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3 BREAST, SK IN , AND SOFT T ISSUE

ACS Surgery: Principles and Pract

5 BREAST PROCEDURES —

D. Scott Lind, M.D. , F.A.C.S. , Barbara L. Smith, M.D. , Ph.D. , F.A.C.S. , and Wiley W. Souba, M.D. , Sc.D. , F.A.C.S.

5 BREAST PROCEDURES

The procedures used to diagnose, stage, and treat breast disease

are rapidly becoming less radical, less invasive, and, possibly, more

precise. Breast imaging procedures—such as mammography,

ultrasonography, and magnetic resonance imaging—are playing

increasingly important roles in management, and any surgeon cur-

rently treating patients with breast disease should have a working

knowledge of all of these modalities. In many surgical practices,

breast ultrasonography and ultrasound-guided biopsy are now

routinely performed. Ductoscopy and ductal lavage, though less

well established than ultrasonography, are nonetheless promising:

their predictive value and clinical utility are not yet clearly defined,

but it appears that they can provide important information regard-

ing the status of the breast duct epithelium.1 Excisional breast

biopsy has largely been supplanted by fine-needle aspiration(FNA) biopsy for palpable breast lesions and by percutaneous

biopsy for nonpalpable breast lesions. Stereotactic and ultra-

sound-guided core-needle biopsies are less invasive and less cost-

ly alternatives to open surgical biopsies for most patients with non-

palpable breast lesions from which tissue must be acquired.2

Breast conservation has supplanted mastectomy for local

breast treatment in most patients. Updates of multiple prospec-

tive, randomized trials involving thousands of breast cancer

patients continue to demonstrate that survival after lumpectomy

and radiation therapy does not differ significantly from survival

after mastectomy.3 Local recurrence rates after lumpectomy and

radiation therapy range from 3% to 10%, depending on selection

criteria. Even though most women with breast cancer are candi-

dates for breast conservation, some either require or prefer mas-tectomy. Advances in reconstructive techniques have led to sig-

nificantly improved outcomes after breast reconstruction.4 In

addition, management of the axilla has changed dramatically

since the early 1990s, and sentinel lymph node (SLN) biopsy has

virtually replaced routine axillary dissection.5 Finally, various per-

cutaneous extirpative and ablative local therapies have been

developed for managing breast cancer in certain carefully select-

ed patients.The roles of these therapies remain to be defined, and

investigations are currently under way.6

In what follows, we describe selected standard, novel, and inves-

tigational procedures employed in the diagnosis and management

of breast disease.The application of these procedures is a dynam-

ic process that is shaped both by technological advances and by

our evolving understanding of the biology of breast diseases.

Breast Ultrasonography

The increased use of breast ultrasonography has paralleled the

augmented use of screening mammography.7 Unlike mammog-

raphy, however, ultrasonography is not an effective screening tool;

it is mainly used in the office setting for further characterization

and biopsy of breast masses and suspicious axillary nodes.

Ultrasonography is

particularly useful for differentiating cystic from solid breast

lesions.Sonographically, simple cysts tend to be oval or lobulated

and anechoic, with well-defined borders. Solid masses are char-

acterized sonographically with respect to shape, compressibility,

height-width ratio, margins, internal echo pattern, and pres

of shadowing versus posterior enhancement. Carcinomas are

ically hypoechoic masses that are taller than they are wide,

irregular borders and broad acoustic shadowing. As with m

mography, however, some malignancies cannot be visualized

ultrasonography, and thus, all clinically suspicious breast ma

should undergo biopsy.

In the operating room, ultrasonography can help the surg

locate and excise nonpalpable breast lesions and achieve c

lumpectomy margins. It is also being used to guide various in

tigational tumor-ablating procedures [see Minimally Inva

Ablative Techniques, below].

TECHNIQUEMost real-time ultrasound imaging is performed with ha

held probes generating frequencies of 7.5 to 10 MHz. The

cedure is conducted with the patient supine and a pillow beh

the shoulder.The outer breast quadrants are best visualized

the ipsilateral arm extended over the head. Application of so

graphic transmission gel between the transducer and the

reduces air artifacts, and slight compression of the transd

improves image quality. The entire breast and axilla should

imaged, usually in a radial pattern outward from the nip

Lesions may also be viewed in several planes but should be c

acterized in at least two orthogonal planes.

Many interventions done on the breast and the axilla can

performed under ultrasonographic guidance, including F

core-needle biopsy, and wire localization. Intraoperative usonography can also assist in the identification and remova

nonpalpable masses and can reduce the miss rate with nee

localized excisional breast biopsy. Ultrasonography can also

used to guide biopsy of clinically suspicious axillary lymph no

so as to better identify patients who are likely to benefit from n

adjuvant therapy.

Breast Duct Visualization and Epithelial Cell Sampling

DUCTOSCOPY

Advances in endoscopic technology have made visualiza

and biopsy of the mammary ducts possible. Mammary

toscopy is a procedure in which a microendoscope is employevisualize the ductal lining of the breast directly and to pro

access for retrieval of epithelial cells by means of lavage. At

sent, this technology is only available at a few centers, and as

all new technological developments, there is a learning c

associated with its application.

Ductoscopy is currently being evaluated for use in three m

areas: (1) evaluation of patients with pathologic nipple discha

(2) evaluation of high-risk patients, and (3) evaluation of br

cancer patients to determine the extent of intraductal dis

and, perhaps, define the extent of resection more preci

Further study will be required to determine the precise rol

this investigational technique in the evaluation and managem

of breast disease.




3 BREAST, SK IN, AND SOFT T ISSUE

ACS Surgery: Principles and Practice

5 BREAST PROCEDURES — 2

Technique Patients may undergo mammary ductoscopy

either in the office setting or in the OR with minimal discomfort.

