Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1157_Библиотеки_им_академика_М_И_Перельмана.pdf
160 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
differences, none of the six trials demonstrated a
difference in overall survival for BCT compared
with mastectomy. The trials also demonstrated
several points worth mentioning.
When discussing treatment options with
patients, many leantoward mastectomyto avoid
any chance of local recurrence. It is important
to note that mastectomy does not guarantee freedom from local recurrence. This is true
for all stages of breast cancer. Recurrence rates
after mastectomy range from 3% to 20%, depending on the size of the tumor, the presence of
regional metastases, and the use of systemic therapy. Overallthe risk ofa localrecurrence isabout
the same for BCT and mastectomy. Chest wall
recurrences after mastectomy tend to occur later
than in-breast recurrences after breast conservation, although most will occur within the first
3 years after surgery for both groups.
Radiation eradicates microscopic residual
foci that are present in the breast after surgery.
The effects of radiation have no effect on the
future risk of breast cancer. Therefore the risk
of a second primary cancer in the treated
breast is the same as in the contralateral breast.
The six randomized trials all demonstrated
that even when local recurrence was higher (as
with lumpectomy without radiation), overall
survival was the same. This has been interpreted
as meaning that local therapy has minimal if
any effect on the risk of developing distant disease. Based on this interpretation, surgeons have
been increasingly willing to accept therapies
that have higher rates of local recurrence, arguing that even if an increased number of those
patients ultimately require completion mastectomy, overall survival would not be affected.
But these trials were all individually too small
to detect a small impact on overall survival.
Even if there was no difference in overall
survival when comparing BCT to mastectomy,
patients who had BCT and developed a local
recurrence do have a worse outcome. In one
matched-pair analysis, BCT patients who had
a local recurrence had an overall survival of
71% compared to 81% for those who did not
have a local recurrence. This in itself did not
prove that prospectively preventing a local
recurrence would have improved survival by
this degree. It could be that the local recurrence is a marker reflecting the propensity of
the tumor to metastasize distantly. So rather
than metastases developing from the recurrence, the patients with more aggressive
tumors are more likely to develop both.
So does the prevention of a local recurrence
improve overall survival? Yes, as demonstrated
by the Early Breast Cancer Trialists Collaborative Group (ECGTCG) metaanalysis. Several of
the randomized trials that established the efficacy of breast conservation included arms in
which women underwent lumpectomy alone,
without radiation, and most demonstrated that
despite a significant increase in local recurrence, there was no impact on overall survival.
However, these trials did not have the power
to detect a small survival advantage from the
improved local control provided by radiation
therapy. In addition, the morbidity and mortality associated with radiation therapy negated some survival advantage, particularly with
older methods for delivering radiation. The
most recent update of the ECGTCG metaanalysis demonstrates that the 15-year breast cancer
mortality risks were significantly lower in the
patients who received radiation therapy (30.5
versus 35.9, P ¼ .002). A pooled analysis of
mortality data from 13 randomized trials also
showed a worse survival in women who did
not receive radiation therapy, with an 8.6%
excess mortality. These data clearly demonstrate that improved local control does impact
survival, and women with an exceedingly high
risk of in-breast recurrence with BCT compared to mastectomy may be better served by
the latter. It also establishes that radiation is
a critical component of BCT.
Patient Selection
Although the surgeon plays many roles in the
management of breast cancer, one of the most
important is deciding whether the patient
is a good candidate for BCT or whether the
patient will require a mastectomy (Box 12–2).
BOX 12–2 WORKUP TO DETERMINE
SUITABILITY FOR BREAST
CONSERVATION
Complete history and physical
Past medical history
Medications
Complete family history
Thorough bilateral breast
examination
Bilateral mammogram with diagnostic
imaging of the cancer
Review of the histology
? Ultrasound of the primary tumor
? Magnetic resonance imaging
16112—SURGICAL MANAGEMENT OF PRIMARY BREAST CANCER
There are several absolute contraindications to
breast conserving therapy, some relative contraindications, and some factors that are not
contraindications, but are wrongly thought
to be. The American College of Surgeons, the
American College of Radiology, the College of
American Pathologists, the Society of Surgical
Oncology and the Canadian Steering Committee on Clinical Practice Guidelines for the Care
and Treatment of Breast Cancer have developed consensus standards of care for BCT.
