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190 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
BOX 13–4 RELATIVE ADVANTAGES
AND DISADVANTAGES OF
INTRAOPERATIVE SENTINEL LYMPH
NODE ANALYSIS IN BREAST CANCER
Advantages Disadvantages
No routine
intraoperative
analysis
Touch-prep
cytology
Frozen
section
Less operating
time
Improved
scheduling
Quick,
minimal
impact on
operating
time.
Allows for
simultaneous
axillary
lymph node
dissection
(ALND).
Highly
accurate.
Allows for
simultaneous
ALND.
Read by
pathologist.
All patients who
are sentinel
lymph node
(SLN) positive
require a second
operation
Adds some time
to each case.
More difficult to
schedule cases if
each case has
possible ALND.
Requires an
experienced
cytopathologist
to read.
Possibility of
false-positives.
Adds some time
to each case.
More difficult to
schedule cases if
each case has
possible ALND.
to the procedure, and there is some concern
that frozen section significantly decreases the
subsequent detection of micrometastases.
Touch-prep protocols provide a rapid approach
to sentinel node diagnosis, with sensitivity
ranging from 40% to 95.7%. Combining
immunohistochemistry (IHC) with intraoperative touch-prep plus IHC increases the sensitivity to around 80%. Although a negative
SLN intraoperatively does not completely preclude a return to the operating room for subsequently discovered metastases, it will spare
many women the need for a second operation
(Box 13–4).
Postoperative Care of the Sentinel Lymph Node Biopsy
The morbidity of SLN biopsy is dramatically
less than with ALND, but this is not to say
the procedure is without complication. Many
surgeons are under the impression that SLN
biopsy eliminates the risk of lymphedema,
but this is not the case, with lymphedema
rates reported between 1% and 7%. This partly
depends on how one defines lymphedema.
Lymphedema is more common for upper
outer quadrant tumors and may be exacerbated by removing the sentinel node through
the same incision used for the wide excision
of an upper outer quadrant tumor (this also
may complicate the radiation planning). Obesity is also a risk factor for lymphedema after
SLN biopsy. Trauma or infection in the extremity in the postoperative period will increase
the risk of lymphedema, and so patients
should be cautioned to take care.
Seroma and infection are also possible complications of SLN biopsy. With the use of prophylactic antibiotics, wound infections are
rare. Patients with a symptomatic seroma after
biopsy can be easily managed by needle aspiration. Patients with asymptomatic seromas will
typically resolve on their own, although this
may take a few weeks. Hematoma formation
is also a possible, albeit rare, complication of
SLN biopsy. Any expanding hematoma should
return to the operating room for evacuation
and identification of any bleeding points.
Delayed hematomas will resolve with time.
Any attempt to aspirate a hematoma should
be avoided because it is unlikely to work and
may introduce infection. A large or symptomatic hematoma should be removed in the
operating room.
A temporary sensory neuropraxia can occur
after SLN biopsy from irritation of the intercostobrachial nerve. This can vary in intensity,
from numbness of the region under the arm
and along the inner aspect of the arm, to
dysesthesias. Patients often describe a sunburnlike sensation or an itching that is not
relieved by scratching. Patients should be reassured that these symptoms will resolve with
time, although it may take several weeks. For
the most severe cases, Neurontin may be of
benefit. Injury to the motor nerves or to the
brachial plexus is extremely uncommon after
SLN biopsy.
Histopathologic Examination of the Sentinel Lymph Node
When an ALND is performed, the pathologist
typically takes each node and bisects it, staining each half with hematoxylin and eosin
(H&E) to identify tumor cells. Only a small
area of each lymph node is examined because
subjecting each lymph node to a more meticulous search, considering there may be from 10
to 30 lymph nodes in the specimen, is time
and cost prohibitive. However, with SLN
biopsy, the pathologist typically has only 1 to
4 lymph nodes to examine. This allows for
serial sectioning for a more thorough examination of the nodes and the identification of
metastases that would have otherwise been
missed (Fig. 13–10). The nodes should be
examined by H&E at a minimum of 2-mm
intervals. With this technique, SLN biopsy is
more sensitive at finding lymph node metastases than ALND.
