvania. 00:01:39 MELVIN J. SILVERSTEIN, MD, FACS: Pennsylvania. Okay, I 9m happy to have you here -- 00:01:42 BETH DUPREE, MD, FACS: Thanks for having me. 00:01:43 MELVIN J. SILVERSTEIN, MD, FACS: At our medical school. We 9re going to have a fun time today. We 9re going to talk about the international consensus conference on image - detected breast cancer that was held in Miami Beach in January of 2005. You can see on your screen a nice picture of Miam i and how nice it was at that time. This consensus conference consisted of 23 experts who came together and sat in a room for 2 ½ -- 3 ½ days and discussed all aspects of image - detected breast cancer. And they produced a paper entitled, cImage - Detected Bre ast Cancer: State of the Art. d That 9s a paper that you can download. If you go to the OR - LIVE site, there 9s an area there where you can click cdownload the paper. d The paper is filled with interesting gems about image - detected breast cancer. Today we 9re on ly going to focus on a couple of those gems. During this conference, image - detected breast cancer was defined as any lesion detected by any imaging modality, but for all practical purposes it 9s going to be a mammography - detected lesion because that 9s the m ost common imaging tool that we use. Image - detected cancers are generally nonpalpable, and depending on how aggressively you use mammography, they can represent anywhere from 30% to 60% of your practice. The typical image - detected cancer is either an in si tu lesion, a T0 lesion, or it 9s a relatively small lesion, 2 cm or smaller, a T1 lesion. So it 9s either T0 or T1 most of the time. It 9s typically an N0, node - negative case. M0. So most of these cases are stage zero or one. They do not require an intensive workup. You don 9t need to do a bone scan. You don 9t need to do a CAT scan. You don 9t need to do a PET/CT or any of these sophisticated tests for image - detected lesions, as a general rule. This graph shows the outcome of different stages of breast cancer, a nd 85% of the image - detected breast cancers will be on the blue line or the red line. They 9re stage 0 or stage 1. Only about 15% of image - detected breast cancers are node - positive, and they would be on the green line, or stage 2. The outcome is really good for image - detected breast cancers. For the DCIS lesions, you can expect 99% to 100% survival at 10 years. And for the generally stage - one lesions, you can expect 85% to 90% survival at 10 years. Image - detected cancers are generally ideal for breast conser vation except for the very large DCIS lesions. Now, the paper is divided into five different sections: accepted basic comments; imaging and biopsying, which we 9re going to talk a little bit about today; pathology and prognostic issues, which we won 9t discu ss today. There 9s a whole range of treatment issues discussed in this paper, and today we 9ll look at one of those issues. We 9ll look at oncoplastic surgery and oncoplastic lumpectomy, which is the coming rage. It 9s as hot today as a sentinel node biopsy wa s 8 or 10 years ago. And there 9s a section in the paper on economic issues, which we won 9t touch today. So, as I mentioned, you can download this paper by going to the OR - LIVE website and clicking on the area where it says download consensus conference pap er. Now, today we will discuss certain aspects of imaging and biopsy and we 9ll talk about certain aspect of oncologic, oncoplastic surgery. 00:05:40 So let 9s start with imaging and biopsying for a second. Mammography 4 the conference group said that mammogr aphy is the only imaging modality that should be used routinely to screen breast cancer patients. It 9s the only imaging modality for routine screening. We talked about ultrasound. Ultrasound is an enormously valuable tool, but currently it 9s not a screenin g tool. There is a study underway to see how valuable it will be as a screening tool, and very likely in the future it will become a screening tool, but today it 9s an adjunct. However, it should be used by any adequately trained physician without regard to turf issues. This is not the property of just radiologists; it 9s the property of any physician who is well - trained with ultrasound. We 4 the group suggested that breast ultrasound be used whenever you take a mammogram and have a BI - RADS 4 or 5 lesion. The e ntire quadrant where that lesion was found should be ultrasounded. In fact, most people go beyond that and ultrasound the entire breast and often the opposite breast. But this group felt they only could suggest that the quadrant where the lesion be found b e ultrasounded for sure. They also suggested that the axilla be ultrasounded. And if an abnormal node was found, either a fine needle aspiration biopsy or a core biopsy should be performed. And if that needle biopsy was positive, then of course you would s kip the sentinel node biopsy and go directly to axillary node dissection. If that needle core biopsy was not positive, then you could go ahead and do a sentinel node biopsy. We talked a great deal about breast MRI, and in the paper there 9s a whole list of rationales and reasons why you might do breast ultrasound. Breast ul 4 I mean, breast MRI. Breast MRI is currently dramatically growing in value as the experience increases and the technology improves. But today it 9s still an adjunct to both mammography and ultrasound. We feel strongly at USC that anybody with a diagnosis of breast cancer probably should have bilateral breast ultrasonography. And of course it 9s particularly useful for somebody who present with an axillary metastasis and you can 9t find the pri mary with mammography. But there are a lot of other uses, and you 9ll find a whole discussion of that in this paper. We talked a great deal about minimally invasive breast biopsy, and that 9s something we 9re going to focus on today in the first half of this program. There 9s a number of ways to do a minimally invasive breast biopsy. You can use a small needle and do fine needle aspiration and do cytology. You can use a larger core biopsy, typically a 14 biopsy. Or you can go to a vacuum - assisted tool, and most of those tools today are 7 to 11 gauge in size. And then there are even larger tissue acquisition systems. All of these work under the appropriate circumstances. One of the important things that the consensus group said was that they really redefined brea st biopsy. They said that a breast biopsy is an outpatient procedure performed with a needle. Let me repeat that: a breast biopsy is an outpatient procedure performed with a needle. It 9s not a procedure that we should routinely be doing in the operating ro om. When a patient goes to the operating room, she should go there knowing the diagnosis and knowing what procedure 9s going to be done. If minimally invasive breast biopsy is used appropriately, it has the potential to spare as many as 80% of people who cu rrently get open breast biopsies from having to have open breast biopsies. We know that 80% of the lesions that are seen on x - ray that require biopsy are benign. And so, a minimally invasive biopsy has the potential to keep those 80% of people out of the o perating room. It permits the optimal pre - treatment planning, it permits a single trip to the operating room where the correct, definitive operation can be performed. And one important thing about needle biopsies, it 9s not important to talk about the size of the lesion or the margins because