CONTACTS 
0201 - Medical Offices Nima Grissom                                                                                                                                       O-00000849 0601
020101 - Ms. Mary NLN; Secretary                                                                                                                                          O-00000849 0601
020103 - Administration Department                                                                                                                                        O-00000849 0601

SUBJECTS
2nd Opinion #2 Surgical Oncologist 2nd Referral by UCSF on Criteria
2nd Opinion #2 Received Referral #2 from UCSF Presents Patient Optio

1104 -
1104 -    ..
1105 - Summary/Objective
1106 -
110601 - Follow up ref SDS 32 0000. ref SDS 31 0000.
110602 -
110603 -
110604 -
110605 -
110606 -
110607 -
110608 -
110609 -
110610 -
110611 -
110613 -  ..
1107 -
1108 -
1109 - Progress
1110 -
111001 - Talked to Mary.
111003 -  ..
111004 - She offered to fax the letter.
111006 -  ..
111007 - Upon discusson, Mary recalled getting the letter on 050914 that listed
111008 - the address for mailing the 2nd opintion to the Primary Care
111009 - Physician, ref SDS 31 XY6T, and also a copy to the surgeon at Kaiser,
111010 - shown in the same letter. ref SDS 31 XY7W
111012 -  ..
111013 - Mary will mail the 2nd opinions today, as set out in the letter on
111014 - 050914, including to Millie, and with the computer file submitted via
111015 - email.
111016 -
111017 -
111019 -  ..
1111 -
1112 -
1113 - 1008
1114 -
111401 - Received ref DRT 1 0001 from Doctor Grissom presenting a 2nd opinion
111402 - on using surgery for controlling local disease, IBC, in the left
111403 - breast.  This is a well reasoned opinion that addresses issues
111404 - presented by the patient during the meeting on 050912, ref SDS 30
111405 - HU9M, and accurately reflects patient history which was reviewed with
111406 - the doctor, ref SDS 30 AI8N, and was supplemented by examination at
111407 - that time. ref SDS 30 FH6O
111408 -
111409 -            [On 050921 Millie submits letter of appreciation to Doctor
111410 -            Grissom. ref SDS 34 M73J
111412 -             ..
111413 -            [On 050922 copy submitted to Doctor Shim in Kaiser's
111414 -            Oakland office. ref SDS 35 TL4I
111416 -             ..
111417 -            [On 050923 surgeon at Kaiser in Walnut Creek office
111418 -            received Doctor Grissom's 2nd opinion; discussed during
111419 -            meeting with patient. ref SDS 36 7J67
111421 -             ..
111422 -            [On 051109 letter reports results implementing Doctor
111423 -            Grissom's 2nd opinion; Kaiser reports Millie is
111424 -            disease-free, indicating a complete response to treatment
111425 -            guided in part by Doctor Grissom's opinion. ref SDS 44 R29J
111427 -  ..
111428 - Doctor Grissom says in the 2nd opinion...
111430 -         ..
111431 -    1.  The meeting consisted of record review, examination of the
111432 -        patient and a discussion of surgical options and treatment
111433 -        planning.  The patient is interested in surgical options for
111434 -        treatment of locoregional recurrence of her breast cancer.
111435 -        ref DRT 1 JC6H
111437 -  ..
111438 - Purpose of a 2nd opinion was set out in the letter to Doctor Grissom
111439 - on 050823, ref SDS 24 Z29R, and explained again during a meeting with
111440 - the doctor on 050912. ref SDS 30 HU9M
111442 -  ..
111443 - Records on patient history for the 2nd opinion were submitted with the
111444 - letter on 050823 citing the case study on 050812. ref SDS 19 6L4M
111445 - Pathology reports on tests, along with films and slides were hand
111446 - delivered on 050909. ref SDS 29 0001
111448 -  ..
111449 - Doctor Grissom's 2nd opinion continues...