A key feature of SLN biopsy is the detailed
pathologic review. By focusing on a few nodes,
rather than the entire axilla, a more thorough
examination of each node in the sentinel node
specimen is feasible (Fig. 13–11). As compared
with bivalving the SLN, several studies have
demonstrated the importance of obtaining
multiple sections in detecting axillary metastases. Many centers also examine nodal sections with IHC, a more sensitive method of
detecting metastatic cells. The use of IHC staining will be discussed in further detail later in
the text.
With increased scrutiny of the SLN, smaller
and smaller metastases can be identified.
Although it would seem quite reasonable to
presume that the discovery of any disease in
the lymph node would portend a worse prognosis, this is not necessarily the case. Several
retrospective studies of patients with negative
ALND have involved reexamining the lymph
Figure 13–10. Micrometastases identified on sentinel lymph node biopsy. (Image courtesy of Dr. Maria
Braman, Department of Pathology, University of
Michigan.)
19113—REGIONAL MANAGEMENT OF BREAST CANCER
Figure 13–11. Step-sectioning the sentinel lymph
node as opposed to bisecting it, allows for evaluation of a greater cross-sectional area of the lymph
node and improves the accuracy of axillary staging.
In this example, a micrometastasis would have been
missed by bisection (false-negative) but is detected
by step-sectioning.
nodes by serial sectioning and IHC, and the
outcomes of patients with occult metastases
compared to those without. Although some
studies found a worse outcome associated with
micrometastases, most found no negative
impact on prognosis.
The significance of micrometastases detected
by IHC is further called into question by the
DCIS literature. Micrometastatic disease can
be detected in as many as 10% of patients
undergoing SLN biopsy for DCIS, which has
a nearly 99% survival and for which axillary
recurrences are extremely rare. In addition,
three studies have demonstrated that micrometastases detected by IHC correlate more
with the method of biopsy than with the
biology of the cancer, suggesting they may
be an artifact rather than a biologic phenomenon. Thus, the available evidence does
not support the routine use of IHC in the
evaluation of the SLN. IHC may be used
selectively, such as in the case of lobular
carcinoma, which may be difficult to identify
in the lymph node. If metastases are detected
by IHC, their presence should be confirmed
on H&E.
Patients with micrometastases less than
0.2 mm are considered node negative (current
American Joint Committee on Cancer [AJCC]
staging stages these patients as N0mic) and
should not be considered for completion dissection or adjuvant chemotherapy based solely
on their nodal status. Patients with metastases
greater than 0.2 mm should continue to be
treated as node positive. Pending data from
recent prospective trials will hopefully help
clarify these issues.
192 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
Management of the Clinically Positive Axilla
Axillary Lymph Node Dissection
Whether the disease was identified by physical examination, axillary ultrasound, or SLN
biopsy, ALND remains the standard of care
for patients with known involvement of the
axillary lymph nodes. The few patients in
whom a sentinel node cannot be identified,
even intraoperatively, are also candidates for
primary complete axillary lymphadenectomy
for staging purposes. The axillary dissection
for breast cancer involves en bloc resection of
the level I and level II lymph nodes. The axilla
is anatomically defined posteriorly by the
subscapularis and latissimus dorsi muscles,
medially by the chest wall and the overlying
serratus anterior muscle, laterally by the skin
and subcutaneous tissue of the underarm area,
and superiorly by the axillary vein. These anatomic boundaries do not imply that lymph
nodes do not reside above the axillary vein,
and these nodes can be included in the specimen by pulling the fatty tissue above the vein
inferiorly with the specimen, taking care not
to injure the brachial plexus. However, aggressive dissection above the vein exposes the brachial plexus to injury. This area encompasses
the intercostobrachial nerve(s), thoracodorsal
bundle, and the long thoracic nerve, which
are often intimately involved with the soft
tissue and lymphatics of the surgical specimen.