The evaluation of the breast cancer patient to
determine whether she is a suitable candidate
for BCT includes:
A complete history and physical examination before treatment. This includes a
complete past medical history, present
medications, and family history of cancer.
Bilateral mammographic evaluation, with
appropriate magnification views, within
3 months of surgery. The tumor size,
whether the mass is associated with
microcalcifications, and the extent of the
calcifications within and outside the mass
should be included in the report.
Accurate histologic assessment of the primary tumor, including histologic subtype
and hormone receptor status. Thus a
core-needle biopsy or excisional biopsy
rather than fine-needle aspiration is the
optimum choice for making a tissue diagnosis when BCT is considered.
The most difficult part of the evaluation is
the assessment of the patient’s needs and
expectations. This requires that the
patient and her physician discuss the benefits and risks of mastectomy compared to
BCT in regard to long-term sur vival, the
possibility and consequence of local recurrence, and the impact on cosmetic outcome and psychosocial adjustment.
Recently, the use of magnetic resonance
imaging (MRI) to determine eligibility for BCT
has become more popular. Proponents state it
can more accurately determine the extent of
the tumor as well as identify multicentricity.
However, the use of MRI is not without controversy. MRI of the breast is highly sensitive, but
has limited specificity (see Chapter 2). As such,
MRI will detect many benign lesions that would
otherwise not preclude breast conservation.
MRI is also limited in its ability to detect ductal
carcinoma in situ (DCIS), which is often a reason why negative margins are not attainable.
Most importantly, many institutions have the
ability to perform MRI but not the technology
to perform MRI-guided biopsy. If a woman
undergoes a preoperative MRI and other lesions
are detected, then she may undergo additional
mammograms or ultrasound to try to identify,
and biopsy, the MRI-detected lesion. However,
if the mammogram and ultrasound are unable
to identify the lesion and MRI-guided biopsy
is not available, the woman is placed in a difficult position. She can ignore the findings of
the MRI and proceed with BCT (risking increased recurrence) or proceed with mastectomy
knowing she might have been a suitable candidate for breast preservation. Many women naturally choose the latter, and even when MRIguided biopsy is available, some women choose
mastectomy rather than go through additional
biopsies. Thus the use of MRI may be leading
to an unnecessary increase in mastectomy rates
without having a significant effect on local
recurrence rates. Further prospective studies
are necessary before MRI can be considered
a routine part of the preoperative staging process, and a full discussion of the risks, benefits,
and possible outcomes of preoperative MRI
should be discussed in detail with the patient.
Preoperative MRI may be a reasonable option
in patients who have dense breast tissue, limiting the ability of mammography to detect the
true extent of the cancer or second cancers,
or in women with a high risk of synchronous
cancers (such as women with BRCA mutations)
who desire breast conservation rather than
bilateral mastectomies.
Absolute Contraindications
Multicentricity is an absolute contraindication
to BCT (Box 12–3). This means two or more
tumors are located in separate quadrants of the
BOX 12–3 ABSOLUTE
CONTRAINDICATIONS TO BREAST
CONSERVING THERAPY
Patient does not desire breast
conservation therapy
Unable to receive radiation therapy
First or second trimester of pregnancy
(see Chapter 22)
Collagen-vascular disease
Previous chest wall radiation
Diffuse suspicious microcalcifications on
mammography
Multicentric disease
Inability to achieve negative margins
162 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
breast. In patients with a known breast cancer
and a suspicious lesion on either physical examination or breast imaging, a biopsy should
be performed on the second lesion before proceeding with breast conservation, even if this
means an additional procedure. Multicentricity is not the same as multifocality, which
implies multiple foci of tumor when examined
histologically. This has more to do with the
pattern of tumor growth. The presence of multifocality is not a contraindication to BCT, as
long as negative margins can be obtained.