111450 -
111451 -    2.  Ms **** is a 69 year old woman who initially was treated for
111452 -        carcinoma of the left breast at Kaiser Hospital.  She was
111453 -        diagnosed in February 2002 and underwent a left lumpectomy and
111454 -        axillary dissection.  The sentinel node was positive with
111455 -        perinodal invasion and three out of three axillary nodes were
111456 -        positive.  The tumor measured 2 cm.  It was poorly
111457 -        differentiated, ER/PR and HER2NEU negative.  Margins were
111458 -        involved.  The patient subsequently underwent re-excision with
111459 -        negative margins on 3/27/02. ref DRT 1 JC6O
111461 -  ..
111462 - Aligns with patient history reported on 050812 showing discovery of
111463 - cancer in 2002, ref SDS 19 UF4J, and results of surgery performed on
111464 - 020312. ref SDS 19 TW6H
111466 -  ..
111467 - Doctor Grissom's 2nd opinion continues...
111468 -
111469 -    3.  The patient was started on Adriamycin/Cytoxan for two cycles,
111470 -        but was changed to Taxotere after elevation of CA15-3.  Ms ****
111471 -        underwent full breast radiation at Mt.  Diablo hospital
111472 -        followed by four more treatments of taxotere ending on 12/4/02.
111473 -        ref DRT 1 JC7O
111475 -  ..
111476 - PET scan finding adenopathy in left axilla also contributed
111477 - significantly to changing treatment, reported in case history on
111478 - 050812. ref SDS 19 7E8M
111480 -  ..
111481 - Doctor Grissom's 2nd opinion continues...
111482 -
111483 -    4.  In January 2003, the patient developed a red rash involving the
111484 -        left breast and axillary swelling.  This was treated
111485 -        intermittently with antibiotics without resolution.  In
111486 -        February 2004, the patient developed supraclavicular adenopathy
111487 -        which prompted needle biopsy.  This showed metastatic
111488 -        carcinoma.  The patient began Avastin and taxol. ref DRT 1 JC84
111490 -         ..
111491 -    5.  A punch biopsy of the left breast skin was taken in April 2004.
111492 -        This revealed dermal lymphatic invasion consistent with
111493 -        inflammatory carcinoma.  The patient was seen at UCSF by Dr.
111494 -        Benz in October 2004 and Dr.  Gardino at Stanford in December
111495 -        2004.  Avastin and taxol were stopped after 7 cycles due to
111496 -        pulmonary emboli.  The patient had four more cycles of A/C
111497 -        starting in January 2005 as recommended by Dr.  Gardino.  Her
111498 -        disease progressed with this treatment.  As previously
111499 -        recommended by Dr.  Benz at UCSF, the patient started taxotere
111500 -        and xeloda in April 2005.  She has had resolution of her
111501 -        cervical and axillary adenopathy and improvement in her breast
111502 -        erythema with this latest treatment.  Her CA15-3 has also
111503 -        fallen. ref DRT 1 JC92
111505 -         ..
111506 -    6.  On examination today, the right breast appears normal to
111507 -        inspection and palpation.  There is no axillary or
111508 -        supraclavicular adenopathy on the right. ref DRT 1 JC45
111510 -         ..
111511 -    7.  The left breast has moderate post-treatment retraction.  There
111512 -        is diffuse skin thickening and mild erythema of the inferior
111513 -        portion of the breast.  The prior skin biopsy site at 6:00 has
111514 -        healed.  There is no adenopathy.  The breast is mobile on the
111515 -        chest wall. ref DRT 1 JC46
111517 -  ..
111518 - This aligns with understandings from examination reported on 050912.
111519 - ref SDS 30 FH6O
111521 -  ..
111522 - Doctor Grissom's 2nd opinion continues...
111523 -
111524 -    8.  Ms. **** has the unusual situation of skin recurrence post
111525 -        lumpectomy and radiation.  This is considered inflammatory
111526 -        cancer in view of dermal lymphatic invasion.  The patient has
111527 -        evidence of locoregional disease by biopsy of her
111528 -        supraclavicular node, but no findings of systemic spread of her
111529 -        cancer. ref DRT 1 JC52
111531 -         ..
111532 -    9.  It is unclear by physical examination whether the current skin
111533 -        changes of the left breast are due to postradiation changes or
111534 -        residual cancer. ref DRT 1 JC58
111536 -         ..