The thoracodorsal bundle, consisting of a
nerve, artery,and vein, contains the major blood
supply and innervation to the latissimus dorsi.
Disruption of the thoracodorsal nerve results in
weakness during abduction and medial rotation
of the shoulder. The long thoracic nerve is the
sole motor nerve to the serratus anterior, a thin,
flat muscle primarily responsible for anchoring
the scapula to the posterior chest wall. Injury
to the long thoracic nerve results in “winging”
of the scapula, in which the medial edge of
scapula protrudes involuntarily and uncomfortably from the posterior thorax.
Axillary dissection is accomplished in concert with mastectomy (a MRM) via an oblique
elliptical mastectomy incision or in concert with
a lumpectomy using a separate curvilinear incision connecting the anterior and posterior axillary lines, just inferior to the axillary hairline.
Technique
Patient Position
Before being brought back to the operating
room, the correct arm for dissection should
Figure 13–12. The patient is positioned supine
with the arm out at 90 degrees, never hyperextended. The entire arm prepped to the wrist and the
shoulder and lateral chest are prepped down to the
table. The armboard is covered with a sterile drape
and the arm sheathed to above the elbow with a
sterile impervious Stockinette, keeping it within the
sterile field. Bland KI, Copeland EM 111. The Breast,
3rd ed. Philadelphia: WB Saunders, 2004.
be marked in the preoperative area. This is
not only to avoid performing a lymph node
dissection on the wrong side, but also so that
the nurses and anesthesia team place all intravenous lines, blood pressure cuffs, and monitors on the contralateral arm. Long-acting
muscle relaxants should be avoided so that
motor nerves can be identified during the procedure. Short-acting muscle relaxants during
intubation are okay because these typically
wear off before nerve identification.
arm out at 90 degrees (Fig. 13–12). The arm
should not be hyperextended at any point in
the operation. The armboard should be padded appropriately to avoid subluxation of the
shoulder because this can stretch the brachial
plexus. Standard skin prep is used, with the
entire arm prepped to the wrist. The shoulder
and lateral chest are prepped down to the table
because these will be exposed when the arm is
brought across the chest. The armboard is covered with a sterile drape and the arm sheathed
to above the elbow with a sterile impervious
Stockinette. The arm is brought through a lap
sheet, with the drapes underneath the shoulder so that the arm is within the operative
field.
Procedure
The surgeon stands below the arm with a first
assistant above the arm. If available, a second
assistant can be positioned on the contralateral side. A curvilinear incision is made just
inferior to the hair-bearing area, extending
from just posterior to the pectoralis major
muscle and just anterior to the latissimus dorsi
The patient is positioned supine with the
19313—REGIONAL MANAGEMENT OF BREAST CANCER
muscle. The first step is to raise superior and
inferior skin flaps. A common error is to make
these flaps too thin. This does not increase the
number of lymph nodes removed and can lead
to a more pronounced cosmetic defect in the
axilla. The incision should be carried straight
down to just above the axillary fascia and then
flaps created. Once the flaps are raised, the
next step is to identify three landmarks; the
pectoralis major and minor muscles, the axillary vein, and the latissimus dorsi muscle
(Fig. 13–13). Although these can be identified
in any order, the pectoralis muscle is usually
the easiest to expose. Once identified, the lateral aspect of the pectoralis major muscle is
exposed with electrocautery along its length.
With the pectoralis major muscle retracted
medially, the pectoralis minor muscle is
exposed, and the investing fascia can be
opened in a similar manner. During the exposure of the muscles, it is important to identify
and preserve the medial pectoral neurovascular bundle. There is typically a small vascular
branch coursing toward the axillary contents
that will need to be divided. However, cutting
the nerve will cause atrophy of a portion of
the pectoralis muscle and can be easily
avoided with careful surgical technique.
