Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

Quadrantectomy usually refers to a wider excision that resects a quadrant of breast tissue, sometimes associated with the resection of redundant skin.

Lumpectomy is combined with sentinel node biopsy and/or axillary dissection for an invasive cancer (see Chapters 10 and 11).

Lumpectomy is usually followed by radiotherapy.

Randomized trials have demonstrated that patients who undergo lumpectomy, axillary staging, and radiotherapy have the same overall survival as those who have modified radical mastectomy.

STEP 2: PREOPERATIVE CONSIDERATIONS

In a well-screened population, breast cancer is commonly identified as a nonpalpable mammographic abnormality. Interval cancers may occur in a well-screened population, especially in patients who are BRCA1 and BRCA2 gene mutation carriers. A clinician experienced in breast disease may also palpate small breast cancers.

Preoperative evaluation of a screen-detected nonpalpable abnormality or palpable lesion requires diagnostic mammograms. Additional images may include magnification and exaggerated and medial-lateral views. Other imaging modalities such as ultrasound and magnetic resonance imaging (MRI) may provide detailed information to map the area involved with tumor.

A pathologic diagnosis of an image-detected abnormality or a palpable abnormality is obtained by fine needle aspiration, core biopsy, or excisional biopsy. The preferred method is a core biopsy, which allows for receptor analysis and permits discussion of

treatment options.

Selection of a surgical option for local control of breast cancer is a complex decision, based on the tumor features, breast size, location, associated medical problems, and individual choice. Interdisciplinary discussion with radiation oncologists, medical oncologists, and plastic surgeons in addition to the oncologic surgeon provides a comprehensive understanding of the options available to the patient.

Lumpectomy with axillary staging may be an alternative procedure to a modified radical mastectomy for many women, especially in the current era of mammographic screening, identification of earlier stage disease, and the use of induction chemotherapy to reduce the size of the primary tumor.

Lumpectomy is followed by breast radiotherapy.

Whole breast irradiation may be given with or without a boost to the site of the tumor.

Accelerated partial breast radiotherapy is a recent approach that limits the radiation to a smaller field, delivering a higher dose over a shorter period of time.

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Evaluation of the primary lesion and the planned procedure should be reviewed with the radiologist and the radiation therapist.

Palpable tumors may be initially treated with neoadjuvant chemotherapy to downsize them if they are too large to result in a good cosmetic outcome.

Nonpalpable tumors will require preoperative ultrasound-guided, stereotactically placed, or on rare occasions, MRI-directed needle localization.

Size and extent of lesion relative to breast size will dictate the ability to perform breastconserving surgery and the cosmetic outcome.

Centrally located tumors may require resection of the nipple-areolar complex.

Multifocality is the presence of satellite tumors within the index quadrant. If they are close enough together to permit resection through a single incision, breast conservation remains an option.

Multicentricity, the presence of tumors in different quadrants of the breast, is usually taken as a contraindication to breast conservation.

Calcifications that are associated with a malignancy may be treated with breast conservation unless they involve too extensive an area for a good cosmetic outcome or if they involve the entire breast.

Breast conservation may not be an option:

When extensive resection would lead to poor cosmesis

Large tumor size relative to breast size

Diffuse suspicious calcifications

Multicentric disease

Inflammatory carcinoma

Locally advanced disease

When medical contraindications are present

Previous chest wall irradiation

Active collagen vascular disease

Presence of a pacemaker

Significant cardiac disease

Significant pulmonary disease

When the patient is pregnant

Radiotherapy is contraindicated in pregnancy but may be delayed until after delivery if other treatment is ongoing.

STEP 3: OPERATIVE STEPS

1. ANESTHESIA

Monitored anesthesia care with local anesthetic is usually sufficient for a small lumpectomy.

Larger resection or resection in the vicinity of the nipple-areolar complex may require a general anesthetic.

General anesthesia is usually preferable for lumpectomy combined with sentinel node biopsy and axillary dissection.

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When a nonpalpable lesion is localized with a wire, review of the mammogram with attention to the lesion and the wire tip dictates the placement of the incision. The entrance point of the wire may be far removed from the lesion, and an incision placed at the entry point of the wire may lead to extensive unnecessary dissection of normal breast tissue. Multiple bracketing wires may be used for extensive calcifications.

Some radiologists inject a small amount of methylene blue at the tip of the wire to aid the surgeon.