The initial experience with ductoscopy involved the use of cum-

bersome rigid systems; however, newer systems are now com-

mercially available that are small in diameter (0.9 mm) and have

an outer air channel on the fiberscope, which permits instillation

and collection of saline to retrieve cells from the ductal system.8

Before the procedure, a nipple block is usually performed withtopical lidocaine cream,supplemented (if necessary) by intrader-

mal injection of 1% lidocaine around the nipple-areola complex,

by intraductal instillation of lidocaine after cannulation of the

duct, or by both.The breast is massaged to promote expression

of nipple aspirate fluid and to facilitate visual identification of a

ductal orifice.The ductal opening is then gently dilated, and the

mammary ductoscope is advanced with the help of insufflation

under direct visualization. Most ducts are readily identified and

can be dilated sufficiently to allow passage of the ductoscope.

The procedure is usually well tolerated.

DUCTAL LAVAGE

The majority of breast cancers originate from the epithelium of

the mammary ducts. Ductal lavage is a method of recoveringbreast duct epithelial cells for cytologic analysis via a microcatheter

that is inserted into the duct. It has several promising potential

applications, such as identifying high-risk women, predicting risk

with the help of molecular markers, monitoring the effectiveness

of chemopreventive agents as evidenced by regression of cellular

atypia, and delivering drugs directly into the ducts. At present,

however, ductal lavage remains investigational, and its predictive

value and clinical utility await further definition.9

Technique The breast duct epithelium may be sampled by

means of either nipple fluid aspiration or ductal lavage. In nipple

fluid aspiration, the nipple is scrubbed with a dekeratinizing mild

abrasive gel after the application of a topical anesthetic, a suction

device is applied to the nipple, the nipple and breast are gentlymassaged, and the fluid recovered is sent for analysis. In ductal

lavage, the nipple duct orifice is cannulated, the duct is irrigated

with saline, and the effluent is collected for cytologic analysis.

Cannulation of the duct is possible in the majority of women.

Both nipple fluid aspiration and ductal lavage are generally well

tolerated.The former is simpler and less expensive, but the latter

retrieves more cells.10

Breast Biopsy

OPTIONS FOR PALPABLE MASSES

Cytologic or tissue diagnosis of a palpable breast mass may be

obtained by means of FNA biopsy, core-needle biopsy, or openincisional or excisional biopsy. Needle biopsy techniques are less

invasive, less costly, and more expeditious than open biopsy but

are significantly more likely to yield false negative results. The

choice of a biopsy technique should be individualized on the basis

of the clinical and radiographic features of the lesion, the experi-

ence of the clinician, and the patient’s condition and preference.

Fine-Needle Aspiration Biopsy

FNA biopsy permits the sampling of cells from breast lesions

for cytologic analysis. It is an appropriate first step in the evalua-

tion of dominant breast masses, but it requires substantial expe-

rience on the part of both the operator and the cytopathologist.

FNA biopsy is usually the diagnostic procedure of choice for T3

and T4 primary lesions, as well as chest wall and axillary recur-

rences for which systemic chemotherapy or irradiation is indicat-

ed as the first treatment modality. Because of sampling error, the

procedure is less useful in evaluating small masses and areas of

vague thickening or nodularity. In addition, it often cannot reli-

ably distinguish invasive from noninvasive cancer.

Discrete masses discovered on physical examination may be

either cystic or solid. Unless previous ultrasonographic examina-tion has shown the mass to be solid, the needle used should be

large enough to permit aspiration of potentially viscous fluid if

the lesion proves to be cystic (i.e., 20 or 21 gauge). If the mass is

known to be solid, a smaller needle (22 to 25 gauge) is sufficient

for obtaining diagnostic tissue and will cause the patient less dis-

comfort. For sufficient suction to be generated, a syringe with a

capacity no smaller than 10 ml should be used. A variety of

syringe holders are available that facilitate application of suction

with a single hand.

Technique Once informed consent is obtained, the skin of

the breast is prepared with alcohol or iodine, and the lesion that

is to undergo biopsy is held steady between the thumb and the

index finger of the nondominant hand.A local anesthetic is usu-ally not necessary; if it is used, it should be injected so as to cre-

ate only a small skin wheal, so that there will be minimal distor-

tion of the approach to the lesion.To facilitate visualization of the

collected sample, 1 to 2 ml of air is introduced into the biopsy

syringe before the needle enters the skin.The tip of the needle is

advanced into the lesion before any suction is applied to mini-

mize collection of tissue outside the lesion. Once the tip is in

place, strong suction is applied, and the needle is moved back

and forth within the lesion repeatedly along a 5 to 10 mm long

track to loosen and collect cells. (This oscillation of the needle

along the same track is the most effective way of obtaining a cel-

lular, diagnostic specimen.) The back-and-forth movement of

the needle within the lesion is continued until tissue becomes vis-

ible in the hub of the needle. Suction is released while the needleis still within the lesion (again, to prevent collection of contami-

nating tissue from outside the lesion).

The needle is then withdrawn from the lesion,and its contents

are expelled onto prepared glass slides, spread into a thin smear,

and fixed according to the preferences of the cytology laborato-

ry. Additional passes through the lesion may be made to ensure

that a sufficiently cellular sample has been obtained, and the

syringe may be rinsed so that a cell block can be prepared for fur-

ther analysis.An adhesive bandage is applied to the biopsy site. If

the lesion proves to be cystic, all fluid should be aspirated; this

should cause the mass to disappear. The fluid need not be sent

for analysis unless it is bloody or a palpable mass remains after as

much fluid as possible has been aspirated. If the fluid is to be sent

for analysis, it is injected directly into the pathologic preservative.The patient is reexamined 4 to 8 weeks after successful aspi-

ration. If the same cyst has recurred, it should be aspirated again

and the fluid sent for cytologic analysis.