111537 -   10.  My recommendations to this patient are that she could either
111538 -        continue her current chemotherapy which appears to be
111539 -        controlling her disease, or consider mastectomy to assist in
111540 -        controlling her local disease.  She understands that her risk
111541 -        for systemic spread of her cancer is high and might not be
111542 -        affected by her local treatment. ref DRT 1 JC62
111543 -
111544 -            [On 050922 Doctor Bailey recommends against left breast
111545 -            mastectomy, and continuing with systemic treatment for
111546 -            local control, ref SDS 35 XD6U, and if diagnostic testing
111547 -            shows evidence of IBC cancer, then mastectomy could be
111548 -            considered. ref SDS 35 XD8P
111550 -         ..
111551 -   11.  If she does decide to pursue mastectomy, I would certainly
111552 -        recommend restaging with a PET scan.  She should also have skin
111553 -        biopsies to determine whether she has had a complete response
111554 -        of her local disease.  Using several around the outer edge of
111555 -        the breast, it may be possible preoperatively to obtain some
111556 -        idea of how wide the skin resection at the time of the
111557 -        mastectomy should be.  The skin biopsies would be better
111558 -        performed as thin full thickness surgical biopsies with suture
111559 -        closure rather than punch biopsies in view of the difficulty
111560 -        with healing of the last punch biopsy. ref DRT 1 JC64
111562 -  ..
111563 - PET scan test and biopsies aligns with understandings from meeting on
111564 - 050912. ref SDS 30 BV8I
111565 -
111566 -     [On 050923 the surgeon at Kaiser in Walnut Creek proposed that if
111567 -     PET scan test and biopsies are favorable, then the patient can
111568 -     consider a standard mastectomy, rather than a very wide surgery to
111569 -     remove previously infected skin. ref SDS 36 4G4L
111571 -      ..
111572 -     [On 051005 Millie got a PET and CT test combination at Kaiser in
111573 -     Walnut Creek. ref SDS 39 0001
111575 -      ..
111576 -     [On 051007 favorable PET test indicates no evidence distant
111577 -     metastatis; prior local regional pathologies resolved. ref SDS 40
111578 -     L66M
111580 -      ..
111581 -     [On 051018 Millie notified favorable results from skin biopsies,
111582 -     no evidence of cancer. ref SDS 42 QN3I
111584 -      ..
111585 -     [On 051021 surgeon performed surgery and explained that a very
111586 -     wide mastectomy was accomplished with standard closure and without
111587 -     complications. ref SDS 43 MM6M
111589 -  ..
111590 - Biopsies were considered during the meeting with the surgeon at Kaiser
111591 - on 050324, ref SDS 10 OV8L, and again during a follow up meeting at
111592 - Kaiser on 050727. ref SDS 13 SZ6M
111594 -  ..
111595 - Doctor Grissom's 2nd opinion continues...
111596 -
111597 -   12.  I would not recommend mastectomy if the PET scan shows evidence
111598 -        of metastasis or if the skin biopsies show extensive skin
111599 -        involvement with cancer outside of the previously irradiated
111600 -        area of the breast. ref DRT 1 JD35
111602 -         ..
111603 -   13.  If the PET scan shows no evidence of metastasis and the skin
111604 -        involvement seems to be localized or to have resolved, and the
111605 -        patient wants to proceed with mastectomy, I would recommend a
111606 -        very wide simple mastectomy.  This would need to include all
111607 -        the breast tissue and all the previously irradiated skin using
111608 -        the radiation tattoos as a guide. ref DRT 1 JD45
111610 -  ..
111611 - Consultation with Doctor Grissom on 050912 presented the purpose of
111612 - "very wide mastectomy" to reduce the risk of relapse by removing all
111613 - of the tissue previously infected by IBC; reducing local relapse in
111614 - turn reduces the risk of IBC spreading cancer that causes distant
111615 - metastasis?  This proposal expands on Doctor Guardino's 2nd opinion
111616 - received on 041209, and citing the prospect of surgery following
111617 - regression of inflammation, ref SDS 7 SN97, as noted by Doctor Grissom
111618 - today.  Doctor Grissom's proposal compliments the surgeon's plan for
111619 - setting wider than normal boundaries of standard mastectomy surgery
111620 - that reduce Millie's risk of relapse with a patient profile of
111621 - secondary IBC, as discussed on 050727. ref SDS 13 JV5F
111623 -             ..