Likewise, the presence of two masses within
the same quadrant may not require mastectomy. This may represent a dumbbell-shaped
tumor. If both masses can be excised in one
excision, this is acceptable if the cosmetic
result is reasonable. On the other hand,
performing more than one lumpectomy for
multiple tumors is associated with high rates
of local recurrence (>30%) and poor cosmetic
outcomes.
The presence of diffuse microcalcifications
on mammography, often described as extending beyond one quadrant, is another contraindication to breast conservation. These often,
but not always, represent DCIS extending
beyond the invasive cancer. Unfortunately,
the pathology report of the mastectomy specimen often does not reveal extensive DCIS
associated with these calcifications, which
can make the surgeon and the patient question the need for the mastectomy. However,
the presence of the calcifications not only
may indicate more extensive disease, but also
may make surveillance of the breast for local
recurrence extremely difficult.
Another contraindication is a history of prior
therapeutic irradiation to the breast region,
which when combined with the proposed
treatment would result in an excessively high
total radiation dose to the chest wall. This
includes women who have already been treated for breast cancer in that breast with radiation and women who have had radiation for
other reasons such as for Hodgkin’s lymphoma
(Fig. 12–2). Prior radiation to other body sites
is not a contraindication. Sometimes in evaluating a patient with a history of radiation,
there is a question as to the dose and exact
fields used. In these cases, it is best to obtain
the previous treatment record and consult with
a radiation oncologist before proceeding with
breast conservation.
Pregnancy in the first or second trimester
is an absolute contraindication to the use of
breast irradiation. It may be possible to perform
breast-conserving surgery in the third
Lymph nodes
Cervical
Supraclavicular
Mediastinal
Axillary
Figure 12–2. The field of radiation (including the
mantle field) for Hodgkin’s disease. (From Roses D.
Breast Cancer. Philadelphia: Elsevier, 2005.)
Mantle
field
trimester, deferring breast irradiation until
after delivery. Breast cancer during pregnancy
is discussed in more detail in Chapter 22.
Because lumpectomy and radiation go hand
in hand, one must consider the morbidity of
radiation therapy when one is discussing lumpectomy with the patient. Radiation often leads
to fatigue, may lead to skin changes and inflammation of the breast, and can result in a temporary cough secondary to fibrosis of the lung.
In the long term, radiation can lead to prolonged breast edema, shrinkage of the breast
or induration of the cavity, fat necrosis, excessive fibrosis, irradiation pneumonitis, rib fractures, and pleural effusion. Cardiac effects and
radiation-induced secondaryneoplasms arealso
a concern. These are discussed in more detail in
Chapter 15. However, it is important that the
surgeon be able to discuss these with the patient
when presenting the choice between BCT and
mastectomy. On the other hand, the surgeon
must be careful not to present mastectomy as
“a way to avoid radiation”; depending on the
pathology results, postmastectomy radiation
may still be recommended.
Relative Contraindications
Some oncologists consider connective tissue
disease to be an absolute contraindication to
breast conservation because many of these
patients tolerate irradiation very poorly. However, most consider it a relative contraindication, depending on the type of connective
tissue disease and the relative risks and benefits of therapy. Scleroderma is an absolute contraindication. Systemic lupus erythematosus
patients may also have a poor reaction to radiation therapy. For other types of collagenvascular disease, such as Raynaud phenomenon,
rheumatoid arthritis, Sjo¨gren’s syndrome, or
polymyositis, the response to radiation has
not been as severe, and these patients may still
be considered for BCT.
16312—SURGICAL MANAGEMENT OF PRIMARY BREAST CANCER
The ideal candidate for breast conservation
is the patient with T1 or T2 tumors and a
breast large enough to encompass an adequate
resection. However, this is subjective and size
is not an absolute contraindication. Women
with large breasts can undergo resection of a
4- or 5-cm tumor with a good cosmetic result
and successfully undergo breast irradiation,
although they may require radiation in the
prone position to assure reproducibility of the
patient set-up. Patients with large tumors
who still want breast conservation may consider neoadjuvant chemotherapy to downstage the tumor (see Chapter 18).