Interpretation of results Analysis by an experienced

cytologist is critical for accurate interpretation of FNA biopsy

results. Many cytology laboratories are able to perform immuno-

histochemical analysis for hormone receptors on FNA specimens

if an appropriate fixative has been used. In most cytology labs,

the false positive rate for a diagnosis of malignancy in an FNA

biopsy of a breast mass is only 1% to 2%.11 Thus, a diagnosis of

malignancy that is based on cytologic analysis of an FNA speci-

men may generally be believed, and definitive surgery may be




3 BREAST , SK IN , AND SOFT T ISSUE



planned without further biopsy. Because FNA biopsy does not

distinguish between invasive and in situ breast cancer, intraoper-

ative frozen section should be performed if necessary to deter-

mine the need for axillary dissection.

The false negative rate for identifying breast malignancy, how-

ever, is high: FNA fails to diagnose as many as 40% of cancers.11

Any cellular atypia on FNA biopsy is an indication for open biop-

sy. A diagnosis of normal or fibrocystic breast tissue should alsobe viewed with suspicion; subsequent open biopsy is usually indi-

cated if the physical examination or a mammogram of the biop-

sied lesion gives rise to even a minor degree of concern about

malignancy. If the cytologic analysis is diagnostic of a specific

benign lesion (e.g., a fibroadenoma or a lactating adenoma), it

may generally be relied on if it is in concordance with the clinical

features of the lesion, and no further workup is necessary. If the

evaluation is nondiagnostic, either aspiration should be reat-

tempted or core-needle or excisional biopsy should be performed.

If the FNA biopsy results are negative, core-needle or excisional

biopsy should be done unless it is also the case that the physical

examination suggests a benign lesion and the mammogram is

normal (the so-called triple negative criteria). It has been sug-

gested that no further workup is required when the triple negativecriteria are present, particularly in younger women.

Core-Needle (Cutting-Needle) Biopsy

In contrast to FNA biopsy, core-needle biopsy removes a nar-

row cylinder of tissue that is submitted for standard pathologic

rather than cytologic analysis; consequently, this technique is

preferable if a skilled cytologist is not available for interpretation

of FNA biopsy specimens. Core-needle biopsy is highly accurate

when successful targeting of the lesion is confirmed by means of

breast imaging.12 The technical difficulty of accurately placing

and firing the core needle in small mobile lesions or in lesions sur-

rounded by dense fibrocystic tissue makes other biopsy tech-

niques preferable in these settings. Core-needle biopsy is, howev-

er, ideal for sampling large lesions or chest wall recurrences; thelarger samples permit more detailed pathologic analysis and easy

determination of hormone receptor levels.

Technique If the mass is palpable, the surgeon can perform

the core-needle biopsy in the office. A large needle (usually 14

gauge) is placed either by hand or with a biopsy gun device.

Injection of a local anesthetic is usually required—again, in a

quantity that will create only a small skin wheal. A nick is made

in the skin with a No. 11 blade to permit easy entry of the biop-

sy needle into breast tissue and into the lesion. As with FNA

biopsy (see above), the lesion is held steady in the nondominant

hand while the biopsy needle is advanced into the lesion and a

core sample obtained.

Interpretation of results Atypia on core-needle biopsy is

an indication for open biopsy of the sampled lesion. In addition,

any core-needle biopsy (especially one done without stereotactic

or ultrasonographic guidance) that yields benign or fibrocystic

tissue should be viewed with some suspicion because of the risk

of technical or sampling error.Open biopsy should be considered

if there is any discordance between a benign core-needle biopsy

result and the clinical or mammographic features of the lesion.

Open Biopsy

The vast majority of open breast biopsies are now performed

with either local anesthesia alone or local anesthesia with I.V.

sedation (monitored anesthesia care [MAC]).General anesthesia

is reserved for situations in which multiple lesions must

excised and the amount of local anesthetic required would exc

the maximum safe dose.

Technique Open biopsy incisions should generally be cu

linear and should be placed directly over the lesion to minim

tunneling through breast tissue [see Figure 1]. Resection of a

tion of overlying skin is not necessary unless the lesion is extrely superficial. In case the lesion proves to be malignant, all o

biopsy incisions should also be oriented so that they can

excised with any subsequent lumpectomy or mastectomy i

sion. Accordingly, if an open biopsy is to be done at an extre

a

b

Figure 1 Open breast biopsy. (a) In most cases, a curvilinear

incision is preferred. If the mass is close to the areola, a peria

lar incision may be used. (b) Extremely lateral or medial inci-

sions may be radial. In any case, incisions should be placed

directly over the lesion and should be oriented so that they wil

included within a subsequent mastectomy incision if margins

prove positive and mastectomy is indicated.







ly lateral or medial site, it may be best approached via a radial

incision placed over the lesion rather than via a more vertical

curvilinear incision.

The incision should be long enough to provide adequate expo-

sure and to ensure that the mass can be excised as a single spec-

imen with a small margin of grossly normal tissue. The surgeon

should orient the specimen, and the pathologist should ink all

margins. Meticulous hemostasis should be achieved before clo-sure to prevent the formation of hematomas that could compli-

cate subsequent definitive oncologic resection.Deep breast tissue

should be approximated only if such approximation does not

result in significant deformity of breast contour.A cosmetic sub-

cuticular skin closure is preferred.

OPTIONS FOR NONPALPABLE MASSES

The increasingly widespread use of screening mammography

has led to the identification of more and more nonpalpable breast

masses and microcalcifications for which tissue diagnosis is

required. In most series, 15% to 30% of such lesions prove to be

malignant.12-14 Nonpalpable masses and microcalcifications may

be approached via core-needle biopsy or open biopsy with wire

localization.