111624 -            [On 051007 primary care physician proposes purpose of
111625 -            standard mastectomy is palliation of future relapse.
111626 -            ref SDS 40 6A4N
111628 -             ..
111629 -            [On 051010 Doctor Grissom explains purpose of very wide
111630 -            mastectomy for patient presenting with secondary IBC and no
111631 -            evidence of distant metastasis for 4 years is for local
111632 -            control that could yield a cure. ref SDS 41 GW5K
111634 -             ..
111635 -            [On 051021 doctor performed surgery and explained that a
111636 -            very wide mastectomy was accomplished with standard closure
111637 -            and without complications. ref SDS 43 MM6M
111639 -  ..
111640 - The construction in this part of the 2nd opinion which says "...if the
111641 - patient wants to proceed with mastectomy... " should be expanded to
111642 - indicate the patient wants a mastectomy to increase local control that
111643 - reduces risk of relapse, including distant metastasis, and to provide
111644 - benefits of a disease-free period without chemotherapy for better
111645 - quality of life, as requested in comments on the 1st draft reviewed on
111646 - 050918. ref SDS 31 4R9F
111648 -             ..
111649 -            [On 050922 Doctor Bailey recommends against surgery, but
111650 -            says any surgery in this case would require removing a very
111651 -            large area in order to remove any involved skin.
111652 -            ref SDS 35 XD8P
111654 -             ..
111655 -            [On 050927 surgeon at Kaiser cites discussion on 050923
111656 -            proposing that test findings of no disease supports
111657 -            performing standard mastectomy. ref SDS 37 WX5F
111659 -  ..
111660 - Doctor Grissom's 2nd opinion continues...
111661 -
111662 -        As above, preoperative skin biopsies could help in planning the
111663 -        amount of skin which would be removed to obtain negative
111664 -        margins.
111666 -         ..
111667 -        A microvascular flap such as a DIEP flap or possibly a TRAM
111668 -        could be used for closure.  Even with wide excision, local skin
111669 -        recurrence could recur.  With a large tissue flap, the patient
111670 -        could possibly have localized radiation again if really needed.
111671 -        It is unlikely that skin grafts would provide adequate coverage
111672 -        of previously irradiated tissue.  Ms **** understands that this
111673 -        is a major operation requiring many hours of operating time and
111674 -        anesthesia. ref DRT 1 XR5H
111676 -  ..
111677 - This confirms understandings from consulation meeting on 050912
111678 - calling for contemporaneous collaboration during surgery with a
111679 - plastic surgeon, ref SDS 30 X545, and further addresses a question in
111680 - comments on 050916 about determining layout of surgery. ref SDS 31
111681 - XX4Y
111682 -
111683 -            [On 050922 Doctor Bailey does not offer guidance on
111684 -            determining the precise area of breast and skin to remove
111685 -            for a very wide mastectomy. ref SDS 35 JZ4K
111687 -             ..
111688 -            [On 050922 copy submitted to Doctor Shim in Kaiser's
111689 -            Oakland office asks for comment on Kaiser's experience
111690 -            performing procedure described by Doctor Grissom proposing
111691 -            a microvascular flap such as a DIEP flap or possibly a TRAM
111692 -            for closure of the surgical wound. ref SDS 35 TL4I
111694 -             ..
111695 -            [On 050928 plastic surgeon at Kaiser in Walnut Creek cites
111696 -            risk that despite best efforts during the original
111697 -            mastectomy surgery, there is a risk that clear margins will
111698 -            not be achieved, and so if immediate reconstructive surgery
111699 -            is performed, this makes reexcision more difficult; as a
111700 -            result the plastic surgeon at Kaiser recommends deferring
111701 -            reconstructive surgery for a week or so until after the
111702 -            biopsy of the tissue removed during primary surgery
111703 -            establishes clear margins have been achieved; however, this
111704 -            scenario would leave the surgeon without a method to close
111705 -            a very wide mastectomy; the plastic surgeon proposes
111706 -            standard closure, which seems problematic; one solution is
111707 -            to include immediate biopsy analysis with the 10 - 20 hour
111708 -            operation contemplated in this case. ref SDS 38 2491
111710 -             ..