Skin excision is usually unnecessary unless the tumor is too close to achieve a clear margin.

3. DISSECTION

Dissection of the area of interest may be performed with sharp dissection (Figure 9-3) or electrocautery.

If electrocautery is used, the skin edges are at risk from thermal injury, and there may be significant cautery artifact of the specimen, making histopathologic evaluation of the margins difficult for the pathologist.

Sharp dissection is an alternative and requires meticulous hemostasis once the lesion is removed.

When the tumor is located, a 1-cm margin of normal tissue may be grasped with Allis forceps (Figure 9-4). If the glandular tissue is almost completely replaced with adipose tissue, traction with instruments on the friable fatty tissue can damage the surrounding normal margin and preclude accurate margin assessment. In these cases, gentle pressure should be applied to separate the area of interest from the remaining breast. The incision may need to be larger for better visibility.

The pectoralis fascia is removed in cases in which the tumor approaches the chest wall.

When the specimen is resected, it is oriented for the pathologist with marking sutures so that the medial, lateral, superior, inferior, posterior, and anterior margins can be evaluated for proximity of the tumor cells.

The presence of the lesion is placed on a grid, and the location of the lesion is confirmed by specimen mammogram. The radiologist can place marking needles in the specimen for the pathologist to identify the lesion.

The submission of separate shaved margins from the cavity is a technique that provides additional information about margins.

The cavity is demarcated with metal clips for the radiation oncologist, unless partial breast irradiation with a MammoSite balloon catheter is anticipated. The balloon is susceptible to rupture from the sharp metallic clips.

FIGURE 9–3

FIGURE 9–4

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4. CLOSING

Surgeons vary in their recommendation for closure of the partial mastectomy defect. In most cases, the defect in the breast can be closed by approximating the fascia of the superficial subcutaneous adipose tissue and the skin (Figure 9-5). The cavity is allowed to accumulate a fibrinous seroma, which helps maintain the natural shape of the breast.

Some surgeons are concerned that lack of cavity closure will leave a dimple in the contour and therefore elect to close the parenchyma. The goal in breast conservation is to remove the tumor with a healthy margin to reduce risk of recurrence, minimize deformity, and preserve the location of the nipple.

Oncoplastic advancement flaps may be helpful when a large cavity remains but should be applied only by individuals experienced in the techniques. When applying oncoplastic procedures that shift tissues around, the surgeon must be reasonably certain that the margins are free of tumor.

Reapproximation of the subcutaneous fat with an absorbable suture leads to better skin closure (see Figure 9-5).

Skin closure may be performed with absorbable or nonabsorbable sutures or Dermabond, according to individual preference.

Closure done with subcuticular running suture pattern

FIGURE 9–5

5. PROCESSING OF RESECTED SPECIMEN

Orientation of the specimen is the responsibility of the surgeon, and any concerns should be communicated to the pathologist.

The specimen may not be a perfect sphere or rectangle but rather an irregular specimen that requires detailed orientation.

Specimen mammography aids the surgeon who can perform additional resections at the time of lumpectomy.

Specimen mammography aids the pathologist who can process the areas of interest in greater depth.

Pathologic processing is most helpful when multicolor inking of the specimen margins is performed.

6. REEXCISION LUMPECTOMY

If the margins demonstrate transected tumor, discussion for reexcision lumpectomy or mastectomy must be undertaken.

If reoperation is desired by the patient, the same incision may be used.

Multicolored inking of the initial lumpectomy specimen can identify a specific margin that is positive, and re-resection may be limited to the affected margin.

STEP 4: POSTOPERATIVE CARE

A variety of dressings can be used, from Opsite alone to fluffs and a specialized postsurgical bra.

Showers may be taken in 48 hours.

Tub baths and swimming are avoided until the wound is completely healed.

Strenuous exercise should be avoided in the first week to prevent bleeding.

Silicone-based sheets, such as Biodermis, may be applied to reduce scarring by direct pressure.

A sports bra worn 24 hours a day may be comfortable for some, whereas others find any form of bra uncomfortable.

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STEP 5: PEARLS AND PITFALLS

Discussion with the interdisciplinary team will sequence treatment in the most appropriate manner.

Surgical planning preoperatively with the radiologist is critical to achieve negative margins the first time.

Complex resections may require input from a plastic surgeon, especially when contralateral symmetry may be an issue.

