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423
PLATE
197
INDICATIONS Sentinel lymph node dissection (SLND) is an important
procedure in the staging of patients with cutaneous melanoma. As opposed
to breast cancers, which may have lymphatic spread in a random manner,
skin melanomas have a straightforward lymphatic ow that can be mapped.
e metastases rarely skip to higher lymph nodes; therefore, an SLND can
provide the rst evidence of metastatic spread of the melanoma. is operation is indicated in patients who do not have palpable regional lymph nodes.
e original melanoma on histologic studies following wide excision should
be of intermediate or greater thickness (> mm). If thinner, the melanoma
should have associated high risk factors such as ulceration. Additional risk
factors to be considered are age, site, Clark’s level of invasion, and gender.
An SNLD that uses both radionuclide and blue dye is highly accurate in
nding positive lymph nodes. It allows a focused pathologic examination
by the pathologist with both routine hematoxylin and eosin (H&E), plus
immunohistochemical staining on the lymph nodes that are most likely
to contain metastases. Finally, an SLND should be considered prior to a
wide excision of the primary melanoma site. is is especially important if
a rotational skin ap is planned for closure, as the resultant scar will alter
the dermal lymphatic ow.
PREOPERATIVE PREPARATION In the example shown (figure 1), the
cutaneous melanoma was excised from the midportion of the patient’s back.
is is considered a watershed area—that is to say, the lymphatic drainage may go to either axilla or groin. Accordingly, a preoperative scintigram
is required to demonstrate which lymphatic basin receives the lymphatic
drainage from the tumor site. e most common areas are the axillary and
inguinal regions for extremity or truncal lesions and cervical or supraclavicular regions for head and neck primaries. Other sites include deep
iliac, hypogastric, and obturator regions and the popliteal or epitrochlear
regions for legs and arms, respectively. Last, ectopic sites are also possible.
e skin must be cleared of any active infections, as must the excision
site for the melanoma. Preparation, inspection, and monitoring of the radionuclide solution must be coordinated with the nuclear medicine sta .
A few hours before operation, the patient is injected with a radionuclide
solution intradermally about the perimeter of the surgical site, using sterile
S L N D, M
technique. is may be done by the radiologist or the surgeon. e commercially available human serum albumin or sulfur colloid solution tagged
with technetium m is ltered and sterilized. Two separate syringes are
each loaded with mL of solution containing about C for a total
dose of about mC. e area for injection is prepared with an antiseptic
solution. Disposable paper drapes are widely placed and the physician is
gloved. Extensive shielding for radioactivity is not required, but the site
and supplies are monitored with a radiation survey meter. e gloved physician injects the radionuclide in an intradermal pattern about the incision
(figure 2). e area is washed and all the disposable items are surveyed
and disposed of in a radiologically safe manner.
e lymphatic drainage area or basin is noted on a large or whole-body
scintigram; a hand-held gamma detector is used to identify the hottest area.
is spot is marked with indelible ink as a temporary tattoo and the patient
is transported to the operating room.
ANESTHESIA Deep sedation plus local or a general anesthesia may be
used.
POSITION e patient is placed in a comfortable supine position. If an
axillary SNLD is planned, that arm should be out at a -degree angle on a
padded arm board. If the dissection is planned in the neck, the head of the
table may be elevated and the patient’s head turned to the opposite side.
OPERATIVE PREPARATION e hair is shaved about the tattoo and a
routine skin preparation and draping is performed. e surgeon performs
another intradermal injection about the perimeter of the melanoma excision site using to mL of isosulfan blue vital dye (figure 3). e area
is massaged for a few minutes, and a faint blue streaking of the dye may
be seen in the dermal lymphatics heading toward the SLND site. In this
illustration, the sentinel node is within the le axilla. Using a hand-held
gamma probe in a sterile cover (figure 4), the surgeon veri es that the tattoo marks the hottest spot. A small -cm transverse incision is made over
the tattoo and dissection is carried into the subcutaneous fat (figure 5).
e fat is retracted laterally and the probe explores the open incision to
nd the area of maximum radioactivity (figure 6).