111711 -            [On 051010 Doctor Grissom explains purpose of very wide
111712 -            mastectomy for patient presenting with secondary IBC and no
111713 -            evidence of distant metastasis for 4 years is for local
111714 -            control that could yield a cure. ref SDS 41 GW5K
111715 -
111717 -  ..
111718 - Doctor Grissom's 2nd opinion continues...
111719 -
111720 -   14.  Again, it is very important for the patient to understand that
111721 -        there is no way to calculate whether or not she would have any
111722 -        significant improvement in survival or quality of life with
111723 -        mastectomy as opposed to continued chemotherapy.  There also is
111724 -        no way to make a decision as to whether more chemotherapy is
111725 -        appropriate after surgery based on the surgical findings.
111726 -        ref DRT 1 JD54
111728 -  ..
111729 - This expression might be clarified.
111731 -  ..
111732 - If PET scan finds distant metastasis, then surgery would be less
111733 - effective for the patient, say yielding in the range of 0% - 20%
111734 - palliative solution for quality of life, and add nothing to longevity.
111735 - If PET scan finds no distant metastasis and PET testing along with
111736 - biopsy finds some cancer only in the left breast, then surgery might
111737 - play a significant role for local control, called out by PCP.  If
111738 - follow up PET testing and other tests show disease is controled, then
111739 - surgery would seem to achieve say a 70% - 90% solution, given that
111740 - cancer is rarely cured, and that surgery removed a source of future
111741 - disease.  This same calculation would seem to flow in the event that
111742 - pre-op PET and biopsy tests show the breast is free of cancer in
111743 - addition to no distant disease.  In that scenario, surgery might
111744 - strengthen local control leading to an 80% to 90% chance of cure
111745 - called out by Doctor Shim in a 2nd opinion received on 050907.
111746 - ref SDS 27 F49H
111748 -  ..
111749 - This analysis is criticized by the fact that, even if in the ballpark
111750 - of sound medical reasoning, results depend on successful surgery, and
111751 - this seems very high risk for error due to complexity of such an
111752 - operation cited by Doctor Grissom today, per above, ref SDS 0 XL8U,
111753 - and also in Doctor Bailey's 1st draft received on 050918, ref SDS 33
111754 - XK5P, including a long period for healing the wound, and prospects of
111755 - cancer flaring up requiring chemo, which diminishes healing.  On the
111756 - other hand, brain surgery, and heart surgery are complex, and people
111757 - still have successful outcomes.  Experts argue in this case that
111758 - breast cancer patients have a reasonable alternative to continue with
111759 - systemic treatment.  Don't side effects at some point swing the
111760 - balance toward accepting some risk of surgery in order to avoid
111761 - certainty of excrutiating and debilitating side effects?
111763 -  ..
111764 - Doctor Grissom's 2nd opinion concludes...
111765 -
111766 -   15.  This patient has difficult decisions to make regarding her care
111767 -        and is free to contact me in the future if she has any further
111768 -        questions. ref DRT 1 JD68
111769 -
111770 -            [On 051010 Doctor Grissom provided follow up consultation
111771 -            explaining Millie's opportunity for possible cure rather
111772 -            than palliation using a surgical treatment for stage IV
111773 -            cancer with left breast secondarey IBC involvement, and
111774 -            currently testing NED. ref SDS 41 RG6J
111776 -             ..
111777 -            [On 051021 surgeon performed surgery and explained that a
111778 -            very wide mastectomy was accomplished with standard closure
111779 -            and without complications. ref SDS 43 MM6M
111781 -             ..
111782 -            [On 051109 letter of appreciation and report good results
111783 -            implementing Doctor Grissom's 2nd opinion; Kaiser reports
111784 -            Millie is disease-free, indicating a complete response to
111785 -            treatment guided in part by Doctor Grissom's opinion.
111786 -            ref SDS 44 R29J
111787 -
111788 -
111789 -
111790 -
111791 -
111792 -
111793 -
111794 -
111795 -
111796 -
111797 -
111798 -
111799 -
111800 -
1119 -