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Axillary Surgery forBreast Cancer
https://t.me/med1917
MackenzieN.Abraham, RachaelB.Lancaster, andCatherineC.Parker
1 Introduction
Axillary lymph node status remains an important factor in the staging and prognosis
of breast cancer. Additionally, nodal status has implications for radiation and medical oncology therapies. Over the past several decades, axillary surgery has been
deescalated based on landmark studies indicating that sentinel lymph node biopsy
(SLNB) is a safe and often favorable staging procedure compared to axillary lymph
node dissection (ALND) [1–3]. Additionally, advancements in other areas of breast
cancer care including the identication of breast cancer subtypes and genomic testing have become important in guiding prognosis and treatment recommendations.
Axillary dissection continues to have a role in patients with clinically positive axilla
or multiple pathologically conrmed nodes, though ongoing trials continue to evaluate whether axillary dissection is necessary in these specic populations. Most
patients with clinically node negative disease are now recommended for SLNB,
which has decreased rates of infection, seroma, hematoma, lymphedema, and sensory decits compared to ALND [2–6].
Based on the previous edition chapter “Axillary Procedures for Breast Cancer” by Sara E.Holden
MD and Heather B.Neuman MD, MS.
M. N. Abraham (*) · R. B. Lancaster · C. C. Parker
Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
e-mail: mnabraham@uabmc.edu; rlancaster@uabmc.edu; ccparker@uabmc.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_12
111© The Author(s), under exclusive license to Springer Nature
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M. N. Abraham et al.
2 Sentinel Lymph Node Biopsy
Sentinel lymph node biopsy (SLNB) is based on the concept that breast cancers will
drain to a single node or group of nodes prior to draining to more distal nodes. The
status of the SLN can then be used as a marker for the status of the axilla as a whole;
if there are no metastases present in the SLN, there is a low likelihood of additional
nodes being positive. SLNB or ALND should be performed on the majority of
patients with invasive breast cancer. Select patients over age 70 with early-stage
hormone receptor positive invasive breast cancer may omit SLNB due to evidence
of equivalent survival with and without SLNB in this population [7]. Patients with
ductal carcinoma in situ (DCIS) undergoing mastectomy typically also undergo
SLNB in the event that invasive cancer is identied on pathology, as SLNB is unable
to be performed after the breast has been removed. Numerous trials have concluded
that surgeons can successfully identify a SLN in >97% of patients [8, 9]. SLNB has
shown to accurately reect the axillary status in 97% of patients, with a false negative rate (FNR) <10% [9]. Therefore, further axillary surgery can be safely avoided
in patients with a negative SLNB.Most patients with clinically negative axilla are
candidates for SLNB.This technique is contraindicated in patients with inammatory breast cancer or those unable to receive mapping agents (allergies to tracers or
dyes). Pregnant patients may undergo SLNB using radioactive tracers, but the use
of blue dye is typically contraindicated during pregnancy [10]. Patients with locally
recurrent breast cancer may be eligible to undergo repeat sentinel lymph node
biopsy following breast conserving surgery as it has been shown to be both feasible
and reliable with a FNR <10% [11].
2.1 Preoperative Localization andPreparation
When performing a SLNB, blue dye and/or radiotracers are utilized for lymphatic
mapping. Although either technique is reliable in the hands of an experienced surgeon, the combination has shown to be the most accurate [12, 13]. Injection of the
radiotracer, typically technetium-99m (
24h of surgery and is frequently followed by lymphoscintigraphy to conrm localization. Injections are most commonly peritumoral or subareolar, with high identication and concordance rates between the two sites, though subareolar injection is
generally favored for non-palpable tumors and multicentric disease [14]. Injection
of blue dye occurs in a similar fashion with either 1% isosulfan blue (5cc) or dilute
methylene blue (1–2 cc diluted to 5 cc with normal saline). The dye should be
injected 5–15min prior to the procedure in a periareolar or peritumoral location.
Methylene blue can result in skin or nipple necrosis if injected too supercially and
care should be taken to avoid this. Furthermore, the anesthesiologist should be
informed when injection of the blue dye occurs, as this can cause decreased oxygen
saturation, mild blue rash, or hives (0.4%), and in rare cases a severe anaphylactic
99m
Tc) sulfur colloid, should occur within
ab
Axillary Surgery forBreast Cancer
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Fig. 1 Incision markings for sentinel lymph node biopsy (a) and axillary lymph node dissection (b)
113
reaction (0.2%) [9]. Gentle massage should then be applied to the breast for 3 to
5 min to facilitate drainage through the lymphatic channels to the nodal basin.
Alternative tracer options are available, such as magnetic tracers, which may be
benecial by allowing for delayed detection and have shown to be non-inferior to
radiotracer in clinical trials [15].
SLNB is usually performed under general anesthesia, though it can also be safely
performed under regional block or monitored anesthesia care. If general anesthesia
is utilized, paralytics should typically be avoided if possible. The patient should be
positioned with the involved arm extended out on an arm board; some prefer to
place a towel roll under the ipsilateral shoulder to elevate the axillary contents into
the eld. After injection of the blue dye, the ipsilateral chest and axilla are prepped.