CONTINUES
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425
PLATE
198
OPERATIVE PREPARATION e blue dye may be seen in
lymphatic channels owing into a now palpable lymph node (figure 7).
is node should be blue and hot. e node is dissected free, as are any
neighboring lymph nodes that are faintly blue or have signi cant radioactivity counts (figure 8). Signi cant radioactivity is identi ed as a level
≥ percent of the counts of the hottest sentinel node or a level greater than
two or three times the background activity of the axillary tissue. A small
cluster, usually two or three lymph nodes, is excised (figure 9), as o en
there is more than one sentinel node. e nodal basin is scanned with the
probe to verify that no other hot areas or potential sentinel lymph nodes
exist. e probe demonstrates a basal background level (figure 9). e
nodal cluster removed is examined and the lymph nodes are separated.
One node, the principal sentinel lymph node, should be blue and quite hot
(figure 10a). In this illustration, lymph nodes B and C are considered sentinel lymph nodes, as they have signi cant radioactivity counts. Any other
S L N D, M
regional nodes that have any blue coloration are also considered sentinel
nodes, even if they do not have elevated radioactivity counts. A nal visual
and gamma probe survey is performed about the operative site and careful
hemostasis is obtained.
CLOSURE Subcutaneous tissue and Scarpa’s fascia are closed with inter-
rupted absorbable sutures. e skin is approximated with ne subcuticular sutures. Adhesive skin strips and a dry sterile dressing are applied.
POSTOPERATIVE CARE In most cases, this procedure can be performed
in an ambulatory surgery setting. e patient returns home when discharge
criteria for this surgery are met. e patient is given written instructions
concerning activities and signs of bleeding or infection. Simple oral pain
medication should su ce. At the follow-up visit, the surgeon reviews the
pathology ndings with the patient, who may require a formal lymphadenectomy if any sentinel lymph nodes show metastases. ■
426
427
PLATE
199
B A I
A. ANATOMY
e regional anatomy of the breast is illustrated in figures 1 and 2. e prin-
cipal blood supply to the breast comes from the medial perforating branches of
the internal mammary artery and vein a er they transverse the pectoralis major
muscle and its anterior investing fascia. e medial aspect of the breast has lymphatic drainage into the internal mammary chain of lymph nodes within the
chest; however, this is quite variable. e majority of the lymphatics from the
breast drain to the axillary lymph node basin. e most proximal node or nodes
may be located in atypical locations such as within the breast in the axillary tail
of the upper/outer quadrant or very low on the lateral chest wall. e identi cation of these nodes using radionuclide tags and blue dye localization techniques
is one of the additional bene ts of a sentinel lymph node dissection. Axillary
lymph nodes have been classi ed according to three levels or areas delineated
by anatomic boundaries of the pectoralis minor muscle (
level I or II nodes are removed in axillary lymph node dissections. e overall
boundaries of this standard axillary lymph node dissection (ALND) are the
chest wall (serratus anterior muscle) medially, the axillary vein superiorly, the
subscapularis muscle plus thoracodorsal and long thoracic nerves posteriorly,
and the axillary fat laterally. Level I nodes are de ned as those lateral to the edge
of the pectoralis minor muscle. is area includes the external mammary, subscapular, and lateral axillary nodes. Level II nodes are behind or posterior to the
muscle and are commonly de ned as the central axillary lymph nodes. Level III
nodes are located medial or superior to the pectoralis minor muscle. is group
includes the subclavicular or apical lymph nodes. ey reside in the apex of the
axillary space behind the clavicle and deep to the axillary vein.
e axillary vein is the major structure de ning the superior border of
the surgical dissection. e axillary artery (posterior and pulsatile) plus the
brachial plexus (superior and solid) are palpable but not exposed. Common
regional ndings are dual axillary veins or a very large, long thoracic vein running longitudinally along the lateral chest. A er the axillary vein is exposed
by the surgeon, a key landmark aids in nding thoracodorsal nerve, which is
deep upon the subscapularis muscle. A pair of subscapular veins are identi ed
(
figure 1). e more super cial one is divided, revealing the deep subscapu-
lar vein and the adjacent subscapular artery, which may be mistaken for the
thoracodorsal nerve. is nerve, however, is posterior to the axillary vein and
medial to the deep subscapular vein. It tends to angle toward the deep subscapular vein, whereas the subscapular artery is more parallel. A gentle mechanical
stimulation of this nerve will result in muscle contraction.