The latissimus dorsi muscle can then be
identified at the inferior aspect of the axilla
and then exposed superiorly, staying on the
anterior edge of the muscle to avoid injury to
the thoracodorsal bundle. The latissimus dorsi
muscle should be exposed to the point where
the axillary vein crosses it. During this dissection, the lateral aspect of the intercostobrachial nerves will be encountered. Preserving
these nerves, although adding time to the
procedure, will avoid numbness of the upper
inner arm.
Finally, the axillary vein needs to be exposed. The vein is often encountered during
the exposure of the muscles. If it was not seen,
careful exploration and dissection should be
used to identify it. It is important not to dissect superior to the level of the axillary vein
because an injury to the brachia plexus can
be one of the most debilitating complications
Figure 13–13. Superior and inferior flaps are raised, and the pectoralis major, latissimus dorsi, and axillary
vein are identified.
194 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
of an ALND. Once the vein is identified, dissection should be on its inferior aspect. Skeletonizing the entire anterior surface of the
vein may increase the potential for lymphedema. This dissection is greatly facilitated by
retracting the axillary contents caudally. As
the fat is dissected from the vein, small superficial branches of the axillary vein are divided
and ligated with 3-0 silk sutures. As the vein
is cleared laterally to medially, the next step
is to identify the thoracodorsal bundle. The
thoracodorsal vein is usually the first deep
branch off of the axillary vein as one moves
medially. The artery is often seen in close proximity. At this point, the nerve is not typically
running with the vein, but rather located more
medially (Fig. 13–14). It will eventually join
the vein and artery as they course toward the
latissimus dorsi muscle. Once the entire bundle is identified, the fibrofatty tissue can be
cleared from the neurovascular structures so
that they may be seen entering the latissimus
dorsi muscle. Although this portion of the dissection may be deferred until the end of the
case, with the optimal exposure it is worth
completing. During this dissection, it is important not to divide this tissue to reveal the bundle, but rather retract the tissue medially and
dissect it off of the underlying subscapularis,
sparing the thoracodorsal bundle. Otherwise
the node-bearing tissue between the latissimus
dorsi muscle and the thoracodorsal bundle is
left behind.
As the thoracodorsal vein is cleared, a
branch is noted heading toward the chest wall.
This “crossing branch” can often provide a
clue to the location of the long thoracic nerve.
Some surgeons will routinely follow this
branch to the serratus anterior at this point
in the dissection to identify the long thoracic.
Others identify the long thoracic after the dissection of the level II nodes. Either way is
acceptable, but regardless of when the long
thoracic is identified, this crossing branch
should be preserved.
For a level I and II dissection, the pectoralis
minor muscle must be raised to allow access
to the level II nodes. Division of the fascia
and ligation of the external mammary vessels
found near the lateral border of the pectoralis
Pectoralis major
and minor
mm.
Long
thoracic
nerve
Serratus
anterior m.
Intercostobrachial
nerve
Latissimus
dorsi m.
Teres major m.
Thoracodorsal
neurovascular
bundle
Subscapularis m.
Figure 13–14. The thoracodorsal neurovascular bundle is seen laterally. Near the axillary vein, the thoracodorsal nerve is more medial than the artery and vein. As they course toward the latissimus dorsi, they are in
closer proximity. (From Roses D. Breast cancer. Philadelphia: Elsevier, 2005.)
19513—REGIONAL MANAGEMENT OF BREAST CANCER
minor muscle allows for mobilization. Again,
care is taken not to injure the medial pectoral
nerve. The pectoralis minor is then retracted
upward and medially to allow removal of the
nodes beneath it. This is greatly facilitated by
rotation of the arm medially. The exposure of
the axillary vein can then be continued under
the pectoralis minor muscle with inclusion of
this fibrofatty tissue with the specimen. During this portion of the dissection, an aggressive
use of suture ligation should be employed to
avoid bleeding in a difficult to visualize area.