Image-Guided Core-Needle Biopsy

Needle biopsy techniques are increasingly being used to diag-

nose nonpalpable breast lesions. In general, FNA biopsy of non-

palpable lesions is inadvisable because of its high false negative

rate. Little is lost by attempting an FNA biopsy of a palpable

lesion in the office setting, but performing a stereotactic or ultra-

sound-guided FNA biopsy of a nonpalpable mass carries a sig-

nificant cost in terms of time, patient discomfort, and expense.

The diagnostic accuracy currently achievable with FNA biopsy in

this setting does not justify this cost. Consequently, image-guid-

ed core-needle biopsy is the preferred approach for needle biop-

sy of nonpalpable lesions.

In choosing core-needle biopsy, both patient and physicianmust be comfortable with the fact that the lesion will only be

sampled rather than excised, must recognize that the possibility of

a sampling error that will cause the examiner to miss the lesion is

higher with core-needle biopsy than with open biopsy, and must

realize that equivocal findings will necessitate follow-up with

open biopsy. The trade-off for these limitations is that core-nee-

dle biopsy generally costs less than open biopsy, takes less time,

and leaves only a tiny scar.After a core-needle diagnosis of malig-

nancy, the surgeon may proceed directly to wide local excision

and will often be able to obtain clean margins with a single open

procedure.

Stereotactic versus ultrasound-guided core-needle

biopsy Whenever feasible, core-needle biopsy is performedwith ultrasonographic guidance, which permits real-time docu-

mentation of needle position within the lesion. Stereotactic mam-

mography-guided core-needle biopsy is performed if the lesion is

not visualized ultrasonographically. Stereotactic biopsy is appro-

priate for lesions that are favorably located within the breast (i.e.,

that can be stably positioned in the biopsy window of the

machine). Lesions very close to the chest wall or the areola may

not be accessible to stereotactic biopsy and are best approached

via open biopsy with needle localization (see below).

Clustered microcalcifications may also be approached by

stereotactic core-needle biopsy. If the cluster is not large enough

for calcifications to remain to guide subsequent wide excision if a

malignancy is found, a clip should be placed to mark the biopsy

site.Alternatively, if the surgeon has experience with breast ultra-

sonography, this imaging modality may be used intraoperatively

to identify the hematoma that results from stereotactic core-nee-

dle biopsy.

Interpretation of results The introduction of large core-

biopsy needles (11 and 14 gauge), coupled with the use of vacu-

um assistance to draw additional tissue into the needle, hasmarkedly improved the false negative rate for core-needle biopsy.

Currently, false negative rates for this procedure fall into the 1%

to 2% range,13 results that compare favorably with those report-

ed for wire-localized open biopsy. It is now routine to perform

radiography of core-needle biopsy specimens to confirm that tar-

geted calcifications have been removed.When the targeted lesion

comprises dense tissue rather than calcifications, care must be

taken to confirm that the lesion was adequately sampled and thus

ensure that the findings can be interpreted reliably. Immediate

postbiopsy radiography may be performed to demonstrate that a

hole was made in the lesion.A finding of benign or fibrocystic tis-

sue on such a biopsy should be viewed with some suspicion and

interpreted in relation to the lesion sampled. One must decide

whether the pathologic findings adequately account for the lesionvisualized. If any concern remains, open biopsy is indicated.

Because false positive results are rare, a diagnosis of malignan-

cy may be believed and acted on without further biopsy. In plan-

ning treatment after core-needle biopsy that shows only carcino-

ma in situ, one should remember that the lesion was only sam-

pled and that invasive tumor may still be found when the lesion

is completely excised.The likelihood of finding invasive tumor on

surgical excision after a core-needle biopsy indicative of ductal

carcinoma may be as high as 20%.14

A finding of atypical ductal hyperplasia on core-needle biopsy

is an indication for wire-localized open biopsy. Open biopsy after

a core-needle biopsy indicative of atypical ductal hyperplasia may

reveal ductal carcinoma in situ (DCIS) in as many as 50% of

patients; this may be a less frequent finding when a larger (e.g.,11 gauge) needle was used for the core-needle biopsy.

Follow-up Whether short-interval mammographic follow-

up is necessary after core-needle biopsy depends on the patho-

logic findings and the mammographic appearance of the lesion.

With a well-circumscribed lesion that pathologic evaluation shows

to be a fibroadenoma or with calcifications that pathologic evalu-

ation shows to be located in benign fibrocystic tissue, no special

follow-up is required, and routine screening at normal intervals

may be resumed. In general, if the pathologic findings are equiv-

ocal or discordant with the appearance of the lesion, immediate

open excision is preferable to a 6-month repeat mammogram.To

ensure appropriate follow-up, there should be close communica-

tion between the physician ordering the core-needle biopsy, thephysician performing the biopsy, and the pathologist analyzing

the specimen.

Open Biopsy with Needle (Wire) Localization

As is the case for open biopsy of palpable lesions, the vast

majority of needle-localized breast biopsies are now performed

with local anesthesia or local anesthesia with intravenous seda-

tion.15 General anesthesia is reserved for excision of multiple

lesions or other special circumstances.