you 9re only sampling a teeny piece, so the needle core biopsy does not reflect the true size or the margin status. The consensus panel strongly agreed that percutaneous histologic biopsy is the optimal initial diagnosti c procedure for virtually all patients with image - detected abnormalities. In other words, the diagnosis should be made with a needle, not with a scalpel in the operating room. The consensus group said that there should be few open surgical biopsies for ima ge - detected lesions. There are occasionally lesions that simply can 9t be biopsies, but they are few and far between. Open procedures in the operating room are for definitive treatment. The goals are really simple. The goal is to keep every benign case out of the operating room and to take every patient with a malignant lesion to the operating room one time for the correct definitive procedure. Those 4 we 9ll never achieve those goals 100%, but those are the goals. The group also said that stereotactic guidance was the optimal approach with an 11 - gauge or larger vacuum - assisted tool for microcalcifications without a mass, and that ultrasound guidance was the optimal approach for any lesion that could be seen by ultrasound. Now with that said, let me go to Dr. Be th DuPree, and let 9s hear about how we do needle biopsies with ultrasound guidance. Beth? 00:11:24 BETH DUPREE, MD, FACS: Mel, thank you so much. First of all, it 9s just an honor to be here with you. After our lunch discussion, finding out that you were do ing Halsted radical mastectomies when I was in kindergarten during your residency, to be sitting next to someone of your stature who has had to adopt a completely different way of approaching breast cancer during your career. I thought it was a big deal fo r myself going from learning open surgery biopsies in residency to becoming a minimally invasive surgeon, but you 9ve maintained a practice on the cutting edge of medicine throughout your career, and that is to be commended because you could have adopted th e approach that many other surgeons have who said, cI 9ve always done it that way, that 9s the way I 9m going to continue to do it. d So you 9re the one that 9s to be applauded because you are truly on the cutting edge of what we do. So thank you. 00:12:13 MELVI N J. SILVERSTEIN, MD, FACS: Thank you, Beth, for that, but not for giving away my age. 00:12:15 BETH DUPREE, MD, FACS: Your age is not the issue. I value your age, and I value your wisdom. The first slide that I am showing is compliments to Dr. Lazlo Tabar , who is a phenomenal mammographer who was able to show that you can have up to a 40% reduction in death just by having women get screening mammography. And it 9s usually the fear of the mammogram that keeps women from 4 it 9s the fear of the breast cancer tha t can come from the diagnosis from a mammogram that keeps women from getting diagnostic mammography and screening mammography. But what they have to be aware of is when we find image - detected breast cancers, we can diagnose them minimally invasively and re ally allow these women to be treated with less invasive procedures and with sometimes less chemo, and certainly a decrease in the risk of dying of breast cancer. So mammography screening done annually leads to early detection and decrease from death, and t hat 9s what it 9s all about. We 9re trying to keep women from dying from breast cancer. We use diagnostic mammography in my practice, and in 4 as well, we use breast ultrasound and MRI, and occasionally positron emission mammography in the workup of a detected lesion. But again, screening mammography is still the standard and the only tool that we use for screening. And as you said, the consensus statement: minimally invasive breast biopsy is the standard. And I spend a fair amount of my travel time teaching sur geons minimally invasive and ultrasound - guided techniques throughout the country. I know how difficult it can be to incorporate a new modality into a surgical practice because of the pressures of the learning curve that we have, but just like we did with m inimally invasive gall bladder surgery, it became the standard of care, and that 9s where we 9re heading with breast disease. The device that I like to use is a Mammotome device. It allows me to do not just image - guided biopsies with ultrasound and stereotac tic guidance, but also allows me to remove some palpable lesions that I previously would have taken to the operating room. And the great thing about breast ultrasound is that it 9s a real - time procedure. You can see the lesion on ultrasound, the patients ca n see it, the patients become a part of the process. And even from the insertion of the lidocaine, the image is still very, very easy to see the lesion as we 9re going to biopsy it. On the slides shown, the density can be seen well within the notch, which i s the sampling notch of the device, and you can also turn the transducer 90 degrees so that you can have absolute confirmation that you are biopsying a lesion at hand. And this is something where, as a surgeon, I think we really need that confirmation that we 9re actually biopsying what we 9re going after. This slide depicts how we insert a marker that is visible in ultrasound and also visible in mammography so that we can have follow - up verification by our image studies that we have gotten the lesion that we are going after. And one of the things that is absolutely mandatory is making sure that we have concordance, meaning that our pathology matches the lesion that we 9re biopsying. And I recently did a minimally invasive biopsy for a very tiny 4 mm lesion tha t I thought for sure was going to be a cancer. And in that patient, since I got back a benign pathology, that is a patient that I will now take for open surgical biopsy, just to make sure that my image detection was not what was off. Because I need to make absolutely certain that that lesion is adequately sampled. At the end of the procedure, I insert a marker which has two different aspects of it: one is a collagen pledget; the other area is a collagen marker that expands within the breast. It can easily b e seen under ultrasound. And there 9s also a titanium chip inside of there so that it can be seen on the mammogram for future reference. So in the event that I have a malignant lesion, I can use that image guidance to be able to help direct my lumpectomy or to be able to follow - up in the future if this is a benign process. The nice thing about this marker is that four weeks later, it 9s clearly visible under ultrasound. And I have been able to convert about 98% of my lumpectomy patients from a needle localiza tion 4 wire localization, where the wire is placed by the radiologist 4 to a procedure in the operating room where the patient is scanned and I don 9t have to insert a needle, with the patient awake and alert. The patient can be under anesthesia as I 9m doing my ultrasound localization. And as you know, the anxiety for the patients undergoing the needle localization can be tremendous because they 9re awake and a stranger 9s putting a needle into their breast. And when we do image localization in the operating room, we 9re actually helping the patients tremendously by doing it with this technique. I started my minimally invasive life doing stereotactic biopsies. When stereotactic technology became available, at my facility we kept the stereotactic biopsies under the g uidance of surgeons. Because our