Finally, there is the question of microscopic
negative margins. Often described as a contraindication to BCT is the inability to obtain
negative margins. If after a reasonable attempt
at reexcision there are still diffusely positive
margins, then a mastectomy is indicated. It is
ideal that negative margins be obtained before
proceeding to radiation, because the majority
of studies have demonstrated a lower local
recurrence rate with negative compared to positive margins. The impact of a closemargin is less
clear, and the decision whether to reexcise must
be made on a case-by-case basis, taking into
consideration the radiation planned and the
use of systemic therapy. Close margins, which
have been associated with an increased risk of
recurrence in some series but not in others.
Not Contraindications
There are several features that may be associated
with an increased risk of recurrence, but are not
necessarily contraindications to breast conservation (Box 12–4). The most commonly misquoted contraindication is the presence of
axillary nodal metastases, whether these are
clinical or pathologic. Given the increased likelihood of systemic disease when the lymph
nodes are positive, the impact of local control
on overall survival diminishes. In addition, the
risk of chest wall recurrence after mastectomy
increases with the number of positive axillary
lymph nodes. This is not true for breast conservation, possibly due to the use of radiation
therapy. This is why chest wall radiation is considered after a mastectomy when the axillary
nodes are positive (see Chapter 15).
Age is not a contraindication to BCT; physiologic age and the presence of comorbid conditions should be the primary determinants
of local therapy in older women. It is also
obviously wrong to assume that an older
woman would be less concerned with her
physical appearance or the effects of a
BOX 12–4 VARIABLES NOT
CONSIDERED TO BE
CONTRAINDICATIONS TO BCT
Variables Associated with an
Increased Risk of Recurrence after
Breast Conservation
Tumor size
Positive or close margins
High grade
Angiolymphatic invasion
Excessive delay in radiation (>16 weeks)
Young age (may be associated with
higher grade or may be associated with
surgeon willingness to compromise
margins for cosmetic purposes)
Variables Associated with a Decreased
Likelihood of Negative Margins but No
Difference in Recurrence If Negative
Margins Are Obtained
Extensive intraductal component,
defined as greater than 25% or more of
the tumor composed of ductal carcinoma
in situ both within and at the periphery
of the margin
Lobular carcinoma
mastectomy on her sexual image. Likewise,
being young is not a contraindication. Even
though some series have shown a higher risk
of relapse in young women (defined as either
younger than 35 or 40), some of these series
have also shown that younger women have
worse prognosis lesions (high grade, vascular
invasion, ER-negative tumors) and a greater
likelihood of distant disease.
Histologic subtypes other than invasive ductal
carcinoma (e.g., invasive lobular cancer) are not
associated with an increased risk of breast cancer
recurrence, nor is the presence of an extensive
intraductal component. This is defined as an
invasive cancer associated with a large component of intraductal cancer (>25%) within the
tumor and in the surroundingbreast tissue. Both
lobular carcinomas and noncalcified DCIS may
extend beyond what is visualized on imaging
studies, so it may take a wider lumpectomy or a
reexcision to obtain negative margins. However,
if negative margins can be obtained, then breast
conservation is reasonable.
As with tumor size, tumor location must be
considered on a case-by-case basis and is not in
itself a contraindication to breast conservation.
The surgeon should discuss with the patient the
cosmetic implications of the position of the
lumpectomy. Tumors in the 6-o’clock position
164 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
of the breast will often cause downturning of
the nipple after therapy. Tumors in the superficial subareolar location may require resection
of the nipple-areolar complex to achieve negative margins. The patient and her physician
need to assess whether each resection, and the
effect on cosmesis, is preferable to mastectomy
and reconstruction.