Also running parallel to the axillary vein and rising perpendicularly from
between the ribs on the chest wall are the sensory intercostal brachial skin
nerves. One or more of these nerves may pass directly through the axillary
fat and lymph nodes that will be removed in the dissection. Division results
in hypesthesia in the posterior axillary web and in the upper/inner arm. Conversely, the long thoracic nerve runs longitudinally over the serratus anterior at
the depth of an axillary dissection. If the surgeon dissects the axillary fat and
specimen cleanly o of the serratus anterior muscle, the long thoracic nerve
will be found not on the muscle but rather out in the axillary fat about or
cm deep to the lateral edge of the pectoralis minor muscle. Gentle mechanical stimulation will elicit contraction of the serratus anterior muscle. It is also
important to note that the long thoracic nerve tends to arch anteriorly as it
proceeds caudally.
figure 2). In general,
B. BREAST INCISIONS FOR EXCISIONAL BIOPSY
e principal indication for biopsy is the presence of clinically suspicious ndings on physical examination or diagnostic studies. Studies may be sampled
with ne needle aspiration (FNA) and cytologic evaluation. A better diagnosis
is obtained with a core-cutting biopsy and histologic study. Asymmetric nodularity, architectural distortion, or suspicious patterns of microcalci cations may
require excisional biopsy guided by wire localization. In general, a wide excisional biopsy with a clear margin of several millimeters of surrounding normal
glandular tissue is planned. e placement of the incision is determined by the
location of the lesion (
rants should be avoided, as they are most visible. Circumareolar or inframammary incisions tend to give the best cosmetic result. Curvilinear incisions along
Langer’s lines may be used in most areas; however, some surgeons prefer radial
incisions, especially in the medial breast. e incision should be kept small and
placed over the lesion. e incision for a wire localization need not be placed
about the entrance site of the wire, because most wires are exible enough to be
drawn through the skin and subcutaneous fat into an open biopsy site.
figure 3). If possible, incisions in the upper/inner quad-
C. SIMPLE OR TOTAL MASTECTOMY
INDICATIONS A simple or total mastectomy is indicated in patients who are
not candidates for breast-conserving (lumpectomy) operations. e principal
indications are for large cancers that persist a er adjuvant therapy, especially in
a smaller breast, in multicentric disease, and in elderly poor-risk patients with
localized lesions.
PREOPERATIVE PREPARATION (See Plate .)
ANESTHESIA General anesthesia is given via an endotracheal tube. Short-
acting muscle depolarizing agents are used for the intubation.
POSITION e patient is placed in a comfortable supine position with the arm
on the involved side abducted approximately degrees, in order to give maximum exposure of the region.
OPERATIVE PREPARATION A routine skin prep is performed and the area
is draped in a sterile manner.
INCISION AND EXPOSURE A horizontal elliptical incision is inked so as to
include the entire areolar complex (figure 4). e two skin edges should be
of equivalent length, as measured with a free suture between hemostats at each
end. e two incisions should come together without tension.
DETAILS OF PROCEDURE e skin incision is made sharply with the scalpel
for the depth of cm or so. Any signi cant vessels should be secured with ne
ligatures. e skin aps are elevated with large skin hooks that are li ed vertically
so as to provide countertraction as the surgeon pulls the specimen away from
the skin ap. e dissection proceeds superiorly almost to the clavicle, medially to the sternal edge, and inferiorly to the costal margin near the insertion of
the rectus sheath. is should include virtually all of the glandular tissue of the
breast. e lateral ap dissection is carried to the edge of the pectoralis major
muscle. is leaves the axillary fat and lymph nodes for a separate dissection.