Technique The lesion to be excised is localized by inserting

a thin needle and a fine wire under mammographic or ultrasono-

graphic guidance immediately before operation.To facilitate inci-







sion placement, images should be sent to the OR with the wire

entry site indicated on them. With superficial lesions, the wire

entry site is usually close to the lesion and thus may be included

in the incision.With some deeper lesions, the wire entry site is on

the shortest path to the lesion and so may still be included in the

incision. The incision is placed as directly as possible over the

mass to minimize tunneling through breast tissue. Once the inci-

sion is made, a core of tissue is excised around and along the wirein such a way as to include the lesion [see Figure 2].This process

is easier and involves less excision of tissue if the localizing wire

has a thickened segment several centimeters in length that is

placed adjacent to or within the lesion.One then follows the wire

itself into breast tissue until the thick segment is reached and only

then extends the excision away from the wire to include the lesion

in a fairly small tissue fragment.

With many lesions, the wire entry site is in a fairly peripheral

location relative to the position of the lesion, which means that

including the wire entry site in the incision would result in exces-

sive tunneling within breast tissue. In such cases, the incision is

placed over the expected position of the lesion [see Figure 3], the

dissection is extended into breast tissue to identify the wire a few

centimeters away from the lesion itself, and the free end of thewire is pulled up into the incision. A generous core of tissue is

then excised around the wire. Again, this process is easier if the

thick segment of the localizing wire is placed adjacent to or with-

in the lesion.

Radiography should immediately be performed on all w

localized biopsy specimens to confirm that the lesion has b

excised.The patient should remain on the operating table with

sterile field preserved until such confirmation has been receive

the mass was missed and the surgeon has some idea of the li

location of the missed lesion, another tissue sample may be exc

immediately. If, however, the surgeon suspects that the wire

dislodged before or during the procedure, the incision shoulclosed. After the patient has healed sufficiently to be able to t

ate repeat mammography, another mammogram is obtained,

repeat localization and biopsy are performed.

Directional Vacuum-Assisted Breast Biopsy (Mammotomy)

Directional vacuum-assisted biopsy (DVAB), or mammoto

is a special procedure for obtaining specimens from single or m

tiple breast lesions (e.g.,microcalcifications, circumscribed m

es, and spiculated masses).16 DVAB is a diagnostic procedure

is not intended for therapeutic purposes. On the whole, it is

and the complication rate is acceptably low.

In comparison with core-needle biopsy,DVAB is more succ

ful at removing microcalcifications, can obtain more specimen

the course of a single procedure, and is more sensitive in detecDCIS and atypical duct hyperplasia. DVAB also appears to d

nose nonpalpable breast lesions more effectively than stereot

cally guided core-needle biopsy does. It may, in fact, be helpf

perform DVAB after core-needle biopsy when the diagnosi

a

b c

Figure 2 Needle-localized breast biopsy.15 (a) The mammographic abnormality is localized immediately

before operation.The relation between the wire, the skin entry site, and the lesion is noted by the surgeon. (b)

The skin incision is placed over the expected location of the mammographic abnormality.The dissection is

accomplished with the wire as a guide. (c) The tissue around the wire is removed en bloc with the wire and

sent for specimen mammography.Tunneling and piecemeal removal are to be avoided.



atypical duct hyperplasia is being considered; this practice may

lead to a decrease in the number of open biopsies performed.

Suitable candidates for DVAB include patients with nonpalpa-

ble but mammographically visible clusters of suspicious calcifica-

tions, those with well-defined masses that are likely to be benign,

and those with suspicious masses.Target lesions must be clearly

visible on digital images and identifiable on stereotactic projec-tions. DVAB is not recommended for patients with certain lesions

located very posteriorly or very anteriorly in the breast, those with

very small or very thin breasts, and those who, for one reason or

another, cannot be properly positioned for the procedure or can-

not cooperate with the surgeon.The procedure is done on an out-

patient basis and usually can be completed in 1 hour or less.

Patients are restricted from engaging in strenuous activity for 24

hours after DVAB.

The probe employed for the procedure consists of an outer tro-

car cannula,a sliding inner hollow coaxial cutter,a so-called knock-

out shaft, a distal sampling notch, and a proximal tissue retrieval

chamber; in addition, it has a thumbwheel, which is used for man-

ual advancement, cutting, and retrieval of biopsy specimens. It

must be used under the guidance of an imaging modality (e.g.,ultrasonography or roentgenography), and it may be either

mounted or handheld. The device is connected to a suction

machine, which acts first to draw the target tissue into the sam-

pling notch and then to facilitate retrieval of tissue into the proxi-

mal collection chamber.

Stereotactic digital imaging is then performed to visualize the

target and calculate its location in three dimensions,and a suitable

trocar insertion site is identified.The skin is prepared, and a small

amount of buffered 1% lidocaine with epinephrine (usually 10 ml

or less) is administered.The skin at the insertion site is punctured

with a No. 11 blade, the probe is manually advanced to the prefire

site, and the position of the probe is confirmed by means of stereo-

tactic imaging.The device is then fired, repeatedly cutting, rotat-

ing, and retrieving samples until the desired amount has been

removed. If the lesions being removed are calcifications, the suffi-

ciency of the sampling may be confirmed through x-rays of the

specimens.

Once the biopsy is complete, an inert metallic clip is deployed

into the biopsy site through the trocar so as to mark the lesion for

future reference in case it can no longer be visualized after biopsy;

deployment and positioning are confirmed by stereotactic imaging.The biopsy device is then removed, the edges of the skin incision

are approximated with Steri-Strips, and a compressive bandage is

applied.Any bleeding occurring after removal of the biopsy device

should be controlled by manual pressure before the final bandage

is applied.Typically, 1 g of tissue (equivalent to approximately 10

to 12 samples with an 11-gauge probe) is sufficient for diagnosis of

benign disease, atypical ductal hyperplasia, or carcinoma.

Complications are uncommon. Brisk bleeding may occur dur-

ing and immediately after the procedure. Bruising and discol-

oration may result but generally resolve within days. Less fre-

quently still, hematomas may form, fat necrosis may occur, or the

patient may note a palpable lump.Caution is advisable in women

who are receiving anticoagulants. Surgical site infection has been

reported as well, but it is rare.