The hand-held gamma probe is then used to localize the area of maximal radioactive
uptake within the axilla and the spot is marked. For patients undergoing mastectomy, the SLN can be identied and removed through the mastectomy incision. For
patients undergoing breast conserving therapy, the incision is typically made along
the inferior aspect of the axillary hairline, just posterior and perpendicular to the
pectoralis major. Consideration should be made of the optimal ALND incision when
planning the SLNB incision (Fig.1a).
2.2 Operative Technique
A scalpel is used to make the skin incision and electrocautery is used to dissect down
through the subcutaneous tissue and clavipectoral fascia to expose the axillary contents. Using the blue stained lymphatic channels and gamma probe as a guide, a
combination of blunt dissection and electrocautery is used to localize SLNs. The
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Fig. 2 Identication of a blue
sentinel node in the axillary fat
M. N. Abraham et al.
“hottest” (most radioactive) node is removed and an exvivo count should be taken
using the gamma probe. The probe is then used to identify additional nodes with
exvivo counts >10% of the hottest node. Additionally, blue nodes, nodes associated
with blue lymphatic channels, and any suspicious palpable nodes should be removed
(Fig.2). Ex vivo counts should be recorded for all removed nodes with the gamma
probe. After all SLNs have been removed, a background count of the axilla should be
obtained. If this count is >10% of the hottest node, further dissection should be performed to identify additional SLNs. Dissection should be performed along lymphatic
channels and close to the SLNs to minimize damage to surrounding tissues. Though
rarely visualized during the SLNB, care should be taken to avoid injury to the thoracodorsal or long thoracic nerve, especially when dissection is deep in the axilla.
Hemostasis is achieved using electrocautery and the wound is irrigated with
saline. The clavipectoral fascia is closed with 3-0 absorbable suture and the deep
dermal layer is approximated with 3-0 absorbable suture. Finally, the skin is closed
in a running subcuticular fashion with 4-0 absorbable suture and either Steri-Strips
or Dermabond are applied.
2.3 Neoadjuvant Chemotherapy
Appropriate axillary management following neoadjuvant chemotherapy (NAC) is
evolving. If a patient is clinically node negative prior to NAC, SLNB is appropriate
at the time of breast cancer surgery. No axillary dissection is required if the SLNB
is negative; however, if the SLNB is positive, ALND is strongly recommended. For
clinically node positive patients undergoing NAC, the need for axillary lymph node
Axillary Surgery forBreast Cancer
https://t.me/med1917
dissection is under debate due to favorable responses to NAC.The pathologic complete response rate in the axilla has been shown to be around 45% with variation
based on the molecular subtype [16]. Recent trials indicate that SLNB can be used
for nodal staging in this patient population with a combination of dual tracer lymphatic mapping, the removal of at least two SLNs, and the removal of the previously
biopsied and marked positive node [17, 18]. If these parameters are followed, the
false negative rate (FNR) was <10%, in line with SLNB FNR for clinically node
negative patients [9, 18].
Targeted axillary dissection (TAD) is the targeted removal of biopsy-proven positive lymph nodes combined with a sentinel lymph node biopsy. This combination
has shown to reduce the FNR and therefore improve the detection of residual disease following NAC [19–21]. A retrievable localization device can be placed in a
known positive node preoperatively and identied with a probe intraoperatively to
ensure the removal of biopsy-proven positive nodes. The use of a localization device
with TAD has shown high accuracy in recent studies [22, 23].
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3 Axillary Lymph Node Dissection
ALND is currently indicated for the majority of patients with clinically palpable
nodes with biopsy-proven metastases, failed SLNB, or patients with contraindications to SLNB. Previously, ALND was performed on all patients with positive
SLNB; however, the Z0011 trial showed no difference in survival between patients
undergoing breast conserving therapy (lumpectomy and whole breast radiation)
with 1 or 2 positive SLNs who underwent completion ALND versus radiation alone
[24]. This has resulted in fewer intraoperative pathology evaluations as even in the
setting of 1 or 2 positive lymph nodes ALND is not required. ALND is still indicated in patients with >2 positive SLNs or who fail to convert to node negative following NAC.
3.1 Operative Technique
ALND is typically performed under general anesthesia without the use of muscle
relaxant to allow for easy identication of the nerves during the dissection; however, it can be performed under regional anesthesia for some patients. A regional
block may be performed in conjunction with general anesthesia to aid postoperative
pain control. The patient should be positioned supine with the involved arm extended
out to 90° allowing it to be fully prepped into the surgical eld using a stockinette.
A towel roll may be placed under the ipsilateral hemithorax and shoulder to lift the
axillary contents into the eld. A single dose of perioperative antibiotic to cover
skin ora is administered.