Breast implants previously placed for augmentation are not an absolute contraindication to
lumpectomy. If a lumpectomy can be performed
without violating the basic principles (complete
tumor excision, accurate lymphatic mapping),
then radiation can be delivered to the breast
using standard techniques and doses. However,
capsular contracture is a risk, causing the breast
to become rounded, firm, and retracted upward.
The suitability of BCT in women with breast
implants in part depends on how the implant
was placed. For example, if the implant was
placed through an axillary incision, this may
impact the accuracy of sentinel lymph node
biopsy. Subcutaneous implants have a higher
rate of capsular contraction with radiation than
subpectoral. If negative margins cannot be
obtained secondary to the tumor being in close
proximity to the implant (cancers sometimes
invade the fibrous capsule around the implant),
the implant may need to be removed.
Finally, the patient’s individual risk of developing a second cancer is not a contraindication
to breast conservation, although a discussion
should be held with these patients of their
increased risk of a second breast cancer and
the potential benefits of bilateral mastectomy.
Thus breast cancer patients with a strong family history of breast cancer or with a known
BRCA1 or BRCA2 mutation may opt for bilateral mastectomy; if they are not ready for that,
then unilateral mastectomy as treatment of
the known cancer is not warranted if they are
candidates for, and desire, BCT.
incision should ideally be placed directly over
the mass. Excessive tunneling is not recommended because this may compromise margins
and make a reexcision for positive margins
unnecessarily difficult. Circumareolar incisions
result in a superb cosmetic outcome and are
appropriate for lesions located near the areola,
but care should be taken in tunneling too far
simply to use a circumareolar incision.
In the upper hemisphere of the breast, incisions should be curvilinear, following the normal lines of tension in the skin (Fig. 12–3). It is
not necessary to routinely excise skin with the
specimen; however, if the tumor is close to
the skin, an ellipse over the tumor should be
taken to ensure a negative anterior margin.
In the lower hemisphere of thebreast, either curvilinear incisions or radial incisions can be used.
For small tumors in relatively larger breasts,
where it will not be necessary to remove overlying skin and adequate breast parenchyma
will remain around the cavity, curvilinear
Operative Management of Breast Cancer
Lumpectomy
Placement of the Incision
Lumpectomy may be performed either under
general anesthesia or intravenous sedation with
local anesthesia. The patient is placed supine
on the operating room table and the entire
breast and axilla is prepped and draped in an
aseptic fashion. For a lumpectomy, the
Figure 12–3. Planning the lumpectomy incision.
Skin incisions should be placed within the Langer’s
lines when possible. Closer to the areola, circumareolar incisions are appropriate, but excessive tunneling should be avoided. In the lower hemisphere of
the breast, radial incisions should be strongly considered, because these result in less distortion of
the nipple-areolar complex. (From Roses D. Breast
cancer. Philadelphia: Elsevier, 2005.)
16512—SURGICAL MANAGEMENT OF PRIMARY BREAST CANCER
incisions are acceptable. Otherwise, radial incisions should be used. Curvilinear incisions
beneaththe areola,where skinor a goodamount
of breast tissue is removed, will distort the breast
in a way that the breast collapses inferiorly and
the nipple points downward, resulting in an
unacceptable cosmetic outcome. However, one
must keep in mind how this would ultimately
impact a mastectomy incision (particularly a
skin-sparing mastectomy incision) in case the
attempt at breast conservation fails (Fig. 12–4).
The decision to use circumareolar or radial incisions in the lower hemisphere of the breast must
be individualized to the patient, taking into
account the size of the tumor, the size of the
breast, and the pathology.
When the cancer is located in the upper outer
quadrant of the breast, it may seem attractive
to perform the sentinel lymph node biopsy or
the axillary lymph node dissection through
one longer incision. Even though this may
be acceptable when the tumor lies high in the
axillary tail of the breast, it should generally
be avoided. It may result in a long suture line
across normal skin creases, which leads to
excess contraction and deformity. In addition,
it complicates the planning and delivery of
a boost to the tumor bed for the radiation
oncologist. Thus two separate incisions for the
lumpectomy and for the axilla are preferable,
even if they are only 2 to 3 cm apart.