Terminal Duct Excision

Terminal duct excision is the procedure of choice in the surgi-

cal treatment of nipple discharge.17 Local anesthesia with or with-

out sedation (as for breast biopsy) is generally sufficient for this

procedure. The goal is to excise the duct from which the dis-

charge arises along with as little additional tissue as possible. To

this end, the surgeon should carefully note the precise position of

the discharging duct at the time of the initial examination.





a b

Figure 3 Needle-localized breast biopsy.15 (a) It is sometimes

necessary to insert the localizing wire from a peripheral site to

localize a deep or central lesion.The incision should be placeddirectly over the expected location of the lesion, not over the

wire entry site. (b) Once the skin incision is made, the dissection

is extended into breast tissue to identify the wire a short dis-

tance from the lesion.The free end of the wire is pulled into the

wound, and the biopsy is performed as in Figure 2.

Figure 4 Terminal duct excision (single duct).17 (a) A periareo-

lar incision is made. (b) The involved duct is identified by means

of blunt dissection. (c) The duct is removed along with a core of

breast tissue.

a

b

c



OPERATIVE TECHNIQUE

The patient is instructed not to attempt to express her dis-

charge for several days before operation. The breast skin is pre-

pared, and drapes are placed. The surgeon then attempts to

express the discharge so that the offending duct can be precisely

identified. If discharge is obtained, the mark for the incision

should be made at the areolar border in the same quadrant,

extending for about one third of the areola’s circumference [see

Figure 4a].A local anesthetic is then administered, the edge of the

nipple is grasped with a forceps, and a fine lacrimal duct probe

(000 to 0000) is gently inserted into the discharging duct. Anincision is then made as marked at the areolar border, the nipple

skin flap is raised, and the duct containing the wire is excised with

a margin of surrounding tissue from just below the nipple dermis

into the deeper breast tissue [see Figure 4b, c].

If it is not possible to pass the lacrimal duct probe into the dis-

charging duct, the skin incision is made and the nipple skin flap

raised as described.The surgeon then bluntly dissects among the

subareolar ducts to identify the dark, secretion-filled abnormal

duct. If the duct is identified, it is excised along its length from the

nipple dermis to a depth of 4 to 5 cm within breast tissue. An

option at this point is to incise the duct and insert a lacrimal duct

probe to facilitate identification of its course. If no single secre-

tion-filled duct is identified, the entire subareolar duct complex

must be excised from immediately beneath the nipple dermi

a depth of 4 to 5 cm within breast tissue [see Figure 5 ].

In all variants of this procedure, the electrocautery should

be used in the superficial portions of the dissection: it could c

devascularization of the nipple-areola complex and result in

electrocautery artifact that could interfere with pathologic an

sis. If the patient has a history of periductal infection, the cont

of the duct should be sent for culture and the area copiously gated with an antibiotic solution before wound closure. G

hemostasis should be obtained at the completion of the pr

dure. Breast tissue should be reapproximated beneath the ni

before skin closure to prevent retraction of the nipple or inde

tion of the areola.

Surgical Options for Breast Cancer

There are several surgical options for primary treatmen

breast cancer; indications for selecting among them are revie

elsewhere [see 3 :1 Breast Complaints]. It should be emphas

that for most patients, wide local excision (lumpectomy

microscopically clean margins coupled with axillary dissec

and radiation therapy yields long-term survival equivalent to associated with modified radical mastectomy. Currently, ind

tions for mastectomy include patient preference, inability on

part of the surgeon to achieve clean margins without unacc

able deformation of the remaining breast tissue, the presenc

multiple primary tumors, previous chest wall irradiation, p

nancy, and the presence of severe collagen vascular disease (

scleroderma). Nonmedical indications for mastectomy inc

the lack of access to a radiation therapy facility and any o

patient factors that would prevent completion of a full cours

radiation therapy.

Lumpectomy

Lumpectomy—also referred to, more precisely, as wide lexcision or partial mastectomy—involves excision of all cance

tissue to microscopically clean margins. Reexcision or lumpe

my without axillary dissection may be performed with the pat

under local anesthesia, but sedation or general anesthesia is u

ally advisable if a significant amount of tissue is to be excise

if there is tenderness from a previous biopsy. Lumpectomy

axillary dissection usually calls for general anesthesia, but it

be performed with thoracic epidural anesthesia supplemented

local anesthesia as needed.

OPERATIVE TECHNIQUE

Like open breast biopsy incisions [see Breast Biopsy, abo

lumpectomy incisions should generally be curvilinear, shoul

placed directly over the lesion, and should also be oriented sto be included within a subsequent mastectomy incision if m

gins prove positive [see Figure 1]. Extremely lateral or medial

sions may be better approached via a radial incision placed

the lesion. Because accurate assessment of margins is of cen

importance in a lumpectomy, it is critical that the incision be

enough to allow removal of the specimen in one piece rather t

several.

Along with the mass itself, it is generally necessary to remo

1 to 1.5 cm margin of normal-appearing tissue beyond the e

of the palpable tumor or, if excisional biopsy has already b

performed, around the biopsy cavity. In the case of nonpalp

lesions diagnosed via needle biopsy, the position of the le

must be determined by means of wire localization, and 2 to 3





a

b

c

d

Figure 5 Terminal duct excision (entire ductal complex).17 (a)

A periareolar incision is made. (b) The nipple skin flap is raised.