In the patient with grossly involved lymph
nodes, especially when level II involvement is
suspected, a level III dissection should be
included. This can be accomplished by dividing the pectoralis minor muscle near its origin.
This should be done distal to the pectoral
nerve so that innervation to the pectoralis
major is preserved. With this added exposure,
the node-bearing tissue medial to the pectoralis minor (the level III nodes) are easily
included in the specimen.
The axillary contents are now dissected from
medial to lateral off of the serratus anterior
muscle. During this portion of the dissection,
the medial aspect of the intercostobrachial
nerve is identified, and the entire nerve can
be freed from the specimen if the decision
was made to preserve it. The long thoracic
nerve is also identified. Unless disturbed by
previous axillary surgery or tumor, the long
thoracic nerve is in the same anteroposterior
plane as the thoracodorsal nerve (Fig. 13–15).
Knowing where the thoracodorsal nerve is will
help the surgeon identify the long thoracic.
The crossing branch of the thoracodorsal vein
will serve the same purpose. The most common mistake is to look for the nerve directly
on the serratus anterior, thus actually retracting the nerve into the specimen. The nerve is
actually a few millimeters off of the muscle in
the encapsulating fascia. Once identified, it is
cleaned off along its length. With the intercostobrachial, thoracodorsal, and long thoracic
nerves identified and cleared, all that remains
is to free the axillary contents from the underlying subscapularis muscle between the
nerves. With both nerves visualized, the tissue
between the nerves may be clamped at the
inferior margin of the vein and suture ligated.
The tissue may now be dissected free from
the muscle. It is important not to rush through
this portion because excessive retraction of the
Intercostobrachial
nerve
Medial
pectoral
nerve
Pectoralis
major and
minor mm.
Serratus
anterior
mm.
Subscapularis m.
Figure 13–15. After completion of the axillary dissection, the relationship of the nerves can be seen. The
intercostobrachial nerve can be identified and preserved. The long thoracic nerve is identified slightly lateral
to the serratus anterior, in the encapsulating fascia. The long thoracic nerve is in the same anteroposterior
plane as the thoracodorsal nerve, so knowing where the thoracodorsal nerve is will help the surgeon identify
the long thoracic. (From Roses D. Breast cancer. Philadelphia: Elsevier, 2005.)
Long thoracic nerve
Thoracodorsal nerve
Thoracodorsal vein
Thoracodorsal artery
Latissimus dorsi m.
Teres major m.
196 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
specimen inferiorly can pull either the thoracodorsal or long thoracic nerve into the specimen and lead to an inadvertent injury. The
nerves should be visualized throughout this
portion of the dissection.
Once the specimen is removed, hemostasis
is assured and a closed suction catheter is
placed through a separate incision lower on
the chest wall. Do not place this stab incision
too far posterior because this will inconvenience the patient. The drain is secured with
a Nylon suture and attached to a suction reservoir. The wound is closed with absorbable subcutaneous sutures and the skin may be
reapproximated with a subcuticular stitch or
tissue adhesive.
Postoperative Care
The patient is discharged after being instructed
on drain management (Box 13-5). The patient
should be taught to care for the drain and to
record the amount of drainage. When the volume in the reservoir is less than 30 ml/24 hours,
the drain can be removed. All patients will have
some limited abduction of the shoulder after
ALND, but this will return to normal with routine exercises or physical therapy once the
wound is completely healed. Some patients will
completely avoid use of the arm or keep the arm
in a sling after the operation. This should be
strongly discouraged because this can result in
capsular contracture and a frozen shoulder.
Exercises are given to the patient to encourage
mobility; some are to be performed immediately, and others to be included after the drain
is removed. Physical therapy may be necessary
to return to a full range of motion. An orthopaedic consult may be needed in those rare cases in
which full range of motion does not return with
physical therapy.
