Breast

Question 1

Partial Mastectomy with SLN Bx

Answer 1

1- Preoperative coordination with radiology and nuclear medicine for breast lesion and axillary node localization (US or stereotactic guided needle loc pre op or nuclear injection of T-99 radioactive tracer or titanium seed marker)
2- Peri or subareolar blue dye injection and breast massage (methylene blue or isosulfan blue) + radioactive colloid injection
3- Partial mastectomy incision placement with consideration of the potential need for later mastectomy (curvilinear or transverse above nipple, radial below nipple)
4- Intraoperative utilization of localization techniques in addition to palpation (US, needle loc, radioactive seed/tracer)
5- Excise the localized lesion with grossly normal 1-cm margins.
6- Orient specimen and image to ensure the wire, clip, and lesion or calcifications are in the specimen.
7- Axillary sentinel lymph node identification via dual-agent method
8- Removal of all axillary nodes with gamma radiation count ≥10% of sentinel lymph node
9- Aggressive hemostasis with electrocautery
10- Inspection of specimen radiograph for biopsy clip, calcifications, and margin status ( can opt for intraop fresh frozen or additional border shavings to reduce rate of positive margins)

Potential Pitfalls
Lack of identification of the sentinel node- proceed with ax dissection level 1/2

Question 2

Mastectomy

Answer 2

Orient elliptical incision to include nipple–areolar complex, previous biopsy site, and overlying skin.
Use electrocautery and gentle traction to develop the connective tissue plane superficial to the breast parenchyma in creation of the skin flaps.
Dissection borders are superiorly to the clavicle, medially to the lateral border of the sternum, inferiorly to the anterior rectus sheath, and laterally to the anterior border of the latissimus dorsi muscle.
Remove the breast from the pectoralis muscle, including the pectoralis fascia.
Perform sentinel lymph node biopsy utilizing the same incision.
Ensure hemostasis, place drain, and close.

Potential Pitfalls

Skin flaps: Overly thin flaps can lead to ischemia, necrosis, and poor wound healing.Overly thick flaps may leave behind too much breast parenchyma.
Wound closure in large resection specimens requiring undermining or grafting.

Question 3

Axillary LN dissection

Answer 3

-Free draping of the arm in order to allow manipulation during the procedure.
-Incision at the posterior edge of the pectoral fold inferior to the axillary hairline.
-Creation of skin flaps medially, laterally, inferiorly, and superiorly.
-Incision of clavipectoral fascia and identification of the axillary vein by following the latissimus dorsi superiorly until it turns tendinous and is crossed by the vein.
-Identification and preservation of the thoracodorsal neurovascular bundle (branches from axillary vein).
-Identification and preservation of the long thoracic nerve (lateral border serratus anterior).
-En bloc removal of all level I and II lymph nodes as defined by the pectoralis minor muscle (lateral and posterior to muscle).
Palpation of level III nodes and Rotter’s node with potential excision if suspicious (medial to lateral edge of pectoralis minor)
Hemostasis.
Placement of a drain.
Closure of the clavipectoral fascia and skin.
Potential Pitfalls
Injury to the thoracodorsal or long thoracic nerves leading to weakened arm adduction and/or winged scapula.
Injury to the axillary vein potentially causing bleeding and hematoma and increasing the risk of upper extremity lymphedema.
Injury to the brachial plexus from dissection that is too high (above the axillary vein).