Lumpectomy
After creation of the skin incision, skin flaps
are raised over the tumor. It is important that
these skin flaps not be too thin. Thin flaps will
result in excessive retraction of the cavity during radiation, resulting in a concavity at the
site of the lumpectomy. On the other hand,
thick flaps heal much better. The subcutaneous fat helps support the skin, and if left
intact, helps preserve the natural contour of
the breast ( Fig. 12–5). For deep-seated tumors,
after incising the skin, the breast tissue may
be divided straight down to approximately
1 cm above the tumor mass before beginning
the dissection around the tumor. For intermediate masses, the skin flaps should be created
at a 45-degree angle. For more superficial
lesions, an adequate amount of skin overlying
the tumor should be taken so that thin skin
flaps are not necessary for adequate margins.
Once appropriate flaps are raised peripherally around the tumor, the dissection should
continue straight down toward the chest wall.
The surgeon should keep one hand on the
tumor at all times during the dissection to
ensure adequate margins. A rim of normal
breast tissue or fat of approximately 1 cm
should be excised with the tumor centered in
the specimen. The incision should be large
enough to allow this. Removing a tumor
Figure 12–4. As with excisional biopsies, a subsequent
mastectomy should be considered if the attempt at breast
conservation fails. (From Bland
KI, Copeland EM III. The breast,
3rd ed. Philadelphia: WB Saunders, 2004.)
AB
C
166 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
manipulation results in ink approximating
the cancer, and a pathologic finding of
a positive margin, necessitating reexcision.
When needed, a clamp can be used to grasp
the normal tissue around the mass to assist in
retraction, but care should be taken not to pull
too aggressively. A clamp should never be
placed directly on the tumor.
scalpel, scissors, or cautery. Many surgeons
prefer cautery to maintain hemostasis throughout the dissection, increasing visibility. However, the cautery effect on the specimen may
obscure the ability of the pathologist to read
the margins. Sharp dissection results in a
clearer margin status and, with appropriate
technique and retraction, bleeding can be kept
to a minimum. Additional time can be taken
once the specimen is out to ensure hemostasis.
pectomy cavity, it is important to note and
maintain its orientation. Marking sutures are
immediately placed on the specimen. A single
stitch superiorly, a long stitch laterally, and a
double stitch deep is an easily recalled method
Figure 12–5. Preserving the subcutaneous fat
between the skin and the tumor helps avoid excessive skin retraction and indentation. (From Bland KI,
Copeland EM III. The breast, 3rd ed. Philadelphia: WB
Saunders, 2004.)
to orient the tissue the same way each time,
and preprinted stickers can be created for the
circulating nurse (Fig. 12–6).
the adequacy of any margin, an additional
specimen can be taken from the wall of the
through a small incision requires excessive
manipulation of the tumor and an increased
risk of positive margins on final pathology.
Limiting yourself in an attempt to keep the
incision small increases the need for a reexci-
lumpectomy cavity corresponding to the point
opposite the area of concern. With the skin
retracted anteriorly, the wall is grasped with
a toothed pick-up or clamp and a new, ade-
quate margin is obtained. This should be
sion lumpectomy, which will have a worse cosmetic outcome than if the skin incision was
simply lengthened. Excising even a small
ellipse of skin with the tumor often allows
for a wider operative field to work in. As the
mass is freed peripherally, the tumor is grasped
and retracted upward so that the posterior
aspect may be completed. Exposure is aided
by using small retractors. For deeper tumors,
the pectoralis fascia should be included in the
specimen. A portion of the pectoralis muscle
should be included for very deeply situated
tumors to ensure an adequate deep margin.
By working peripherally around the tumor
and waiting until the tumor is circumferentially free to grasp the mass, the surgeon
avoids excessive manipulation of the tumor.
This is important because increased manipulation increases the likelihood of removing
surrounding fat and tissue from the cancer.