A subfascial dissection is performed, li ing the breast o of the pectoralis
major muscle. It is easier to begin superiorly. As the dissection continues medially, the perforating internal branches of the mammary vessel are controlled
with electrocautery or ligature, using ne silk. Last, the axillary ap is developed such that the breast is removed from the lateral chest wall. e specimen
is oriented for the pathologist. e wound is irrigated and careful hemostasis is
obtained. e perimeter may be in ltrated with a long-acting local anesthetic.
is allows the anesthesiologist to awaken the patient sooner and lessens the
amount of pain medication required a er surgery. Either end of the incision
is retracted with single skin hooks. Scarpa’s fascia and the subcutaneous fat
are approximated with interrupted absorbable sutures. ese sutures are
placed so as to serially bisect the incision, thus giving the best approximation if
the two skin incisions are not of equal length. Last, a absorbable suture is
placed for subcutaneous approximation of the skin. Adhesive skin strips and a
dry sterile dressing complete the procedure.
POSTOPERATIVE CARE e patient may use the arm immediately for nor-
mal activities. Vigorous use should be curtailed for about a week, when it is
determined that the skin aps are well sealed to the pectoralis major muscle
without accumulation of serum or hematoma.
D. MODIFIED RADICAL MASTECTOMY
An elliptical incision is placed more obliquely, being angled toward the axilla.
e entire areolar complex as well as the lesion or its biopsy scar should be
included within the ellipse. If no reconstruction is planned, the wider ellipse
illustrated in
incision is marked with ink. e incisions are created to be of equal length.
ere should be no redundant or excess skin at either end of the incision upon
closure. In overweight patients or those with very large breasts, a more lateral
incision with a wider angle is required. Conversely, very creative or commashaped incisions that encircle only the areolar area and then proceed laterally as
a single curvilinear extension to the base of the axilla may be used in coordination with the plastic surgeon, who will be performing a concurrent reconstruction (see also Plate , Modi ed Radical Mastectomy). is incision may be
combined with a separate elliptical incision about a preceding biopsy site.
e full radical mastectomy is no longer included in this atlas, as most surgeons do not remove the entire pectoralis major muscle. Instead, a modi ed
radical mastectomy is performed with a wedging out of a full-thickness section
of the underlying pectoralis major muscle where the cancer is attached.
figure 5 is used. A er the patient is prepped and draped, the
■
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429
PLATE
200
INDICATIONS Over the past years, multiple international clinical stud-
ies have shown equivalent survival between patients treated with modi ed
radical mastectomy and appropriately selected patients treated with breastconserving surgery and adjuvant radiation, hormonal therapy, and chemotherapy. Accordingly, breast-conserving surgery has become the dominant
mode of treatment, with modi ed radical mastectomy becoming the alternate choice in certain circumstances. A residual large cancer a er adjuvant
therapy (especially in a small breast), multicentric cancers, and patient
preference or concerns about the complications of radiation therapy are the
principal indications for the operation. Prior to surgery, the opposite breast
should be evaluated by physical examination and mammography. Appropriate blood tests and imaging scans and mammographic studies are made
in a search for potential metastases to the lung, liver, or bone. e standard
preadmission physical examination and laboratory evaluations are done in
an ambulatory setting, as most patients are admitted to the hospital on the
day of operation.
PREOPERATIVE PREPARATION e skin over the involved area should
be inspected for signs of infection. e skin is shaved and electrical hair
clippers may be used over the axillae. Some surgeons give a single perioperative dose of parenteral antibiotics, particularly if a regional breast biopsy
has recently been performed.
ANESTHESIA General anesthesia is given via an endotracheal tube. Short-
acting muscle depolarizing agents should be requested for the intubation,
such that the motor nerves will be responsive during the axillary node
dissection.
POSITION e patient is placed nearest the margin of the operating table
on the side of the surgeon. e arm is abducted and held by an assistant or
placed upon a support at right angles to the patient to facilitate the preparation of the skin. Some prefer to wrap the arm, including the hand, in sterile
drapes so that the arm can be moved upward as well as medially to facilitate
the subsequent dissection of the axilla.