radiologists were not really interested at that point in having to communicate the procedure with the patients, we did it in conjunction with the radiologists. And at the time, I thought it was eating into my general surger y time and my time in the operating room. And nine years later, I can say that I am very happy that we 9ve maintained this procedure as a surgical procedure because the patients know me, they trust me. When I 9m in the room and I 9m doing their stereotactic b iopsy, I 9m able to, you know, maintain that doctor - patient relationship, which I think one of the things that has been missing for years. And I 9m a firm believer that surgeons need to take back the breast biopsy part of breast care surgery to help maintain that process. There is a tiny little device; it 9s a little tiny piece of plastic called a vase. For years, I had patients that I would have to take to the operating room to do an incisional biopsy when their breast was so narrow 4 when their breast tissue c ondensed, or compressed, to less than about 3 cm, sometimes I 9d have difficulty being able to get to those lesions. Since the advent of this little device called the vase, I 9ve been able to cover part of the aperture and still be able to biopsy these lesio ns where the biopsy chamber previously was outside of the breast. So it took only this little tiny device for me to be able to keep these particular women out of the operating room for diagnosis. I just had a woman with microcalcifications very close to th e chest wall, and she compressed to 20 mm, which is an incredibly narrow field. And I was able to biopsy this woman and diagnose ductal carcinoma in situ, so now we can plan her definitive surgery based upon this minimally invasive biopsy. And the mammo ma rker is visible, and the marker is actually visible on the mammography so that for future reference, in the case of a benign biopsy, the radiologist can confirm that yes, the calcifications or the density has been sampled, and that way we have complete con fidence that we 9ve gotten the appropriate area. The MRI is now a 4 not just a diagnostic tool for looking for multicentricity for cancers, but occasionally in high - risk groups when we 9re looking at MRI we need to biopsy lesions that are found, and the Mammot ome is available for biopsy of these minimally invasive les 4 minimally invasively to do the MRI biopsy. And because of the technology that was created, you can actually see the density very clearly before you actually start doing the biopsy once you 9ve targ eted, and it 9s giving the radiologists and the surgeons that confidence to know that you 9re biopsying the appropriate area. So they certainly had to make changes with the Mammotome to make it compatible with MRI because of the magnet, but I think that the patients and the dedication to the precision has really paid off with the MR - Mammotome. And the patient is biopsied, and there 9s a tremendous amount of sampling confidence because of the technology that was put into this particular device. And one of my fa vorite things about the Mammotome system is being able to visually inspect the samples. I recently had a breast fellow who was working with me, and when she biopsied a cancer, she could see that the coors [sp?] clearly had the stiffness that you would expe ct to see with a cancer diagnosis. And she hadn 9t been used to that with the biopsy device she was training with, therefore the visual inspection, I think, is something that makes the surgeon very comfortable with what they 9re doing. One more thing I want to say about ultrasound before we move to the video clip: when I first started doing breast ultrasound, I did not believe that having color - flow doppler made a big difference for me with a diagnosis of breast lesions. And the lesion shown on the screen was called a complex cystic mass by a radiologist. And this 32 - year - old woman was recommended to have four to six month follow - up of the ultrasound. And when she came to my office and I scanned this patient using color flow, it became very obvious that I was dealing with a very high - grade cancer that had a tremendous ingrowth of vessels, and being able to use color flow in the office under ultrasound allowed me to have the diagnostic capability to make a huge difference in this patient 9s treatment. And breast ultrasound, as you know, is an extension of our fingers. I think we have learned over the years that ultrasound is not a tool to only be used by radiologists. I think that as a breast surgeon or as a general surgeon doing breast surgery, we need to be usin g breast ultrasound as part of our workup, our treatment. It makes us better surgeons. So what we 9d like to do is have you, if you are a surgeon watching this webcast, there 9s an area that you can click onto to let us know if you are currently performing i mage - guided biopsies. It 9s something that we would like to know how many surgeons doing it. 00:22:05 And now we switch to a video of a Mammotome biopsy. And I do telesurgeries live to educate the sales force and other surgeons about the minimally invasiv e biopsy system. And the lesion you can see on the back of the ultrasound screen. I 9d also like to show it to my patients during the procedure because I like to make them part of the procedure. And as I 9m prepping the breast, you can see I have a purple ma rk at about the four o 9clock position in the left breast, which is where the lesion is located. And in this patient, this was a palpable lesion and also an ultrasound - visible lesion, so I was going for two things with this biopsy: number one, to adequately sample the tissue in order to know that the lesion was a benign lesion; and number two, I was trying to remove the palpability so that this patient did not feel this lesion any longer. For years I was seeing patients in the office who had had a core biops y diagnosis by a radiologist, and although they came back to the office with a benign diagnosis of fiberadenoma, the patients didn 9t want to feel the lesion. And this is where using the Mammotome can act not only to make an appropriate diagnosis but also t o treat the lesion by helping the patient not feel the lesion any longer. I 9m using a 30 - gauge needle to inject the lidocaine, as this should be the only portion of the procedure that the patient actually feels. The nick in the skin that I make is dependen t upon the size of the device that I 9m using. Whether it 9s an 11 - gauge or an 8 - gauge device will determine the size of the incision to create the entry point for the biopsy device. Under ultrasound, you can see injection of lidocaine with an 18 - gauge spina l needle. The needle is incredibly visible on the ultrasound machine and you can see the lidocaine welling up underneath this ovoid lesion. And once I go well past the lesion and inject lidocaine, the patient is adequately anesthetized to be able to insert the biopsy device. I like to insert the Mammotome with the blade of the tip actually parallel to the chest wall so that I can see the actual tip of the needle coming in underneath the density. And as I 9m scanning back and forth across the lesion, this les ion was moving a little bit from side to side, so I was just making sure that I was in the appropriate position, looking for the tip of my needle, which is, you 9ll see is the white point. And I was a little bit above it, so I decide to reposition somewhat to get into a better position. And sometimes