Exposing the tumor through excess
Figure 12–6. The lumpectomy specimen should be
oriented in three planes so that the pathologist can
use a multicolor staining system to identify close or
positive margins.
The lumpectomy may be performed with a
As the tissue is removed from the lum-
If there is any concern clinically regarding
Short stitch:
superior
Double stitch:
deep (posterior)
Long stitch:
lateral
16712—SURGICAL MANAGEMENT OF PRIMARY BREAST CANCER
liberal, taking a generous portion of the wall of
the cavity to ensure the margin of concern is
truly excised. Otherwise, the pathologist may
state that you obtained negative margins, but
in reality left behind a close or positive margin. The new specimen should be marked
appropriately with sutures so that the pathologist knows what the true margin is.
Wound Closure
After completion of the lumpectomy, hemostasis should be achieved to avoid a hematoma.
Drains are never used after a lumpectomy. The
surgeon should also never try to simply reapproximate the breast tissue. For large defects,
there are methods to mobilize adjacent tissue
(see later), but in general sutures should not be
placed in the breast parenchyma to close the
cavity. The lumpectomy cavity will fill with seroma and fibrin, and ultimately fibrous tissue,
which maintains the normal, rounded contour
of the breast.
Once hemostasis is achieved, surgical clips
should be placed within the lumpectomy cavity
in the six anatomic locations (anterior, posterior, medial, lateral, superior, inferior). This
helps in the planning of the radiation therapy,
specifically if a boost is planned or if partial
breast irradiation is contemplated. The incision
should then be reapproximated with absorbable deep dermal sutures followed by a subcuticular stitch or tissue adhesive. Interrupted
nylon or silk sutures leave cross-hatching scars
and are not necessary.
Wire-Localized Lumpectomy
With the increased use of screening mammography, many cancers are diagnosed by means of a
stereotactic core biopsy of a mammographic
abnormality. In these cases, a wire-localized
lumpectomy will be necessary. Localization
involves placing a rigid introducer needle with
a flexible hooked wire inside of it at the site
of the abnormality using either biplanar mammography or ultrasound (Fig. 12–7). Ultrasound
is relatively simpler and more comfortable for
the patient. In many cases, the original abnormality is gone, removed by the core-needle
biopsy, and so a clip left by the radiologist is
localized for excision.
Once the rigid needle is in place, it is withdrawn, leaving the hooked wire in place. The
hook keeps the wire in place so it is not easily
moved, although the external wire should still
be secured to the skin so that it is not
dislodged as the patient travels from radiology
to the operating room. The craniocaudal and
mediolateral views of the wire in place accompany the patient to the operating room.
The wire-localized lumpectomy is similar to
the wire-localized biopsy except the surgeon
is attempting to obtain negative margins. In
some cases, more than one wire may be placed
to bracket the mass or calcifications to give
the surgeon a better idea of what needs to be
excised to obtain negative margins. As with
standard lumpectomy, an adequate skin incision should be used to allow adequate room
to excise the entire region and not overly
manipulate the tissue. The incision should be
curvilinear in Langer’s lines, and created with
a subsequent lumpectomy or mastectomy in
mind. The incision should be placed over
the abnormality and not routinely made at the
site of wire entry. The surgeon should use the
wire and images to determine the site of
the abnormality and place the incision directly
over this.
The direction of the dissection is determined
by the lesion size, direction of the wire, and the
relative proximity of the wire to the lesion
(Fig. 12–8). Wires placed just posterior to the
lesion are helpful because the surgeon removes
the lesion by staying deep to the localization
needle. Once the incision is made, it is then
necessary to identify the shaft of the lesion
and retract it into the wound. Dissection in
the plane facing the wire entry site allows for
simple detection of the wire. Once identified,
it is secured at the site of the parenchyma and
the distal end of the wire is brought out into
the wound. Failure to adequately secure the
wire may result in accidental dislodgment.
