Dual surgery conducted under general anesthesia on the patient suffering from breast cancer and a heart tumor
New Delhi, July 25, 2019:
A team of doctors from Fortis Flt. Lt. Rajan Dhall Hospital, Vasant Kunj, consisting of oncologists, cardiologists, radiologists, anesthesiologists and critical care specialists, conducted simultaneous open-heart surgery and segmental mastectomy under general anesthesia on a 55-year-old patient from Gorakhpur, Uttar Pradesh. The treating team consisted of Dr. Mandeep Malhotra, Dr. Tapan Ghose and Dr. Sanjay Gupta. This form of dual surgery is rare and the first of its kind.
The patient was presented to the hospital with a cancer in her right breast. A CT scan of her chest revealed clear lungs, but a malignant mass in her breast and something in her heart (left atrium) which was asymptomatic. The cardiology team then proceeded with further tests – a 2D echocardiograph, angiography and a trans-esophageal echocardiography – which suggested that the mass or lesion in the heart was an atrial myxoma, a benign cardiac tumor. With the presentation of evidence of two separate tumors – one in the breast and one in the heart, treatment options were narrowed. The team assessed the situation as the malignant tumor in the breast needed to be treated urgently and treatment involved surgery, chemotherapy, targeted immunotherapy, radiation and hormonal therapy.
Dr Sanjay Gupta, Director, Cardiac Surgery/ Cardio Thoracic Vascular Surgery FHVKsaid, “Another challenge under the circumstances was that immunotherapy and certain chemotherapeutic drugs, sometimes cause weakening of heart, therefore heart function should be at its optimum best to withstand the treatment. The Atrial Myxoma can form a thrombus, rupture and lodge itself in the internal organs causing a stroke. Also increase in its size can compromise the heart functions. The presence of a tumor in the body had increased the risk of a stroke, and the myxoma compounded this risk. Cancer by itself is a thrombogenic state, chances of stroke are more. If we plan to operate before the breast, it will take at least 4 to 5 weeks for patient to recover from open heart surgery which is ample enough time for stage III cancer to become Stage IV. Starting Breast Cancer treatment before addressing heart tumor, increases the risk of the chances of breast cancer treatment being stopped in case of adverse effects on heart due to treatment drugs which will also affect patient’s life.”
Dr. Mandeep Malhotra Head, Department of Head Neck and Breast Oncoplasty, FHVK shared, “The histopathology of the patient proved that she was suffering from stage 3 breast cancer with an atrial myxoma. Profiling showed that she was an ideal candidate for targeted therapy in the form of Trazatususmab, which often causes weakening of the heart. Had we operated the heart only, delaying the surgery for breast, then this could have led to progression of cancer impacting the patient’s survival. Therefore, in order to ensure survival and proper treatment, the heart needed to be stable. Only then could the treatment for the breast cancer be properly administered and completed. It was, therefore, decided in our medical board in consultation with the patient, that both the operations would be done together, and the patient would be placed under general anesthesia. She then underwent an open-heart surgery first, and after the chest was closed and the patient stabilized, the breast was operated on, to remove the cancer. She was kept in the ICU for 48 hours, following which she was shifted to the ward. Her post-operative period was smooth and she was discharged on the 7th day, post her surgery. At present the patient’s main tumor or disease load due of Breast Cancer has gone, heart has been optimized to withstand the chemotherapy and Targeted Therapy to prevent the Breast cancer from coming back.”
Dr Tapan Ghose, Director, Cardiology, FHVK added, “During the heart surgery, the patient was put on a heart-lung machine and administered blood thinners. Therefore, the second surgery had to be meticulously performed to avoid bleeding. The team also took all precautions to keep the patient stable for the second surgery and optimize her heart to bear targeted therapy and chemotherapy. She is now free to take the necessary therapy for the next few months, to be completely cured of breast cancer.”
Ms. Mangla Dembi, Facility Director, FHVK said, “Two major operations in one sitting is in itself a major challenge. We appreciate the courage and will of the patient and her family, and also the faith they had in our team and institute. Our competent, experienced anesthesia and critical care teams who are highly equipped, was a major reassurance. Conducting two major surgeries simultaneously is a rare case. We are satisfied with our considered decision and the procedure was seamless. The patient is recovering well and her previously undetected heart problem has also been dealt with, alleviating the future risk of stroke and thrombus formation.”