in younger patients with dense breasts, especially if I can feel the lesion, I use a little bit of gentle pressure once I know I 9m in the appropriate position to move forward and get the aperture, or the biopsy notch, directly under the density at hand. So now I can see the tip of my needle. And at this point I 9m showing how turning the needle tip from side to side changes whether you see the tip. And when you turn it to the side you lose the tip, which is why I go in, so that you can actually see that last 4 that extra 4 to 5 mm on the screen. And you don 9t have to lose the tip of the needle; you can see it the entire time. And once I 9m in position, you can see my density. The arrow is pointing to the density. And now the biopsy device is being used and we 9re actually removing the cores of tissue containing this density. This is the view that I like to call cthe setting sun. d You can actually see as the cutter comes forward, it 9s taking away piece - by - piece the densi ty. And you can see that it 9s directly in the center of my sampling notch. And once I know I 9m in that position and I know that I 9m getting the cores of tissue out and removing this lesion, I can turn my ultrasound probe 90 degrees. And this is a view that I call the Pac - Man view, where now you can see the smiley face of the biopsy device actually taking this density away piece by piece. And I have direct visual confirmation that I 9m removing all image evidence of this density. And in patients where they ca n feel the density and you can see it under ultrasound, you can have palpable confirmation and you can also have ultrasound confirmation that you 9ve removed the lesion at hand. And during this entire time, the patient is incredibly comfortable, and I 9m tal king with her and showing her the lesion on the ultrasound screen, and there 9s something very empowering for women to watch the density and the palpable mass that they 9ve had previously being taken away piece by piece. And I show them at the very end when I have completed the procedure that I no longer see any density on my ultrasound. And once I 9ve completed removing all image evidence, I then at that point put in a marker in order to allow us to be able to follow this area in the future. In the outside ch ance that this lesion was something such as a phyllodes tumor that required open excision of the cavity, I have a marker in place to do 4 to perform that. If it turns out that the lesion that I 9m biopsying would be a cancer, the ultrasound - visible marker wou ld allow me then to do a lumpectomy under ultrasound guidance as well. So this is the video clip of the marker insertion. And then we hold gentle pressure. And the marker is clearly visible, as it is seen on the ultrasound here. The patient then has steri strips placed over the incision. I place them in an ACE wrap, and they get to go back to their routine within 24 to 48 hours. I get to call them with their pathology, and then we move to the next step, which is if it 9s a benign process they go on with thei r life, and if it 9s a malignancy we plan the next phases of their surgical procedures. 00:28:28 MELVIN J. SILVERSTEIN, MD, FACS: That 9s great, Beth. I think one of the most important things is 4 that people forget all the time is the clip. It 9s important to place that clip. Tomorrow I 9m faced with a case that was done at an outside hospital and then referred here. She had a biopsy of a cancer, and they did ER, PR Her - 2 on it. They gave her medicine, neoadjuvant chemotherapy, they shrunk it down. It 9s gone. W e can 9t feel it. We can 9t see it on the original mammogram. It was seen on 4 by MRI. It was 8 cm in size. We did an MRI yesterday. It 9s completely gone. And there 9s no clip left in place. So now how am I going to do a lumpectomy on that patient and feel that I 9ve gotten in the right place? So I just cannot tell you how important it is to put that clip in. 00:29:14 BETH DUPREE, MD, FACS: I put clips in regardless of the size of the lesion because we do use neoadjuvant chemotherapy so often, and you can 9t go ba ck and place the clip later after the lesion 9s disappeared; you really need to place it at the time of the procedure. 00:29:27 MELVIN J. SILVERSTEIN, MD, FACS: We might answer a couple of questions at this point. Somebody wrote in, cHow does the plac ement of a clip help your patient if she has to go to the operating room? d 00:29:36 BETH DUPREE, MD, FACS: The way that the placement of an ultrasound - visible clip helps the patient is that seeing the lesion or the area that was biopsied that needs to be excised under ultrasound does not require a radiologist to do a needle localization. You can do an ultrasound localization with intraoperative ultrasound, and it 9s actually an incredible successful way to do it because you can see the clip directly where y ou are. You 9re not relying on a radiologist with a compressed breast to place a needle. So it 9s actually more accurate to me than doing a needle localization. The other thing is the anxiety of going through a needle localization is something that the patie nts 4 I had one of my partner 9s patients the other day almost walked out before her cancer surgery because she was scared to death of the needle localization. And we had to walk her through that process because the clip that was placed was not ultrasound - vis ible. And we 4 she was someone that came to us for a second opinion, and it was a non ultrasound - visible clip. But the most anxiety - provoking part of the procedure for her was the needle localization, so placing an ultrasound - visible clip can allow you to do an intraoperative localization. 00:30:42 MELVIN J. SILVERSTEIN, MD, FACS: Here 9s another question for you: cWhy biopsy with a Mammotome instead of a 14 - gauge core needle gun? d 00:30:49 BETH DUPREE, MD, FACS: 14 - gauge core needle guns require multiple ins ertions. And when you have a small lesion, placing a biopsy in multiple times can be difficult because you have to re - ultrasound the area to find the density. I used to use a lot of 14 - gauge core needle devices, but for the patients it 9s much nicer to do s ingle - insertion, get in, get your four or five cores that you need, and get out. It decreases the amount of time for the patient, it decreases the patient anxiety, and it also allows you to be absolutely right on the money and place your clip exactly where that lesion was. So, personal preference, but I think it 9s the way to go for patients. It 9s much nicer 4 it 9s what I 9d want to have done to me, which is why I do it for my patients. 