OPERATIVE PREPARATION e skin is widely prepared with topical anti-
septics. is includes not only the involved breast but also the area over the
sternum; the supraclavicular region, shoulder, axilla, and collateral chest
wall; as well as the upper abdomen on the involved side. A slight Fowler
position with a tilt away from the surgeon improves the exposure. e surgical drape should be secured to the skin at appropriate points around the
margin of the proposed eld of operation. e arm should be free to be
moved by an assistant as required for exposure in the axilla.
INCISION AND EXPOSURE If the diagnosis of malignancy has not been
documented by previous biopsy, the diagnosis is rst con rmed by a
biopsy of excised tumor using frozen-section examination by the pathologist. e specimen is also sent for hormone binding and other immunoassays. e underlying pectoralis muscle should not be involved in any way
by the biopsy; otherwise that section of the muscle should be excised en
bloc with the specimen. A er the biopsy wound is closed and sealed, all
instruments and gloves used in the procedure are discarded. Some prefer
to have a second sterile table available, which results in a repeated complete
M R M
skin preparation and sterile draping. Every precaution should be taken to
avoid seeding with malignant tumor.
With proof of malignancy, an oblique elliptical incision is made that may
include a short extension laterally up toward the axilla to ensure a better
exposure for the axillary dissection and a more cosmetically acceptable closure (figure 1). e transverse segment of the elliptical incision includes
the nipple and areola and an appropriate distance of to . cm beyond the
limits of the tumor whenever possible. If reconstructive surgery is planned,
a more limited incision (figure 1, dashed line) that preserves skin can
be made in consultation with the plastic surgeon. e entire nipple plus
an adequate margin about the biopsy site must be taken, while a lateral,
comma-like extension provides the exposure for the axillary dissection.
e initial incisions through the skin should be only cm or so deep,
since it is advisable to include most of the subcutaneous tissue, especially in
the region of the axilla, with the nal specimen (figure 2). e skin aps
require careful elevation, with control of all bleeding points as the dissection progresses. e aps are elevated to the level of the clavicle superiorly,
to the edge of the sternum medially, to the rectus sheath and costal margin
inferiorly, and then laterally to the edge of the latissimus dorsi muscle. Particular attention is required to remove as much subcutaneous fat as possible
in the axillary region, because the lymph nodes and breast tissue are very
close to the skin in this region.
e fascia over the pectoralis major muscle as well as the breast is
resected as a subfascial dissection starting near the clavicle and extending
downward over the midportion of the sternum (figure 3). e fascia is
meticulously dissected o the pectoralis muscle without including any of
the latter within the gross specimen. If the cancer has penetrated this fascia
and invaded the pectoralis major muscle, that section of the muscle can be
excised en bloc with the specimen. It is usually not necessary to perform a
full radical mastectomy with removal of the entire pectoralis major muscle.
e perforating intercostal arteries and veins near the sternal margins must
be carefully clamped and ligated.
e axillary ap is retracted upward, and the fascia over the edge of the
pectoralis major is incised (figure 4), exposing the pectoralis minor muscle
beneath and the junction of the coracobrachialis and pectoralis minor origins superiorly at the coracoid process. Electrodiathermy is o en used in this
operation, but it should be avoided about the axillary vessels and nerves and
for control of bleeding from intercostal perforating vessels lateral to the sternum. e loose tissue over the axillary vein is incised and the vein wall gently
exposed for a short distance beyond the subscapular vessels (figure 5).
Level I and II lymph nodes are removed in the axillary node dissection that begins by incising the clavipectoral fascia along the lateral edge
of the pectoralis minor muscle. Precautions are taken to avoid the medial
and lateral nerves to the pectoralis major muscle. e medial nerve is so
named because it arises from the medial cord of the brachial plexus and then
passes through the pectoralis minor muscles in about percent of patients
or passes laterally around the pectoralis minor in percent en route to
innervating the lower region of the pectoralis major muscle (figure 6). e
dominant lateral nerve to the pectoralis major muscle arises from the lateral
cord. It passes medial to the pectoralis minor muscle near its insertion and is
closely associated with the acromial thoracic artery.