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The borders of the axilla should be identied and marked prior to incision (lateral border of pectoralis major and medial border of latissimus dorsi). A curvilinear
incision is then made in an anterior to posterior fashion between the lateral border
of the pectoralis major and the medial aspect of the latissimus dorsi, just inferior to
the hairline (Fig.1b). Electrocautery is used to dissect through the subcutaneous
tissue to the clavipectoral fascia. The fascia is incised and circumferential skin aps
are made just deep to the fascia to allow space for the dissection. This should extend
laterally to the anterior border of the latissimus dorsi, medially to the lateral aspect
of the pectoralis major, superiorly to the approximate level of the axillary vein, and
inferiorly to the fourth or fth rib. Care should be taken during the lateral dissection
to avoid dissecting a ap lateral to the latissimus muscle as this can be cosmetically
unsatisfactory. The borders of the axilla are then dened by dissecting medially
along the lateral aspect of the pectoralis major muscle and incising the pectoralis
major fascia to expose the pectoralis minor muscle; at this point the medial pectoral
nerve is identied and spared. The lateral dissection continues along the anterior
surface of latissimus dorsi muscle (Fig.3).
Fig. 3 Axillary dissection
during a modied radical
mastectomy
Axillary Surgery forBreast Cancer
https://t.me/med1917
The axillary vein can then be identied using one of two approaches. The vein
can be identied laterally by following the latissimus dorsi muscle superiorly until
its tendinous portion, where it crosses the axillary vein. Medially, the vein can be
identied by looking superior and deep to the medial pectoral bundle. The inferior
aspect of the vein should then be skeletonized. During this dissection, the thoracodorsal neurovascular bundle should be identied. Multiple venous tributaries may
be encountered along the inferior border of the axillary vein; these should be divided
with care until the thoracodorsal neurovascular bundle has been clearly identied.
The largest of these vessels is the thoracoepigastric vein—a landmark for the thoracodorsal neurovascular bundle, which lies just deep and inferior. To conrm identication of the thoracodorsal neurovascular bundle, the thoracodorsal nerve joining
the vascular pedicle should be visualized (usually identied medial to the thoracodorsal vein).
The dissection then continues medially along the vein. The pectoralis minor is
dissected free along its lateral aspect to allow medial retraction and access to level
II nodes. These nodes are then cleared inferior to the axillary vein and swept down
with the specimen. The long thoracic nerve is then visualized coursing along the
chest wall. It typically lies relatively deep in the axilla, and approximately 1cm off
the chest wall. It should remain attached to the chest wall medially with dissection
of all lateral tissues off the nerve and included in the specimen.
The bro-fatty tissue between the thoracodorsal neurovascular bundle and the
long thoracic nerve can then be freed. Skeletonization of the thoracodorsal neurovascular bundle is the last step required to clear the axillary contents. Hemostasis is
achieved and a closed suction drain is placed in the anterior axillary line. The incision is closed in 1 or 2 layers (depending on the thickness of the subcutaneous aps)
with interrupted deep dermal 3-0 absorbable sutures followed by an absorbable 4-0
continuous subcuticular stitch.
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3.2 Intraoperative Specimen Radiograph
Most patients undergoing ALND have biopsy-proven node positive axillary disease.
At the time of biopsy, a clip is typically placed to identify which node or nodes have
been biopsied. Intraoperative specimen x-ray may be used to evaluate the axillary
contents removed and ensure that the clips are present, conrming that the known
positive nodes are included in the removed specimen. A retrievable localization
device may also be placed in the positive node preoperatively and a probe can be
used to help locate the tagged node. Intraoperative x-ray can then conrm the
removal of the localization device as well as the clip. Intraoperative specimen x-rays
are also often utilized in targeted axillary dissections to conrm removal of the
tagged positive node. After the x-ray is reviewed by radiology, the specimen is sent
for permanent section.
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Oncoplastic Breast Reduction
https://t.me/med1917
PamelaRudnicki, CaraMoses, AmandaFang, andBradDenney
1 Introduction
The surgical management of breast cancer ranges from radical mastectomy to breast
conservation therapy. Breast conservation therapy (BCT) incorporates lumpectomy
with adjuvant radiation. Long term randomized controlled trials have demonstrated
that BCT has similar survival outcomes and improved quality of life when compared to mastectomy [1, 2]. Oncoplastic approaches should be considered in patients
who are simultaneously candidates for BCT and a breast lift or reduction.
Coordination between a breast surgical oncologist and a plastic reconstructive surgeon is necessary in order to safely combine the oncologic goals of lumpectomy
with the aesthetic principles breast reduction. There are multiple benets of oncoplastic reduction, including relief of symptoms related to macromastia, reduced
rates of positive margins due to larger excision volume, and improved efcacy of
adjuvant radiation, as a large breast size can lead to a heterogenous dose distribution
due to repeated repositioning [3–5]. Our chapter will discuss the preoperative evaluation, operative techniques, and postoperative care involved in oncoplastic breast
reduction.
P. Rudnicki · C. Moses · A. Fang · B. Denney (*)
University of Alabama at Birmingham, Birmingham, AL, USA
e-mail: parudnicki@uabmc.edu; cmoses@uabmc.edu; hfang@uabmc.edu;
bdenney@uabmc.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_13
121© The Author(s), under exclusive license to Springer Nature
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