00:31:32 MELVIN J. SILVERSTEIN, MD, FACS: Well, that 9s a good reason. Let 9s go on to the oncoplastic portion of this webcast, and then we 9ll come back and answer more questions. Oncoplastic surgery combines oncologic surgery, which is generally wide, destructive surgery, with plastic surgical techniques. Because we 9re trying to a chieve 4 we 9re trying to have our cake and eat it too, so to speak. We want to take the largest piece we can take out, which will give us the widest margins around the tumor, but we also want a good cosmetic result. And typically when you take a large piece of tissue out, it 9s difficult to get a good cosmetic result. Now, there 9s a whole range of different oncoplastic excisions. Many of them were developed right here at USC, and some at the Van Nuys Breast Center. This is the type of surgery we 9ve been doing for 20 - some odd years, and our whole breast fellowship is based upon oncoplastic surgery and the techniques. And we 9re going to show you one of these techniques today. Some of the techniques include the crescent mastopexy, the batwing, the hemi - batwing, th e triangle, and the reduction incision, and there are a few others. Today we 9re going to show you the reduction incision, and how it 9s done, and the kind of results that you can get. And what I 9m going to do first is just show you a couple of slides of pat ients, and then we 9ll show an actual video. The patient you can see on the screen now has very large tautic [sp?] breasts, and in the right breast, coming into the nipple, is a large tumor that has both invasive cancer and a DCIS component. You can see two wires coming in from the 12 o 9clock position. And this is the kind of patient that the nipple needs to be removed because the tumor is intimately involved with it. So typically this patient would simply get a little horizontal ellipse, the nipple would be taken, she 9d be left with breasts that looked pretty much the same way they look now except the nipple would be removed on the right side. So she 9s a perfect candidate for an oncoplastic procedure because she has large breasts that would benefit by being made about half the size. So you can see a typical reduction - type incision has been drawn on both sides, and on the right side we 9ve taken out the reduction pattern, which is a triangle that goes superiorly and then two triangles that go medially and later ally. And you can see the large specimen that 9s been removed. It 9s about a 500 to 600 - gram piece. It contains the nipple areola complex, it has two wires going in superiorly, and it widely excised the lesion with 2 - cm margins in every direction. The excisi on is taken right down to the chest wall, as you can see here. And this is how this patient looks after we 9ve put her back together, and this has taken 13 days after we did it. And she has an opposite side or reduction, and so that you don 9t forget how she looked in the beginning, on one side you can see the pre - op photos, on the other side the post - op photos. This patient had a wide excision. She needs to have her nipple areola complex made. She now looks better than she looked to begin with, number one; a nd number two, her cancer has been widely excised. If this had been a small DCIS, we 9d be done at this point, but because she has an invasive component, we 9ll irradiate this. And you can irradiate a reduction, it handles it very well. And this will be a pe rfect result long - term. Let me show you one other case. A very similar kind of patient: large tautic [sp?] breasts. The side that needs to be removed is the left side, you can see my initials cMS d on that side because that 9s the side we 9re going to do. It 9 s virtually the same operation we did on the previous patient, reduction - type incision. Here you can see it being made. And this is what you 9re going to see in the video clip, exactly this incision being made, only we 9ll be using the Harmonic scalpel to cu t through the tissue. This is the inframammary sulcus that 9s been incised. Now we go right down to the chest wall and take this large segment off the chest wall. Here 9s the specimen that 9s going to be removed. Again, 600 or 700 grams of tissue. Primary les ion widely excised. Here is the specimen 9s been removed. You 9re looking straight back onto the chest wall. And what we do now is we undermine the breast off the chest wall in all directions, and then we 9ll put it back together. And here we 9ve put it back t ogether on the left side, and on the right side we 9ve done a reduction. This is the post - op of this patient. Again, it 9s going to be a perfect result. We 9ll irradiate her, we 9ll make the nipple areola complex, and she 9ll have very perfect, round breasts in stead of long, tautic [sp?] breasts, and her cancer will be removed and she 9ll look as good or better when she started, and her cancer 9s been treated. Now we 9re going to go on and show the video clip. So again, here 9s a large patient. The lines, unfortunat ely, aren 9t drawn on her, but this is the right side. You can see the exact same type of three triangles put together. She 9s got blue dye injected for a sentinel node biopsy. We inject local anesthesia around it. She 9s also got some radioactivity injected in the periareolar area. And this is the gamma probe. Here 9s the counter. This is a fairly low number, so we 9re probably in the axilla. We 9re 4 first thing we 9re going to do is take out the sentinel node through a separate incision. We 9re using the Harmonic shears here, or it 9s called the ace, and this does not cause very much tissue damage. And we 9ve discovered by using the Harmonic tools that there 9s approximately 50% less drainage than we get when we use the electrocautery. And we 9re simply dissecting thro ugh the subcutaneous and fatty tissue to get ourselves into the axilla. Once we get there we 9ll find a nice blue node. And we 9ll use the gamma probe to help direct the direction of the dissection. Here you can see a tinge of blue coming up. You can see a b lue node in the corner there. And it 9s being excised. That blue node was also very hot, with over a thousand counts in it. Then we checked the axilla to see if there 9s any residual radioactivity. There was none in this case. So we 9ll simply pack off the ax illa. Then we 9ll turn to the breast. We 9re going to make the reduction incision. And now we 9re using the Harmonic scalpel to cut through. The Harmonic scalpel liquefies the tissues, so we use a suction very close to it. 00:38:03 BETH DUPREE, MD, FACS: Do y ou actually use the Harmonic scalpel to make your skin incision? 00:38:05 MELVIN J. SILVERSTEIN, MD, FACS: No, we cut the skin with the knife, and then the rest of the operation is completely done with the Harmonic scalpel. Here you can see us following th ese triangles. We 9re going to go right down 4 we 9re electrocoagulating a bleeding here. I shouldn 9t say it like that 4 we 9re stopping the bleeding with the Harmonic energy. But I 4 and you can see how rapidly it cuts, and with little or no bleeding. We 9ll go rig ht down to the chest wall. And now we 9re starting at the inframammary sulcus and working our way up, taking this entire segment off beneath the fascia of the pectoralis major muscle. Another nice thing about the Harmonic tool is that the muscle doesn 9t jum p. It doesn 9t stimulate the muscle, so it isn 9t jumping around as when you 9re using the cautery, and it doesn 9t really destroy the tissue, so we don 9t get complaints from the pathologists that the tissue 9s been coagulated, they can 9t read the margins or th e edges. 00:39:04 BETH DUPREE, MD, FACS: Do you find any difference with the patients, post - operative painwise? 