Once out, the tissue is grasped with an Allis
clamp. It is preferable to grab the tissue near
the wire but not the wire itself because pulling
too hard on the clamp may pull the wire from
the specimen. Resection of the tissue surrounding the wire proceeds. The relationship
between the wire and the lesion, as demonstrated on mammography, helps guide how
much tissue to take.
Immediately upon removal of the specimen,
it is held in anatomic position and marked with
orientation sutures. It is also helpful to place
clips at the periphery of the specimen to allow
for orientation of the specimen radiograph.
These may help guide the excision of additional
tissue of the lesion if there is any concern of
a close radiographic margin. The specimen is
sent to radiology for confirmation that the
lesion in question was removed. If there is any
168 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
A
B
C
Figure 12–7. A and B, Mediolateral and craniocaudal views from wire localization using superior approach.
C, Specimen radiograph demonstrates abnormality adjacent to the reinforced portion of the hookwire. Pathol-
ogy demonstrated ductal carcinoma in situ. (Images courtesy of Dr. Alexis Nees, Department of Radiology,
University of Michigan.)
Wire has been
delivered into
Hooked
wire cut to
manageable
length
Site of wire
entry into
breast
Skin incision
Lesion
Nonpalpable
carcinoma
Figure 12–8. The wire-localized lumpectomy. The placement of the incision and direction of the dissection
are determined by the lesion size, direction of the wire, and the relative proximity of the wire to the lesion.
Once the incision is made, it is best to identify the shaft of the wire and retract it into the wound. Once out,
the tissue is secured and resection of the tissue surrounding the wire proceeds. (From Roses D. Breast cancer.
Philadelphia: Elsevier, 2005.)
operative field
Hemostats
place tension
on stay suture
16912—SURGICAL MANAGEMENT OF PRIMARY BREAST CANCER
clinical concern of a close or positive margin,
that should be excised as a separate specimen.
The specimen radiography may also suggest a
margin that appears close and requires reexcision. Because wire-localized lumpectomies tend
to have a higher rate of close or positive margins than lumpectomies for palpable masses, a
more generous approach to reexcising margins
at the first operation is warranted.
Reexcision Lumpectomy
Reexcision lumpectomy should be performed
in any patient with unknown or positive margins. It is also strongly recommended in patients
with close margins, approximately 2 to 3 mm.
Reexcision is necessary in one fourth to one
third of lumpectomies. Failure to reexcise close
or positive margins stands a high chance of
leaving residual disease and increases local
recurrence rates.
The standard approach to a reexcision lumpectomy is to remove the entire cavity. An ellipse
of skin is drawn around the previous skin incision so that the previous scar is removed with
the specimen. Skin flaps are then raised. The
previous cavity is usually readily palpable, and
the approach to the reexcision is similar to that
of a lumpectomy. As with a lumpectomy, the
surgeon should keep one hand on the cavity
at all times during the dissection to ensure
adequate margins. It is important not to violate
the cavity because this complicates the inking
and evaluation of the new margins.
This approach is necessary when the initial
lumpectomy was not oriented and inked with
the six-color system. In this setting, the surgeon does not know where the close or positive margins are, so the entire cavity needs to
be excised. This approach, however, results in
a large volume of resected breast tissue, often
beyond what is necessary to achieve negative
margins. If the original lumpectomy was oriented and the margin in question is known,
an alternative approach might be to enter the
previous biopsy cavity and excise only the
involved margin. This minimizes the volume
of tissue excised, and studies have shown that
this approach is oncologically sound, with no
increased risk of local recurrence. This stresses
the importance of orienting and using the
six-color inking system on all breast biopsies
and lumpectomies.
To reexcise just the involved margin, the
previous incision may be excised completely
or reopened using a scalpel. The seroma fluid
is suctioned out. If too much time elapses
between the original lumpectomy or biopsy
and the reexcision lumpectomy, the cavity
may no longer be evident. In this case, it is
preferable to excise the entire cavity as
described earlier. However, if there is still a cavity, the margin in question can be grasped at
the top with an Allis forceps and that margin