Management of the Internal Mammary Lymph Nodes
The breast drains predominantly to the axillary lymph nodes, but also drains to the supraclavicular, infraclavicular, cervical, and IMNs.
Anatomically, 75% of the breast lymphatics
drain toward the axilla, and 25% drain into the
IMNs. Going back to the early part of the last
century, attempts to improve on the Halsted
radical mastectomy included attempts to include
the IMN with the resection (known as the
extended radical mastectomy [ERM]). This failed
to improve survival, and momentum shifted
toward less radical surgery, the MRM. The
ERM did, however, give us information on
the incidence of IMN metastases in breast
cancer. Contrary to what many surgeons
believe, metastases to the IMN do not come
only from the inner quadrants of the breast,
but rather from all quadrants. The likelihood
of IMN drainage does decrease as one moves
from medial to lateral. Overall, there appears
to be a low risk of metastases to the IMN in
the absence of metastases in the axillary
lymph nodes. In a study of over 7000 patients
who had ERM, the overall incidence of IMN
metastases was 22%, but only 10% when the
axillary lymph nodes were negative. Of those
patients with negative axillary nodes, the risk
of IMN metastases for medial lesions was
14%, but only 6.5% for lateral lesions.
Given the morbidity of IMN dissection and
the low likelihood of finding disease in the
IMNs that would change adjuvant chemotherapy decisions, few surgeons advocated routine
IMN biopsy for breast cancer. However, with
the advent of SLN biopsy, the question of
how to best handle the IMN has returned.
Lymphatic mapping with lymphoscintigraphy may identify IMN in as high as 25% of
cases, depending on the method of injection
of the Tc99. When Tc99 is injected peritumorally, there will be drainage to the axilla in
99% of cases. In 76%, this is the only drainage.
In 10%, there is primary drainage to the axilla
with secondary drainage to the IMNs. In 5%
there was drainage to the IMNs primarily, with
secondary drainage to the axilla. The remaining cases include combinations of drainage to
the axillary, IMNs, and clavicular lymph
nodes. Other studies have shown slightly
higher rates of IMN-only drainage, as high as
4%. However, if the Tc99 is injected in a subareolar or intradermal manner, drainage to the
IMNs is a relatively rare occurrence.
Studies of IMN metastases in the age of SLN
biopsy show patterns similar to that in the age
of the ERM, with metastases in the IMNs in
27% of patients who have axillary node metastases but only in 7% of patients who are negative in the axilla. As one would expect, the
presence of disease in the IMNs is independently prognostic. Patients tumor-free in both
basins have a higher survival than that of
patients with disease in either the axillary or
IMNs. The survival is the lowest for patients
with disease in both basins.
Whether or not to biopsy these nodes if they
light up on lymphoscintigraphy remains controversial. Unidentified disease in the IMNs
BOX 13–5 PATIENT INSTRUCTIONS ON DRAIN MANAGEMENT
Care of Your Drain
After your surgery you will go home with a bulb drain in place. The drain will remove fluid that
builds up under your wound to promote healing. The drain generally does not cause pain.
1. For the first 3 days, it is recommended that you clean the area where the drain tubing
enters your body and change the gauze. Clean the insertion site using cotton-tipped
swabs and a solution of one-half water and one-half peroxide.
2. Apply a clean drain sponge around the insertion site daily. You may it more often if it
becomes heavily soiled.
3. After 2 days you may shower or gently wash the area where the drain tubing enters
your body.
4. You may use nonperfumed soaps (Ivory or Neutrogena).
5. Always pat dry, never rub.
6. Reapply gauze after cleansing.
7. Women should continue to wear their bra.
Notify your doctor or the breast care center if:
The reservoir cannot be reactivated (it quickly reexpands).
The drain falls out or the stitch holding the drain tube comes out.
The drainage fluid in the reservoir becomes foul smelling.
