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

STEP 4: POSTOPERATIVE CARE

Drains are emptied 2 to 3 times per day and drain output is recorded on a log.

Drainage may be sanguinous immediately postoperatively, but should be dilute.

Continued postoperative frank bloody output indicates ongoing bleeding and warrants return to the operating room.

Drainage clears to serosanguinous, then clear and straw-colored.

Cloudy fluid may indicate bacterial infection and should be cultured.

Drains are removed when the output is less than 30 mL for 2 consecutive days.

Drains usually remain for 7 to 10 days.

Seroma may form after drain removal.

Aspirate in clinic if large, suspicious for infection, or uncomfortable.

Multiple aspirations may be required.

Compression dressing may reduce likelihood of seroma reaccumulation.

Some seromas reabsorb without aspiration if they are small.

Dressings are removed after 48 hours.

Pain out of proportion to the procedure may indicate a significant hematoma, for which dressings should be removed earlier.

Other indications include fever and excessive drainage.

Shower may be acceptable after 48 hours when dressings are removed.

The surgical site is bathed with mild soap and water, patted dry, and redressed around the drain site.

The incision may be left open according to individual preference.

Tub baths are usually not advised while drains are in place.

Antibiotics are usually not needed but may be considered on an individual basis for the following:

Previous surgical biopsy

Immunocompromised individuals

Local wound conditions

Limited exercises are initiated on postoperative day 1 and increased to range-of-motion and strengthening exercises after the drains are removed.

Consultation with American Cancer Society for Reach to Recovery is helpful.

Consultation with occupational therapy for rehabilitation is useful.

Individuals are monitored for lymphedema.

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Patient education about long-term precautions for protection of the affected extremity include the following:

Avoidance of blood pressure measurements and phlebotomy sticks on the affected extremity

No intravenous infusion lines

No constrictive clothing

Electric razors for shaving

Protective gloves for tasks that may lacerate the skin and lead to infection

Early intervention with antibiotics for a hand or arm infection, often requiring hospitalization for parenteral antibiotics

Compression sleeve and glove may be indicated for cases of extensive nodal disease, combination surgery and radiotherapy, and evidence of lymphedema, as well as for prophylaxis for air travel.

Postoperative radiotherapy or chemotherapy is not initiated for 2 to 3 weeks.

Skin flap loss may require local care with wet to dry dressings or silver sulfadiazine (Silvadene) cream if limited or surgical revision if skin loss is extensive.

A bra and prosthesis are measured and fitted for long-term symmetry or for a short interval while the patient is awaiting autologous or implant reconstruction.

Scarring maybe reduced with application of a silicone sheet, such as Biodermis.

STEP 5: PEARLS AND PITFALLS

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

Surgical planning in conjunction with the plastic surgeon will result in optimal cosmetic outcome.

Skin-sparing mastectomy leads to the best cosmetic appearance of the reconstructed breast.

Gentle handling of the skin flaps reduces the risk of flap loss.

Preservation of the fascia of the serratus anterior muscle on the chest wall and identification of the long thoracic nerve underlying it on the chest wall will reduce the risk of transection and the winged scapula deformity.

Dissection along the lateral aspect of the latissimus dorsi muscle reduces the likelihood of injury to the thoracodorsal trunk and weakened shoulder adduction.

Preservation of the medial pectoral nerve prevents atrophy of the pectoralis major muscle and chest wall contour.

Preservation of the intercostal brachial cutaneous nerves maintains sensation to the medial aspect of the upper extremity and prevents bothersome dysesthesias.

Preservation of fatty tissue and lymphatic channels from the arm around the axillary vein reduces the risk of lymphedema.

In obese patients, anatomic boundaries may be more difficult to identify and require wider exposure, increased operative time, and patience during the procedure.

The pulse in the axillary artery is a landmark that can help orient the surgeon to stay inferior.

SELECTED REFERENCES

1. 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.

2. 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.

3. Staradub VL, Morrow M: Modified radical mastectomy with knife technique. Arch Surg 2002;137: 105-110.

4. Stolier AJ, Grube BJ: Areola-sparing mastectomy: Defining the risks. J Am Coll Surg 2005;201:118-124. 5. Veronesi U, Cascinelli N, Mariani L, et al: Twenty-year follow-up of a randomized study comparing

breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347: 1227-1232.