(c) The ductal complex is identified by means of blunt dissection

and transected. (d ) The entire subareolar ductal complex is

excised from immediately beneath the nipple dermis to a depthof 4 to 5 cm within breast tissue.



of tissue should be excised around the wire to obtain an adequate

margin.The specimen should be oriented by the surgeon and the

margins inked by the pathologist; this orientation is useful if reex-

cision is required to achieve clean margins. Reexcision of any

close margins may be performed during the same surgical proce-

dure if the specimen margins are assessed immediately by the

pathologist. Surgical clips may be left in the lumpectomy site

before closure to assist the radiation oncologist in planning theradiation boost to the tumor bed.

In the closure of the incision, hemostasis should be meticulous:

a hematoma may delay administration of radiation therapy or

chemotherapy. Deep breast tissue should be approximated only if

such closure does not result in significant deformity of breast con-

tour.A cosmetic subcuticular closure is preferred.

Minimally Invasive Ablative Techniques

The next step in the evolving application of less invasive tech-

niques to breast cancer is to determine whether ablative local

therapies can be effective substitutes for extirpative local thera-

pies. Cryotherapy, laser ablation, radiofrequency ablation (RFA),

and focused ultrasound ablation have all been studied as meansof eradicating small breast cancers.18 In most of these techniques,

a probe is placed percutaneously into the breast lesion under the

guidance of an imaging modality, and tumor cell destruction is

achieved by means of either heat or cold.

Cryotherapy has been successfully used for some time in the

treatment of nonresectable liver tumors. It kills tumor cells by dis-

rupting the cellular membrane during the freeze/thaw cycle.

Unfortunately, early results of studies evaluating cryotherapy in

breast cancer patients indicate that it does not always achieve

complete tumor destruction. In addition, ultrasonographic mon-

itoring of cell death may not be precise enough to allow accurate

determination of the adequacy of treatment.

Laser ablation causes hyperthermic cell death by delivering

energy through a fiberoptic probe inserted into the tumor.Because of the precise targeting required, ensuring complete

tumor destruction has proved difficult with this technique as well.

RFA is a minimally invasive thermal ablation technique in

which frictional heat is generated by intracellular ions moving in

response to alternating current.Currently, RFA appears to be the

most promising ablative method for small breast cancers. Like

cryotherapy, RFA has also been extensively used to treat liver

tumors. The RFA probe is percutaneously placed in the tumor

under imaging guidance, and a star-shaped set of electrodes is

extruded from the tip of the probe. Postprocedural MRI may help

confirm complete tumor destruction, not only after RFA but after

other ablative techniques as well.

Experience with ablative breast therapies is still relatively scant,

and these techniques remain investigational.To date, most of thestudies examining ablative breast cancer techniques have been

single-institution pilot studies involving highly selected patients

with small, well-defined lesions who do not have extensive intra-

ductal cancer or multifocal disease. In addition, these techniques

have been restricted to lesions that are neither superficial nor

deep, so as to avoid injury to the skin or the chest wall. Most of

the initial ablative series involved subsequent surgical excision to

obtain histologic evidence of cell death. Unfortunately, when

ablative therapies are used alone, the benefits of pathologic

assessment of the specimen, including evaluation of margin sta-

tus, are lost; positive surgical margins are associated with in-

creased local recurrence rates. Preliminary data from the initial

studies demonstrate acceptable short-term results, but the long-

term results must be evaluated against those of standard breast

conservation techniques.18 The minimally invasive ablative tech-

niques clearly are technically feasible, and they appear to offer

some potential advantages, but it remains to be determined to

what extent they are oncologically appropriate.

Lymphatic Mapping and SLN Biopsy

The histologic status of the axillary nodes is the single most

important predictor of outcome for breast cancer patients.

Traditionally, axillary dissection has been a routine part of the

management of breast cancer, but it has become clear that axil-

lary dissection can be associated with sensory morbidities and

lymphedema. The growing recognition of the morbidity of axil-

lary dissection, together with the increasing ability of mammog-

raphy to detect smaller and smaller node-negative tumors, gave

rise to the need for a less morbid axillary procedure. Lymphatic

mapping and SLN biopsy [see 3 :6 Lymphatic Mapping and

Sentinel Lymph Node Biopsy] is a minimally invasive method of

determining occult lymph node metastasis that is less morbid and

more accurate than axillary dissection. SLN biopsy is based on

the principle that the SLN is the first node to which tumorspreads; thus, if the SLN is tumor free, patients can be spared the

morbidity associated with axillary dissection.

The technique of SLN biopsy continues to evolve, but at pres-

ent, the most common method of identifying the SLN employs

both a vital dye and a radionuclide. Lymphatic mapping is a crit-

ical part of the procedure.A radionuclide is injected before oper-

ation, and dynamic gamma-camera imaging is subsequently

employed to delineate sites of drainage. Several series examining

various sites of injection (peritumoral, intradermal, and subareo-

lar) concluded that the breast and its overlying skin may drain to

the same few SLNs.19 In the OR, a vital blue dye is injected (usu-

ally peritumorally), and the breast is massaged to stimulate lym-

phatic flow.The surgeon then makes a small incision in the axilla

and uses a handheld gamma probe to remove lymph nodes thatare “hot” (i.e., radioactive), blue, or both. At the time of breast

surgery, the SLN can be examined by means of frozen section

analysis or touch-print cytology. If metastases are present in the

SLN, axillary dissection may then be performed.