You have a fever or there is any increased redness, swelling, or drainage from the site.
There is an air leak, fluid leak, or malfunction of the drain bulb.
Clots form in the tubing and block drainage and cannot be cleared by “milking” the drain
tubing.
Emptying the Drain (Reservoir)
You will need to empty and reactivate the drain bulb (reservoir). You will also need to record the
amount of fluid collected in the reservoir. Empty the reservoir as many times a day as directed by
your doctor or nurse or if full. Wash your hands before and after handling the reservoir. Empty the
reservoir into the measuring container when the fluid collected reaches the 100 ml mark or before.
Do not let the reservoir completely fill because the drainage will stop.
Keep a record of the amount of fluid collected in the reservoir. Record the date, time, and amount
of fluid that has accumulated from each reservoir. If the drainage stops within the first few days after
your surgery there may be a clot in the drain tubing. Try milking or “stripping” the drain if this is
the case.
Attach the reservoir (using the plastic strap) to your bra or shirt, usually with a safety pin. Do not
disconnect, kink, or puncture the tubing that is connected to the reservoir. You will notice the
amount of drainage decreasing over time. The color of the drainage will also lighten over time.
Milking or Stripping the Drain Tubing
To keep the drain working well you will be shown how to milk the drain tubing three times per day.
You should always wash your hands before handling the drain.
Grasp the tubing close to your body with one hand and pull toward your body.
With your other hand, grasp the tubing below the first hand.
Using an alcohol swab, pinch tubing tightly, sliding your fingers down the tubing and
away from your body, repeat this two or three times.
Be sure that the drainage is flowing into the bulb. It is okay if the tube becomes flat
from the suction. Never disconnect the tubing from the bulb at any time.
19713—REGIONAL MANAGEMENT OF BREAST CANCER
198 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
could potentially account for the poor progno-
sis of patients falsely labeled as node negative
based on the axillary sentinel node. Identify-
ing disease in the IMNs could potentially
upstage patients and change adjuvant therapy
decisions, especially for patients with smaller
tumors who, based on T stage alone, would
not receive chemotherapy if their axillary
nodes were negative. In addition, the presence
of microscopic disease in the IMNs might
change the radiation fields to include the
internal mammary chain, although this is
associated with increased morbidity. Excising
sentinel nodes from the IMN that harbor
microscopic disease might also decrease the
risk of parasternal recurrences. For these rea-
sons, some surgeons advocate the routine
biopsy of these nodes when performing SLN
biopsy. If this is to be done, peritumoral injec-
tions of Tc99 are mandatory.
On the other hand, the increasing use of
chemotherapy for patients who are node negative and the availability of Oncotype DX to
make adjuvant therapy decisions (see Chapter
16) lessens the impact of a positive IMN on
decision making. The decision to radiate the
IMN is often made on the tumor size, location,
and presence of disease in the axillary nodes.
Recurrent disease in the IMN is not a common
occurrence. Given the additional morbidity of
excising an internal mammary SLN, including
the risk of pneumothorax, many surgeons opt
not to go after SLN in the IMN, and inject the
Tc99 in a manner that is unlikely to demonstrate IMN drainage on lymphoscintigraphy.
Internal Mammary Sentinel Lymph Node Biopsy
The internal mammary lymph node biopsy
often takes breast and general surgeons outside
their area of comfort. For surgeons who feel
that biopsy of the IMN should be performed
when the lymphoscintigraphy shows uptake,
but do not feel comfortable performing the
procedure themselves, it is not unreasonable
to do so in conjunction with a thoracic surgeon. The drawback to this approach is obviously that of scheduling because it is usually
not known whether the thoracic surgeon is
needed until the day of (or night before) the
surgery.