C H A P T E R 11

SENTINEL LYMPH NODE BIOPSY

Celia Chao

INTRODUCTION

Regional lymph node status is the most powerful predictor of recurrence and survival in patients with breast cancer and melanoma. Nodal staging remains an essential component in the decision-making process to offer adjuvant therapy for both breast cancer and melanoma. Over the last century, experience with surgical clearance of a nodal basin has shown that this procedure can result in significant morbidity: pain, paresthesias, seroma, infection, limitation of limb motion, lymphedema, and lymphangitis. Sentinel lymph node (SLN) biopsy has proven to be a highly accurate technique with minimal morbidity. The development and adaptation of SLN biopsy has revolutionized the staging of melanoma and breast cancer.

STEP 1: SURGICAL ANATOMY

SLN biopsy is most commonly performed for breast cancer. Although the same principles and techniques apply to SLN biopsy for primary malignant melanoma, this chapter describes in detail SLN biopsy for breast cancer. Figure 11-1 demonstrates the lymphatic drainage of a breast cancer to the axillary lymph nodes.

STEP 2: PREOPERATIVE CONSIDERATIONS

The SLN is defined as the first draining lymph node in the axilla to receive lymphatic drainage from a primary breast tumor. Should regional metastatic disease exist, the SLN is the node most likely to contain metastases. Conveniently, if the SLN is negative for metastasis, then the remainder of the nodal basin should also be negative. Therefore, the SLN should reflect the histopathologic status of the entire axilla. In 1992, Morton’s group performed SLN biopsy in more than 500 patients with melanoma, removing the SLN, as well as the remaining regional lymph nodes. The pathology of the SLN predicted the remaining regional nodal status with 99% accuracy. His pioneering work was validated by studies at other institutions with completion lymphadenectomy, histopathologic nodal examination, and long-term follow-up to identify potential recurrences in undissected nodal basins following a negative SLN biopsy. Similarly, Giuliano reported initial experience with SLN biopsy for breast cancer using vital blue dye injection, including validation with histopathologic examination of the non-SLN.

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Definitions: Successful SLN biopsy is judged by two critical parameters: the SLN identification rate and the false-negative rate. The SLN identification rate is the frequency of finding and removing an SLN. When the SLN cannot be identified, a standard level I/II axillary dissection must be performed. The false-negative rate is the proportion of patients with positive lymph nodes who are incorrectly staged by the SLN biopsy procedure. Understanding that no staging procedure is 100% accurate, we accept a small false-negative rate (5% or less) to spare most true-negative patients the morbidity of a full level I and II axillary dissection.

Pathologic examination of the SLN: By examining serial sections, a more thorough evaluation of the nodal specimen is possible. The SLN biopsy identifies the node(s) that should be more closely scrutinized. Such a focused examination would be prohibitively costly and time-consuming if performed on the entire contents of an axillary dissection.

A team approach: Implementation of SLN biopsy requires the cooperative efforts of multiple disciplines: surgeons and the operating room staff and colleagues from the departments of radiology, nuclear medicine, pathology, and anesthesiology. The “team” must agree on a protocol: how to perform injections, how to dispose of radioactive waste, what type of radionuclide to use, and which adaptation of a SLN pathology protocol should be used.

Supraclavicular

nodes

Subclavian

nodes

Brachial nodes

Parasternal

nodes

Axillary nodes

Interpectoral nodes

Pectoral nodes

FIGURE 11–1

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STEP 3: OPERATIVE STEPS

Patient eligibility: SLN biopsy is appropriate for patients with T1-T3 breast cancers without palpable nodal metastases (clinical N0). SLN biopsy is applicable for patients undergoing either a breast-conserving operation or mastectomy and is equally accurate after open excisional breast biopsy or needle biopsy that has been performed for diagnosis. The procedure is most appropriate for biopsy-proven invasive cancer, including multifocal/multicentric disease. SLN biopsy can be considered for ductal carcinoma in situ, in which there is a high likelihood of an invasive component, or if mastectomy is considered. Contraindications include pregnancy, palpable axillary nodal metastases, hypersensitivity to either blue dye or technetium sulfur colloid, and prior major breast or axillary operations that could interfere with lymphatic drainage.

Dual-agent injection technique: Intraoperative lymphatic mapping using vital blue dye, radioactive colloid, or a combination of both is performed to identify the SLN. I advocate the use of dual-agent injection to facilitate SLN localization. The combination of the two techniques—visualization of the blue dye and intraoperative gamma probe detection— provides overlapping and complementary ability to discriminate the SLN. Some SLNs may be blue-stained but not radioactive (“blue, not hot”), and others may be radioactive but not blue (“hot, not blue”); but most SLNs will be both blue and hot. Use of dual agents provides more accurate nodal staging than the use of either agent alone.