00:39:10 MELVIN J. SILVERSTEIN, MD, FACS: You know, I don 9t think they have a lot of pain no matter how you do it. Here 9s the speci 4 this entire specimen is being removed. And you know, this is an enormous lumpectomy. You know, nobody would 4 no general surgeon would ordinarily dream of doing this. They 9d make a small incision over the lesion and take it out. But this is a very 4 you can see the large piece of tissue that 9s been removed. It 9s now going to go and have specimen radiography. We 9ve now closed the axilla. We 9re stapling together our piece. The other side 9s going to have a reduction at the same time. It 9s now being deepithelialized as we clos e this side. Here she is intraoperatively. Both sides are being closed now. We staple them together to see how they look, then tailor it. Now the reduction 9s being finished on the left side. The right side 9s being glued with Dermabond. We close these subcu ticularly, and then put Dermabond on the skin. And then here 9s the specimen radiograph. You can see the primary tumor was up beneath the nipple areola complex there, but there was plenty of margin around it. You can see it 9s a 10 or a 12 - cm excision, very large. Then the tissue is being processed by the pathologist now. It 9ll be color - coded and then serially sectioned and completely evaluated. The undersurface gets this blue or black color, and then it 9ll be sliced up and then processed in a sequential fash ion so we understand exactly what we 9re dealing with. And here 9s this patient one day after surgery. And here she is two weeks after surgery. And you can see this is 4 again, it 9s going to be a wonderful result when we 9re finished. And here 9s the before and the after. The before 9s on top, the after 9s on the bottom, I hope you can see the whole thing. But that 9s just an example of oncoplastic surgery. It 9s something that really excites our fellows. They love to come here and train and learn oncoplastic surgery . We have both the Norris Cancer Center where we do these cases on private patients, and then we have the County Hospital across the street, the Los Angeles County Hospital where our fellows learn how to do these procedures. 00:41:29 BETH DUPREE, MD, FACS: It 9s a wonderful technology because in general surgery residencies, very few breast procedures are done that are not what you would call a standard mastectomy, where 4 we don 9t 4 in residency, I never even learned skin - sparing techniques. It wasn 9t until I wa s in private practice that I learned how to do a skin - sparing mastectomy, let alone an oncoplastic technique, which of course I learned from you and the other mavens of oncoplastic surgery, which is one of the things that has been so wonderful about the Am erican Society of Breast Surgeons. Bringing the oncoplastic courses to so many surgeons and opening their eyes to the fact that these techniques are available to do a combination reduction and lumpectomy at the same time, it 9s just 4 it makes the radiation o ncologists very happy as well because trying to radiate a very totic, large breast is a difficult process for them. 00:42:18 MELVIN J. SILVERSTEIN, MD, FACS: That 9s true. Here 9s a question from the United Kingdom. This person would like to know how many fe wer radical mastectomies are carried out now that we have modern diagnostic tools like mammography? When 9s the last time you did a radical mastectomy? 00:42:35 BETH DUPREE, MD, FACS: I did one in residency for a breast cancer recurrence, and that was my fo urth year of surgical residency. I have never done another one. When 9s the last time you did one? 00:42:44 MELVIN J. SILVERSTEIN, MD, FACS: I haven 9t done one for 25 years, but I remember very well the person I did the last one on. She still hates me to t his day. You know, she had a small 1 ½ - cm cancer. She was cured with the radical mastectomy. She would have been cured with a much lesser procedure, but it was the olden days. I did it while I was at UCLA. And I saw her at various women advocate meetings y ears later, and she never forgave me for that. 00:43:12 BETH DUPREE, MD, FACS: It 9s a tough procedure. And, you know, there are very few instances where patients who do require mastectomies cannot get immediate reconstruction as well. And it almost 4 probabl y inflammatory breast cancer and sometimes locally advanced cancers are the only ones that are not amenable to immediate reconstruction. And that 9s another thing that a lot of people don 9t understand is that doing immediate reconstruction does not change t he oncologic outcome of the surgery. If 4 as long as you can do the appropriate oncologic procedure, immediate reconstruction is something that should be offered to women. 00:43:48 MELVIN J. SILVERSTEIN, MD, FACS: Right, and it generally comes out far better than a delayed reconstruction because you can 4 you don 9t have to discard skin, you can save the inframammary sulcus, you can do a lot of things that make it come out much better. 00:43:58 BETH DUPREE, MD, FACS: Absolutely. 00:43:59 MELVIN J. SILVERSTEIN, M D, FACS: Here 9s another question that comes from the east coast. And the question is, cWhen do you use stereotactic guidance and when do you use ultrasound guidance? d What 9s the difference? 00:44:10 BETH DUPREE, MD, FACS: My rule of thumb is if a lesion is visible on ultrasound, I will do an ultrasound - guided biopsy because the patient can lie supine with their arm over their head and be very, very comfortable. If a lesion is only seen on mammography, then you have to do a stereotactic biopsy because you ha ve no other means to find it. So most of the biopsies that I do stereotactically are from microcalcifications. Because of the ability to find lesions on ultrasound and the ultrasound scanners that I own today, I can find a tremendous number of lesions that previously were not visible under ultrasound, or I see a lot of patients who get scanned by a technologist to look for a mammographic density, and they can 9t find it but I can because the ultrasound tech is not educated in mammography, so they don 9t know how to take the mammogram and put the mammogram on the patient 9s breast and find out what lesion 4 what area the lesion would really be in. So I teach that to the fellows, where you take the mammogram and use it as a template in the CC and the MLO project to be able to find the density. So a lot of biopsies that previously would have been done under stereotactic guidance I can now do under ultrasound guidance. 00:45:26 MELVIN J. SILVERSTEIN, MD, FACS: I think the general rule should be if it can be seen under ultrasound, do it that way. It 9s a lot easier on the patient. 00:45:00 BETH DUPREE, MD, FACS: Absolutely. Do you have more questions? 00:45:35 MELVIN J. SILVERSTEIN, MD, FACS: Yeah, oh no, yeah. Do you have more piles of questions? Oh, how can a surgeon get trained to use oncoplastic techniques? Well, there are courses that are run by the American Society of Breast Surgeons, and more and more courses will be cropping up because I really think this is going to be the next very aggressive front in breast ca ncer surgery. Once women know that they can have an oncoplastic lumpectomy, they 9re going to much prefer that to the standard lumpectomy. We have a technique where we make the incision in the inframammary sulcus, which is often behind the breast, and then we approach the lesion from behind. Normally, young surgeons are taught to approach the lesion from the front, which requires an incision in the breast, but this inframammary approach is excellent. And I think one way that you can learn how to do this is t o begin to do cases with a local plastic surgeon. Get the plastic surgeon to help you on cases and do them together, and then as time goes by you 9ll learn how to do it, and then try to take some of these 4 some of these courses. 