Breast conservation surgery and sentinal node biopsy: Dr R Botha Moderator: Dr E Osman

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1 Breast conservation surgery and sentinal node biopsy: Dr R Botha Moderator: Dr E Osman

2 Breast anatomy:

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4

5 Breast conserving surgery: The aim of wide local excision is to remove all invasive and in situ cancer with at least a 1cm macroscopic margin of normal surrounding breast tissue. The skin incision must be placed in a position that will obtain the optimal cosmetic result.

6 Langer described the predominant orientation of collagen fibers in the skin around the breast. These lines are circular. Kraisl demonstrated that lines of maximum resting skin tension run in a more transverse orientation across the breast.

7 Scars that are parallel to both the lines of maximum resting skin tension and to the orientation of collagen fibers will produce the best cosmetic incisions with least hypertrophy and keloid formation. Incisions that are at right angles to both these lines will produce the worst cosmetic results.

8 Place incision directly over the cancer. Excising skin directly overlying a cancer is only necessary if the carcinoma is very superficial and/or the skin is tethered. Dissect the skin and subcutaneous fat from the breast tissue. Elevate the skin flaps 1 to 2cm beyond the edge of the cancer.

9 Place fingers of nondominant hand over the palpable cancer. Divide breast tissue at least 1cm beyond the cancer. When breast tissue has been divided beyond the cancer the deep aspect of the cancer can be palpated. Divide the breast tissue below the cancer.

10 In most patients to ensure an adequate margin the dissection will be continued down to the pectoralis fascia. Mark specimen immediately to orientate pathologist.

11 Larger defects in the breast should be closed by mobilization of the surrounding breast tissue. Close in series of interrupted absorbable sutures. Drains should not be routinely used. They do not prevent hematoma formation and increase infection rate. Close skin with a subcuticular suture.

12 Technique of excising impalpable cancers: Impalpable lesions can be located preoperatively by a variety of techniques: Skin marking Injection of blue dye Carbon or radioisotope Insertion of a hook wire with postlocalization mammograms. Intraoperative ultrasound

13 It is suggested to make skin incision directly over the cancer. Localization wires with markings help guide the surgeon.

14 The aim is to remove the mammographic lesion with a 1cm clear lateral radiographic margin.

15 Radioguided occult lesion localization is a newer technique for localization of impalpable lesions. Under mammogram or ultrasound control technetium-labelled human serum albumin or sulphar colloid is injected into the tumour. Gamma detecting probe is used intraoperatively to locate lesion to guide excision.

16 Specimen should be orientated and a orientated specimen radiograph should be obtained. Orientated specimen radiographs improve the rate of complete excision of impalpable cancers.

17 Technique of sentinal LN biopsy: A short skin incision is made in the axilla 3-7 minutes after dye injection. Use electrocautery to dissect through the subcutaneous tissue and clavipectoral fascia into axilla. Superficial blue lymphatics in the subcutaneous tissue can be transected. Dissection continues perpendicular to the skin.

18 Use retractors to improve the exposure. Position the patient s arm up and over the head to help lift the contents towards the skin. Trace blue lymphatics to blue SLN using blunt dissection. Avoid transecting blue lymphatics as this will expose the surrounding tissue to blue discoloration.

19 Sometimes only the hilum of the SLN stains blue, but must still be regarded as a SLN if a blue afferent lymphatic can be demonstrated tracking into the node. When radiocolloid is used a handheld gamma probe covered with a sterile plastic sheath will guide the dissection towards the radioactive hot sentinal nodes.

20 Technique of sentinal LN biopsy: Radioactive and/or blue nodes are excised. Send for histopathological evaluation. Ensure that all blue and/or radioactive nodes have been removed. Carefully palpate axilla and resect all suspicious LN.

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22 If SLNs are tumour free no additional surgery is required. Axillary LN dissection is recommended for any SLN containing macrometastatic disease (>2mm). Micrometastatic disease (0.2 to 2mm) is controversial. No ALND required if isolated tumour cells are present (0-0.2mm).

23 Technique of axillary dissection: Improve exposure by placing a sandbag/ wedge under the ipsilateral shoulder to elevate the axilla. Prepare and drape ipsilateral arm separately to ensure arm can be moved intraoperatively. Lower arm and hand are wrapped in a sterile drape and secured with a stockinette.

24 Skin incision: i. Skin crease incision distal to the hear bearing skin of the axilla. ii. Lazy S incision placed between the pectoralis major and lattisimus dorsi muscle. iii. Anterior axillary fold incision placed parallel and posterior to the lateral border of pectoralis major muscle.

25 Deepen skin incision through the superficial fascia. Create skin flaps deep to superficial fascia. Start with medial dissection: Elevate superior medial and inferior skin flaps with skin hooks. Dissect in plane between the SC tissue and axillary fat. Palpate the lateral border of pectoralis major muscle. Continue with dissection to this border.

26 Dissect superiorly and inferiorly exposing the lateral border of pectoralis major muscle. Identify the lattisimus dorsi muscle.

27 Retract pectoralis major muscle and identify pectoralis minor muscle with dissection of the lateral edge. Identify and preserve the medial pectoral nerve and vessels that pass into the lateral border of the pectoralis minor muscle. Medial pectoral nerve innervate the pectoralis minor and lower lateral third of pectoralis major muscles.

28 Retract pectoralis major and minor muscles. Bend elbow and move arm upward behind the patient s head. Makes retraction of muscles easier. Care should be taken not to overstretch the brachial plexus. Allow identification of LN under pectoralis minor muscle.

29 Visualize a small conical depression covered by clavipectoral fascia, containing the axillary LN. The upper limit of the depression is defined by the axillary vein where it meets the subclavius muscle tendon. Incise clavipectoral fascia and detach pectoralis minor form the lymph adipose tissue.

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31 Identify the axillary vein. The lower border of axillary vein is the superior limit of the dissection. Dissection proceeds from medial to lateral and cranial to caudal. Tease fat and LN away from chest wall by blunt dissection. Identify the intercostobrachial nerve leaving the chest wall (usually from 2 nd or 1st ICS)

32 Preserve intercostobrachial nerve if possible and retract superiorly if dissected free from other structures. Identify and preserve the long thoracic nerve. Situated approximately 2cm posterior to the intercostobrachial nerve Can be pulled out laterally by the axillary contents. Free nerve from axillary tissue and push it back towards chest wall.

33 Identify the thoracodorsal nerve and vessels. Identify about two thirds of the way across the axilla. Thoracodorsal vein drains into posterior aspect of axilla. The nerve is the most medial structure of the neurovascular bundle.

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35 Clean the valley on the subscapularis muscle between the long thoracic and thoracodorsal nerve with cranial to caudal dissection. Remove tissue lateral to and behind the thoracodorsal vessels to the lateral margin of the latissimus dorsi muscle. The inferior margin of dissection is completed by dividing the axillary tail of the breast under direct vision.

36 Irrigate wound with sterile water. Ensure heamostasis Single suction drain is placed into cavity and brought out separately. Close wound in layers with absorbable sutures.

37 For those waiting for exam results...

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