I recommend preoperative dermal radioactive colloid injection using 0.5 mCi of 0.2 m technetium-99 sulfur colloid in a volume of 0.2 to 0.5 mL at least 30 minutes before operation. The use of filtered or unfiltered colloid has been shown to be equivalent in terms of identification rates and false-negative rates. Equal injections into the dermis (intradermally) are accomplished using a tuberculin syringe with a 25to 30-gauge needle (raising a wheal) immediately anterior (superficial) to the tumor site, using four to five separate injections (Figure 11-2). The use of routine lymphoscintigraphy has been shown to be neither necessary nor helpful in SLN biopsy for breast cancer. However, because of less predictable drainage patterns, such as bilateral drainage basins, or the possibility of interval node involvement, a lymphoscintigram is recommended routinely for melanoma.

Injection in the areolar border has been shown to be accurate for breast cancers located in any quadrant or centrally. Embryologically, all the lymphatic drainage of the breast converges in the periareolar or subareolar plexus of lymphatics. Therefore injection of the areola will accurately reflect the drainage of tumors in any part of the breast. This technique has been advocated for patients with multicentric or multifocal breast cancer.

Following radioactive colloid injection, the patient is taken to the operating room. For patient comfort, I perform almost all SLN biopsies with the patient under general anesthesia, without muscle relaxant, although it is possible to use local anesthesia. Patients should be counseled preoperatively that the blue dye injection will impart a change to the color of their urine and that there is a small chance of allergic reaction to the dye (approximately 1 in 10,000). Adverse reactions, including anaphylactic reactions, to vital blue dye are rare but have been documented. Allergic reaction to the blue dye may manifest as blue-colored hives.

Patients will occasionally have a noticeably blue tattoo on the skin after the procedure. They should be told that this color will fade and disappear with time. The anesthesiologist should be aware that pseudohypoxia is often seen intraoperatively as a result of the blue dye, which interferes with pulse oximetry, falsely lowering oxygen saturation readings. The use of radioactive colloid is safe, and numerous reports have documented the relatively low amount of radiation exposure associated with its use.

Axillary artery and vein

Axillary lymph nodes

Tumor

FIGURE 11–2

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For beginners, I recommend that the entire arm (limb) be prepped and draped into the operative field. This allows for mobility of the arm and offers potentially easier access to the SLN(s). After the patient is prepped and draped, 5 mL of Lymphazurin (1% isosulfan blue) dye can be injected peritumorally, in a subareolar location, or subdermally (deeper than intradermal, no wheal), taking care to disperse the dye around the tumor (Figure 11-3). For melanoma, 1 mL of blue dye intradermally (raising a wheal) is sufficient. A 5-minute massage of the area following blue dye injection helps stimulate lymphatic uptake toward the axilla or nodal basin of interest. Peritumoral injection of isosulfan blue dye is performed by injecting 1 mL in each of four corners intraparenchymally around the tumor, with the final 1 mL injected superficial to the tumor (between the tumor and the skin). For palpable tumors, the injection is easily accomplished. For nonpalpable tumors, the injection is guided by ultrasound or by judging the depth and direction of the imbedded wire following standard needle localization. It is helpful for the radiologist to mark on the skin anterior to the tumor with an indelible marker at the time of needle localization. It is not advisable to inject all of the blue dye or radioactive colloid down the localization needle, because this does not disperse the blue dye well and may concentrate the dye deep within the breast tissue. For patients who previously have undergone excisional biopsy, injection should be made around the biopsy cavity, avoiding the seroma cavity.

1.INCISION

The hand-held gamma counter is used to locate the SLN transcutaneously, and a 3-cm incision is made in line with the usual axillary dissection incision, usually just lateral to the pectoralis muscle edge and just below the hairline (Figure 11-4). The localization of the “hot spot” allows for planning of a small incision over the suspected site of the SLN. If a hot spot is not identified, a curved transverse incision in the lower axilla just below the hairline provides excellent exposure.

FIGURE 11–3

Incision line

FIGURE 11–4

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2. DISSECTION

After dissecting through the subcutaneous tissue, the surgeon divides the clavipectoral fascia to gain exposure to the axillary contents. The gamma counter is used to help locate the SLN. As the dissection continues, the signal from the probe should increase in intensity (Figure 11-5). If there is difficulty in identifying an SLN, the clavipectoral fascia along the lateral border of the pectoralis major and minor muscles should be divided to easily access the entire axilla. This is accomplished by elevating and rotating the arm (which has been incorporated in the sterile field) medially.