00:46:45 BETH DUPREE, MD, FAC S: That 9s one of the things that 4 with our new breast health institute, the Comprehensive Breast Care Institute that we 9re building in Bucks County 4 one of the principals in our company is Patrick Maxwell, who you know very well is a phenomenal plastic surge on who believes that oncoplastic surgery and techniques should be performed by breast care specialists, breast surgeons, not just plastic surgeons. And this is another thing where prior to minimally invasive breast surgery, there may have been turf wars be tween radiologists and surgeons. Most plastic surgeons are not going to get into a turf battle because dealing with a patient with breast cancer and being able to give them the best cosmetic result, there 9s really not a turf battle. It 9s a matter of doing the right thing and being trained appropriately. So hopefully through centers of excellence, we 9re going to be able to actually have surgeons come in and watch these procedures being performed and be part of the planning process. One of the things that was awesome with the course that you guys gave at the American Society of Breast Surgeons was the lab where you learned how to mark the patients 4 because if you know how to mark out the patient preoperatively, it 9s just a matter of following the map to get the appropriate closure. And that 9s a tremendously valuable course. 00:47:54 MELVIN J. SILVERSTEIN, MD, FACS: Right. The key thing is measuring the patient, knowing where the nipple should end up, and marking the patient, and then it 9s really cutting on the d otted lines. 00:48:03 BETH DUPREE, MD, FACS: And this is all 4 it 9s all a continuum of care because with minimally invasive diagnosis, you can actually spend the time, plan the procedure, educate the patient, give them their options, and then you 9re making the patient a part of the process, which is why when we talked about MRI as an adjunct, you don 9t want to do a breast - conserving operation on a patient that has multi - focal breast cancer, so I agree with you that MRI is absolutely an appropriate tool durin g the staging process to determine whether or not a patient is actually a candidate for a lumpectomy. The other thing is using neoadjuvant chemotherapy, as you said in your patient, who sounds like she 9s a complete responder, if you don 9t put a marker in w hen you do a biopsy, you don 9t know whether that patient 9s going to be with you for the surgery or not. So think about that patient and place a marker with any type of biopsy that you 9re doing for a cancer or even a benign process because you want to make sure that you can absolutely follow that patient and make sure with confidence that you got the area in question and that if she goes to someone else for treatment that they can have a means to find that area later. 00:49:08 MELVIN J. SILVERSTEIN, MD, FACS : Here 9s a question about how long does it take to get comfortable using the Harmonic scalpel? You know, it 9s a very easy tool to learn how to use, and I would suggest anybody who wants to try it simply contact their representative from Ethicon Endo - Surger y, have them, you know, bring one to your hospital and stand by as you try to use it. It 9s very much like using electrocautery except you 9re using a different type of energy. You 9re using a mechanical energy that 9s generated by the vibrations rather than a heat - electrical energy that 9s generated by the electrocautery. 00:49:40 BETH DUPREE, MD, FACS: If we learn from the ENT surgeons, who clearly use Harmonic scalpel all the time for tonsillectomies because of the decreased tissue trauma to the patient posto peratively, those patients have less pain and less problems postoperatively, and in that particular operation, which is an incredibly painful procedure, having had one myself that I can remember, if we can take that and look at the type of tissue trauma, b eing able to have less tissue trauma during a breast procedure is certainly something that I think everybody would want to have. 00:50:14 MELVIN J. SILVERSTEIN, MD, FACS: Tell us a little bit more about this breast hospital that you 9re involved in. That 9s incredibly exciting. It was actually a dream of mine when we built the first breast center in America in Van Nuys, it was like that, but it was an outpatient facility, and we had to walk across the street to use the hospital. But the dream was to have a h ospital with all kinds of modern tools. And just tell us a little bit more about this. 00:50:37 BETH DUPREE, MD, FACS: Well, this facility came out of a dream from a combination of Dr. Patrick Maxwell, Dr. Pat Whitworth, who you know very well, and the CEO of our company, Dr. Jerry Tannenbaum. And their philosophical belief was that women are placed in a position where there 9s a time between 8 and 12 weeks, from a mammogram to a definitive surgery, to treat the cancer. And what they wanted to do was stop th e scavenger hunt where you go from place to place, going for a biopsy here, a workup for a bone scan another place, going to see a plastic surgeon in another facility, going for your surgery someplace else, and coordinating the care. So the Comprehensive B reast Care Institute was created to try to have a paradigm shift in how we look at the treatment of breast cancer. And for the 80% of women who end up having a benign process, they can get in, get their screening mammography, get their diagnostic studies, and hopefully within 24 or 48 hours know that they have a benign process and go on with their life. And for those women who are diagnoses with breast cancer, we 9re going to be able to help them through the process more expeditiously, with using nurse navig ators to help field them through the process and make sure they have the appropriate support staff. Our facility has six operating rooms, 24 inpatient beds, the state - of - the - art, cutting edge Western medicine technology, and to me the greatest piece that w e 9re bringing in is the whole holistic side of healing, where we 9re going to have a 4,000 square foot medi - spa so that not only will we adequately treat the physical cancer in the patient, but we 9re also going to be able to help bring about the healing, wh ich is sometimes that occurs sometimes well after the breast cancer is treated so that we can help these women and men with breast cancer get back to a place where they are not just going back to living their life but actually living a life that is very em powered because they have gone through the process and at the end can feel stronger, well taken care of, and then have a sanctuary that they can come back to yearly for follow - up. It 9s just been a dream of mine, and I think every surgeon who does a tremend ous amount of breast care and treats breast cancer patients, this is a dream we 9ve all had. And I told you, I was in the right place at the right time, and I live in the right state and have the right patient population, and the universe kind of converged and here we are. And in a few months you 9ll be flying out there, probably to give our opening address at the grand opening of our facility because as a pioneer in breast surgery as you 9ve been, you 9ve led the way to help this process unfold. And it 9s not t o be taken lightly because were it not for the pioneers like yourself and some of your other colleagues, we wouldn 9t be sitting here today doing this WebX to educate other surgeons about the changes in breast care, so thank you. 00:53:27 MELVIN J. SILVERST EIN, MD, FACS: Thank you. And I 9d love to come. Let me hit just one question. We didn 9t talk about this, but someone asked a question about the micromet. How do you treat the micromet? Now, the micromet is defined as a teeny bit of cancer 4 