CONTINUES
430
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PLATE
201
DETAILS OF PROCEDURE e lateral edge of the pectoralis
minor is cleared of fascia to near its insertion on the corticoid process and
several veins are ligated as they come o the axillary vein (figure 7). A
careful search is made for the medial nerve to the pectoralis major, which
is preserved. Ligation rather than electrocoagulation is preferred for all vessels about the axilla and for those adjacent to the sternum.
e pectoralis major and minor are retracted upward and medially,
exposing the uppermost tissues to be divided over the axillary vein. Some
prefer to divide the pectoralis minor muscle from its insertion on the coracoid process as to gain better exposure of the medial area of the axillary vein
and its lymph nodes.
e fascia over the serratus anterior muscle is dissected free, and the
axillary fat and lymph nodes are mobilized o the chest wall and the axillary
vein (figure 8). e arm, wrapped in sterile drapes, is li ed up or manipulated to enhance the exposure as the dissection progresses in the axilla. e
long thoracic nerve should be identi ed deep to the axillary vein. As it lies
within the loose fascia over the serratus anterior muscle, it is possible to
li this nerve away from the muscle; hence, it must be carefully sought and
dissected out from the axillary contents to be contained within the resected
specimen. is nerve should be retained intact, because a “winged” scapula
will result if it is divided. A sensory nerve that is o en sacri ced is the more
transverse intercostobrachial that appears beneath the second rib and provides sensory innervation to the upper inner aspect of the arm.
As the breast is retracted laterally (figure 9), the long thoracic nerve
as well as the thoracodorsal nerve should be free of redundant tissue. e
thoracodorsal nerve is characteristically located adjacent to the deep subscapular vein and artery. Division of the thoracodorsal nerve is avoided
unless there is tumor involvement, since its sacri ce has only a partial e ect
upon the latissimus dorsi muscle.
e specimen is freed from the latissimus dorsi muscle (figure 10)
and nally from the suspensory ligaments in the axilla, where large veins
and lymphatics should be carefully ligated. e operative area is repeatedly
inspected for any bleeding points, which are ligated. e two major nerves
are checked to be certain that their course is free of ligature, and their integrity is veri ed by a brisk but gentle pinch that results in an appropriate
M R M
muscle twitch. e wound is irrigated with saline, and a nal inspection is
made for hemostasis prior to closure. Two closed-system perforated suction
catheters are inserted for drainage. ey are usually introduced through
separate stab wounds made in the lower ap posteriorly. One catheter is
directed up to the axilla. e other catheter is secured anterior to the pectoralis major muscle for drainage from under the skin aps. e catheters
are secured to the skin with nonabsorbable sutures and attached to a closed
system of suction (figure 11).
It is very important that the surgeon spend the necessary time and e ort
to compress the skin aps into place in the axilla and elsewhere as the skin
is nally closed. If the skin aps are so thin that there is minimal subcutaneous tissue, interrupted sutures are used in the skin. Alternatively, some
surgeons use a few interrupted absorbable sutures in the subcutaneous fat
in medium-thickness skin aps.
e manner of dressing the incision is controversial. In the Auchincloss method, the skin is cleaned, dried, prepared with tincture of benzoin,
and approximated with very large strips of elastic tape. ese start above
the level of the clavicle and extend down to the level of the drains. Others
apply a simple gauze dressing and a surgical bra, whereas some prefer bulky
u ed dressings followed by gauze or elastic bandage wrappings.
POSTOPERATIVE CARE Skin sutures, if present, are removed in to
days, with the incision being reinforced with “butter y” adhesive strips.
e suction catheters are removed in approximately to days, when the
drainage is less than mL per day. Any collections of uid may be aspirated in the surgeon’s o ce using strict adherence to aseptic precautions.
Normal use of the arm is encouraged for the rst week; therea er, active
shoulder exercises are performed to ensure return of full range of motion
within the ensuing weeks. Physical therapy may be necessary if progress
is not apparent in this interval. e patient is cautioned to minimize cuts
and possible infection in this arm and to report immediately any injury
that results in infection, since a rapidly spreading lymphangitis is possible.
Finally, a systematic regimen for lifelong follow-up is instituted even if the
nal pathologist’s report does not indicate the need for additional therapy
at the time. ■
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