Large excisions may require oncoplastic techniques to rearrange the remaining breast parenchyma.

Maintenance of the nipple-areolar complex in the native position results in the best cosmetic outcome.

Specimen orientation by the surgeon and communication with the radiologist and pathologist is critical.

Specimen mammography and communication of the findings to the surgeon and pathologist are essential to take additional margins at the first operation.

Specimen multicolor inking aids in determining the location of a close margin, so reresection is limited to the area of residual tumor and not on the negative margins.

SELECTED REFERENCES

1. Anderson BO, Masetti R, Silverstein MJ: Oncoplastic approaches to partial mastectomy: An overview of volume-displacement techniques. Lancet Oncol 2005;6:145-157.

2. Fisher B, Anderson S, Bryant J, et al: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347:1233-1241.

3. Schwartz GF, Veronesi U, Clough KB, et al: Consensus conference on breast conservation. J Am Coll Surg 2006;203:198-207.

4. Veronesi U, Cascinelli N, Mariani L, et al: Twenty-year follow-up of a randomized study comparing breastconserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347:1227-1232.

5. Iglehart JD, Kaelin CM: Diseases of the breast. In Townsend C Jr, Beauchamp R, Evers B, Mattox K (eds): Sabiston Textbook of Surgery. Philadelphia, Elsevier Saunders, 2004, pp 867-927.

C H A P T E R 10

MODIfiED RADICAL MASTECTOMY

Baiba J. Grube

STEP 1: SURGICAL ANATOMY

A comprehensive understanding of the location of the mammary gland in relation to the chest wall musculature, the fascial boundaries, the lymphatic drainage pathways, the vascular supply to the breast and the associated supporting structures, and the innervation of the breast and surrounding tissues is essential for appropriate surgical management.

Figure 10-1 demonstrates the breast gland and the rich intraparenchymal lymph channels coursing toward the deeper major nodal reservoirs.

Figure 10-2 illustrates the relationship of the nodal basins to the chest wall musculature. The lymph nodes lateral to the pectoralis minor constitute level I nodes, those immediately beneath the pectoralis minor level II nodes, and those medial to it level III. The interpectoral nodes (Rotter’s nodes) are located between the pectoralis major and minor muscles and are part of level III nodes. Internal mammary nodes are located medially along internal mammary vessels beneath the sternum. Unnamed intramammary lymph nodes can be present in all quadrants of the breast.

DEFINITION

Modified radical mastectomy constitutes the removal of the breast parenchyma, the nippleareolar complex, and levels I and II axillary lymph nodes.

Other types of mastectomy procedures include the following:

Total mastectomy (removal of the breast only) may be combined with sentinel node biopsy.

Patey’s modified radical mastectomy includes dissection of level III nodes reached by division or resection of the pectoralis minor muscle.

Radical mastectomy further removes the pectoralis major and minor muscles.

Extended radical mastectomy also eradicates the internal mammary lymph nodes.

Nipple-sparing mastectomy preserves the nipple and areola.

Areola-sparing mastectomy preserves the areola, usually with resection of the nipple.

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STEP 2: PREOPERATIVE CONSIDERATIONS

Selection of a surgical option for local control of breast cancer is a complex decision that is based on tumor features, body habitus, and individual patient choice. Interdisciplinary discussion with radiation oncologists, medical oncologists, and plastic surgeons in addition to the oncologic surgeon provides a comprehensive understanding of the options available to the patient.

Modified radical mastectomy may be an option for a diagnosis of the following:

Invasive breast cancer

Multicentric invasive breast cancer

Invasive breast cancer after previous chest irradiation

Invasive breast cancer when postoperative radiotherapy maybe contraindicated (e.g., connective tissue disease, presence of a pacemaker)

Invasive breast cancer in a pregnant patient

Palliative resection in stage IV breast cancer for local control

Lumpectomy with axillary lymph node dissection may be an alternative procedure to modified radical mastectomy for many women, especially in the current era of mammographic screening and identification of early stage disease, or with the use of induction chemotherapy to reduce the size of a larger primary tumor.

Discussion of the planned procedure with the anesthesiologist is critical.

Long-acting paralytic agents should be avoided when an axillary dissection is planned so that intact motor nerve function can be detected.

Inhalation agents may be varied if immediate reconstruction is planned with autologous tissue.