that 9s two - tenths of a millimeter up to two millimeters. What do you do? You don 9t find it in the operating rooms; you find it a couple of days later on permanent sections. What do you do about it? Do you go back? 00:53:54 BETH DUPREE, MD, FACS: It depends on the individu al patient and it depends on the type of cancer that we find. A microscopic metastasis is not considered an actual N1. We call the T 4 the N1 MIC, in which case I will usually have a sit - down with a medical oncologist. It depends whether 4 what I do is I look to see 4 sometimes I 9ll have two or three sentinel nodes that come out at the same time, and if the other nodes are completely negative I feel no need to go back in and to do a complete axillary node dissection because I don 9t think that it 9s going to change that patient 9s outcome. If I have a discussion with the medical oncologist and for any reason they 9re having anxiety or trepidation about it, I will offer it to the patient to go back to do an axillary node dissection. But to me a microscopic metastasis i s something that we never would have found were it not for the immunohistic chemical stains. And I don 9t think there are any studies that clearly show us 100% yet what we should be doing with them. What do you do? 00:54:53 MELVIN J. SILVERSTEIN, MD, FACS: Well, it 9s always a real problem. We teach our fellows and residents, don 9t do a test unless the results of that test will potentially allow you to change the therapy or change the prognosis. And the truth is, in the very beginning when we found micromets, by this definition, we went back and we did it 100 times. And in only one case did it actually turn out to change what we were doing. We ended up with a patient discovering that there were four metastases, four nodes, but in every other case we might 4 most of the time we found nothing else. We found maybe one more node. None of that changes the outcome. Does it change long - term survival? Nobody knows. Those kind of data are not available. So I think we 9ve evolved to the same place that you 9re at, that we ta lk to the patient. Most of the time if the medical oncologist says, cYou know, it 9s not going to change what I 9m going to do, d that patient 9s already T1. Even though it 9s T1 MIC, she 9s already T1, she 9s very likely going to get chemotherapy if it 9s that si ze, and so we probably won 9t go back. If she has what we call isolated tumor cells less than two - tenths of a millimeter, we definitely don 9t go back for that. And if it 9s bigger than 2 mm, we routinely go back for that. That 9s our standard at that point. A nd actually, that 9s what the consensus paper recommends. But I think as more data accrues with sentinel nodes, we 9ll have, you know, we 9ll have a lot more understanding of this. We need long - term data. The only long - term data we have is H&E data on the old - fashioned way, which was complete node dissections. Some of my friends who are old - timers feel that this is the one place where you might actually cure the patient, the patient with a teeny amount of disease that 9s still in a couple of nodes. And this mig ht be the only way you find it. You know, when we take out 30 or 40 nodes and we find one positive, there 9s no guarantee that there aren 9t two or three or four positives that we didn 9t find when we do the sectioning. So I think we just 4 the answers aren 9t i n on this. 00:56:59 BETH DUPREE, MD, FACS: The other thing you have to remember is, every time we go back to do an axillary node dissection, the morbidity from potential lymphoedema is something that cannot be underscored. Because in those patients that d o end up with lymphoedema, it is life - changing and potentially incapacitating to those patients. So I agree with you: unless it 9s going to change how we 9re going to manage that patient, we wouldn 9t routinely go back. For greater than 2 mm, we do because th at to me is considered the standard of care. 00:57:26 MELVIN J. SILVERSTEIN, MD, FACS: So when you find one sentinel node but there happens to be three or our sitting near it that aren 9t sentinel nodes, you 9ll take them anyway because they 9re right there, they 9re free. 00:57:34 BETH DUPREE, MD, FACS: If they 9re sitting right there beside it, yeah. If they 9re palpable and they 9re very noticeable, they 9ll go out. But my average is two to three nodes we 9ll take up either the blue dye or tracer or a combination of both. I always get 4 I do get a little scared when I only find one node that takes up the tracer because I 9m wondering, am I missing, you know, one of the other lymph nodes. But having been doing this for as many years, you know 4 I 9ve been doing sentinel node now, I guess, for 7 or 8 years, and my confidence level is definitely high. The one thing that I did want to mention is, on the video, especially if you 9re just starting sentient node, which there are still a lot of surgeons who are still on that begi nning of the curve, you cannot underestimate the important of manual palpation in the axilla because feeling for a lymph node is incredibly important. Many times a replaced lymph node will take up no tracer and no blue dye, and that lymph node is obviously the palpable sentinel node; that is the node that your surgical skills help you find. So you absolutely have to do a digital palpation of the axilla to look for a replaced lymph node. 00:58:38 MELVIN J. SILVERSTEIN, MD, FACS: Do you use blue dye, isotope , or both? 00:58:41 BETH DUPREE, MD, FACS: I 9m a combination girl; I use the combination of blue dye and radioactive tracer. I 9m on the east coast, so. 00:58:46 MELVIN J. SILVERSTEIN, MD, FACS: Is that what most people on the east coast do? 00:58:48 BETH D UPREE, MD, FACS: Pretty much. It 9s a combination of both the blue dye and the radioactive tracer. 00:58:52 MELVIN J. SILVERSTEIN, MD, FACS: We evolved to using radioactive tracer, and then we put the gamma probe in the axilla. If it 9s hot, we don 9t use the blue dye because it avoids the chance of an allergic reaction, and it also avoids blue miscoloration, which occasionally occurs. 00:59:05 BETH DUPREE, MD, FACS: I do do that for mastectomies. I do that for mastectomies routinely. I won 9t use the blue dye, since if my patient is having a tissue expander, the plastic surgeons will put blue dye into the expander, and then I can confound their process by having had blue tracer in there. 00:59:21 MELVIN J. SILVERSTEIN, MD, FACS: Certainly when you 9re learning I think it 9s 4 it 9s good to do both. I 00:59:23 BETH DUPREE, MD, FACS: Absolutely. 00:59:24 MELVIN J. SILVERSTEIN, MD, FACS: I 9ve just been informed by this thing in my ear that we 9re about done, so I want to thank you for coming all the way across the countr y to spend an afternoon with me. I want to thank those who watch this now or at some later time for giving us an hour of your time. We really appreciate it and we hope that you 9ve learned something. Thank you so much and goodbye from University of Southern California. 00:59:48 ANNOUNCER: This has been a live webcast of new techniques in the diagnosis and management of breast disease from the Keck School of Medicine at the University of Southern California. For more information about this webcast, just clic k one of the request information buttons on the screen. This program was made possible through an education grant from Ethicon Endo - Surgery. 01:00:23 [end of program]

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