The internal mammary sentinel node can be
excised through the same incision as the mastectomy, and in many cases, (because most
tumors that drain to the IMNs are medial)
the lumpectomy incision. In the rare case in
which a more lateral tumor drains to the
IMNs, a separate incision can be made parallel
to the sternum, approximately 3 cm from the
lateral sternal margin. The pectoralis muscle
needs to be exposed for approximately 2 to
3 cm over the interspace identified by the
gamma probe. When performing the biopsy
through a lumpectomy incision, this may
require raising the breast parenchyma off of
the underlying muscle.
The pectoralis major muscle fibers are split
to expose the superior intercostal space, exposing the external and internal intercostals muscles. These need to be divided transversely
from the sternal border for approximately 3
to 4 cm. The two potential injuries during this
part of the procedure are to the anterior intercostal vessels and to the inferior parietal
pleura, leading to pneumothorax. The vessels
course along the inferior aspect of each rib
and are avoided by dividing the muscles in
the middle. Care must be taken not to injure
the parietal pleura when dividing the internal
intercostals muscle. If it does occur, it can be
closed with a fine absorbable suture, and postoperative chest tubes are rarely necessary.
After dividing the intercostals, the internal
mammary vessels should be identifiable. The
artery is approximately 1 to 1.5 cm from the
lateral sternal border. They are located in an
extrapleural space, surrounded by fibrofatty
tissue and lymphatics. This tissue is divided
and small vessels coagulated. A vessel loop
should be placed around the artery and vein
(either together or separately). This not only
helps keep the vessels in view, but it helps prevent major bleeding in the case of accidental
transection. While encircling the vein, coagulation or clipping of some small venous
branches might be needed.
If excessive bleeding from the vein occurs, it
can be ligated. The artery should be preserved
in case it is needed in the future for pedicled
transverse rectus abdominis myocutaneous
(TRAM) flap reconstruction or coronary artery
bypass graft (CABG). However, if transection
does occur, the rib may need to be either disarticulated or transected to obtain control.
Once the vessels are controlled, the probe is
used to identify the node within the surrounding adipose tissue. The SLN may be either
medial or lateral to the vessels. The node is
excised, taking care to clip or coagulate the
small surrounding vessels.
The wound is irrigated and on the final irrigation, the water left within the wound and
observed for small air bubbles that would be
19913—REGIONAL MANAGEMENT OF BREAST CANCER
indicative of an injury to the pleura. The fibers
of the pectoralis muscle are reapproximated
using 2-0 Vicryl sutures, although pulling
these too tightly will transect the muscle
fibers. If the procedure was performed through
a lumpectomy incision, the breast parenchyma can be reapproximated to restore the
shape of the breast.
In the recovery room, a chest x-ray should
be obtained to rule out a pneumothorax, if
there is any question regarding the pleura.
Internal Mammary Node Dissection
An internal mammary node dissection is an
extremely rare operation, typically done in conjunction with a mastectomy when there are
grossly involved internal mammary lymph
nodes. The surgeon identifies the attachment
of the pectoralis major muscle to the sternum
and the first rib. In the first intercostals space,
the medial fibers of the pectoralis major are
split, and the intercostal muscles are identified
(Fig. 13–16). The intercostal muscles are divi-
ded from the sternal border to about 3 cm laterally. Underneath this, the internal mammary
vessels can be identified. These are ligated.
The fifth rib is then identified, and the intercostal space between the fifth and sixth rib is
entered in a similar manner, identifying the
internal mammary vessels and ligating them.
A tunnel can be established underneath the
pectoralis major muscle. A sternal knife is
placed into the first interspace, directed medially to the mid sternum, and directed down
through the mid sternum to the level of the
fifth intercostal space, and then directed laterally to come out in the fifth intercostal space.
The chondral portion of the second, third,
fourth, and fifth ribs are transected lateral to
Internal
thoracic artery,
vein, and nodes
Figure 13–16. The internal mammary nodes. (From Bloom N, Beattie E, Harvey J. Atlas of cancer surgery.
Philadelphia: Elsevier, 2000.)