Because SLN biopsy involves analysis of only one or two

nodes, the pathologist can carry out a more intensive pathologic

examination than would be possible with a standard axillary lym-

phadenectomy specimen containing multiple nodes.Newer tech-

niques (e.g., immunohistochemical and molecular assays) can

also be used to identify micrometastases that light microscopy

would fail to detect, but the therapeutic and prognostic signifi-

cance of tumor cells identified by such means remains unclear.20

Because there is a learning curve for SLN biopsy, the success

rate varies with the surgeon’s experience. Accordingly, it is rec-ommended that surgeons first learning the technique use axillary

dissection as a backup for the first 20 procedures to gain experi-

ence in identifying the SLN. Surgeons competent in SLN biopsy

should be able to identify the SLN with better than 85% accura-

cy and a false negative rate lower than 5%.21 Currently, axillary

dissection is recommended for patients who have a positive SLN;

however, prospective, randomized trials are required determining

to what extent this step is necessary in SLN-positive patients. A

number of studies have confirmed that the absence of metastases

in the SLN reliably predicts the absence of metastases in the

remaining axillary nodes.22-24

SLN biopsy has also been employed in DCIS patients.Women

with DCIS have high survival rates without undergoing any axil-


3 BREAST , SK IN, AND SOFT T ISSUE





lary procedure, and there is concern that indiscriminate applica-

tion of SLN biopsy to these patients may result in unnecessary

axillary dissection and subsequent systemic chemotherapy.

Therefore, SLN biopsy should be limited to (1) patients with

extensive DCIS in whom percutaneous biopsy may have missed

areas of invasion and (2) patients with extensive DCIS who are

undergoing mastectomy that would preclude SLN biopsy if

occult invasive disease were found on pathologic examination.The SLN identification rates and false negative rates reported

when SLN biopsy is performed after neoadjuvant chemotherapy

are similar to those seen when the procedure is performed after

diagnosis but before systemic chemotherapy.25

Contraindications to SLN biopsy include the presence of pal-

pable axillary nodes suggestive of metastatic disease, the presence

of large or locally advanced breast cancers, prior axillary surgery,

and pregnancy or lactation.

Axillary Dissection

Before the advent of SLN biopsy, axillary dissection was rou-

tinely performed in breast cancer patients: it provided prognostic

information that guided subsequent adjuvant therapy, it affordedexcellent local control, and it may have contributed a small over-

all survival benefit.

Axillary dissection for clinically node-negative breast cancer

includes resection of level I and level II lymph nodes and the

fibrofatty tissue within which these nodes lie [see Figure 6 ].26 The

superior border of the dissection is formed by the axillary vein lat-

erally and the upper extent of level II nodes medially; the lateral

border of the dissection is formed by the latissimus dorsi from the

tail of the breast to the crossing point of the axillary vein; the

medial border is formed by the pectoral muscles and the anteri-

or serratus muscle;and the inferior border is formed by the ta

the breast. Level II nodes are easily removed by retracting

greater and smaller pectoral muscles medially; it is not neces

to divide or remove the smaller pectoral muscle. In general,

III nodes are not removed unless palpable disease is present.

Axillary dissection, either alone or in conjunction with lum

tomy or mastectomy, usually calls for general anesthesia, b

may also be performed with thoracic epidural anesthesia supmented by local anesthesia as needed.To facilitate identifica

and preservation of motor nerves that pass through the axilla

anesthesiologist should refrain from using neuromuscular bl

ing agents.In the absence of neuromuscular blockade,any cla

ing of a motor nerve or too-close approach to a motor nerve w

the electrocautery will be signaled by a visible muscle twitch.

STRUCTURES TO BE PRESERVED

There are a number of vascular structures and nerves pas

through the axilla that must be preserved during axillary dis

tion [see Figure 7 ].These structures include the axillary vein

artery; the brachial plexus; the long thoracic nerve, which in

vates the anterior serratus muscle; the thoracodorsal ne

artery, and vein, which supply the latissimus dorsi; and the mal pectoral nerve, which innervates the lateral portion of

greater pectoral muscle.

The axillary artery and the brachial plexus should not

exposed during axillary dissection. If they are, the dissection

been carried too far superiorly, and proper orientation at a m

inferior position should be established. In some patients, t

may be sensory branches of the brachial plexus superficial (a

rarely, inferior) to the axillary vein laterally near the latissi

dorsi; injury to these nerves results in numbness extending to

wrist. To prevent this complication, the axillary vein should

tially be identified medially, under the greater pectoral mu

Medial to the thoracodorsal nerve and adherent to the chest

is the long thoracic nerve of Bell.The medial pectoral nerve

from superior to the axillary vein to the undersurface of greater pectoral muscle, passing through the axillary fat pad

across the level II nodes; it has an accompanying vein whose

color may be used to identify the nerve. If a submuscular imp

reconstruction [see Breast Reconstruction after Mastectomy, be

is planned, preservation of the medial pectoral nerve is espec

important to prevent atrophy of the muscle.

The intercostobrachial nerve provides sensation to the pos

or portion of the upper arm. Sacrificing this nerve generally l

to numbness over the triceps region. In many women, the in

costobrachial nerve measures 2 mm in diameter and takes a

ly cephalad course near the axillary vein; when this is the c

preservation of the nerve will not interfere with node dissect

Sometimes,however, the nerve is tiny, has multiple branches,

is intermingled with nodal tissue that should be removed; wthis is the case, one should not expend a great deal of tim

attempting to preserve the nerve. If the intercostobrachial n

is sacrificed, it should be transected with a knife or scissors ra

than with the electrocautery, and the ends should be burie

reduce the likelihood of postoperative causalgia.

OPERATIVE TECHNIQUE

The incision for axillary dissection should be a transvers

curvilinear one made in the lower third of the hair-bearing ski

the axilla. For cosmetic reasons, it should not extend anter

onto the greater pectoral muscle; however, it may be exten

posteriorly onto the latissimus dorsi as necessary for expos

Skin flaps are raised to the level of the axillary vein and to a p





IIIII

I

Figure 6 Axillary dissection. Shown are axillary lymph node

levels in relation to the axillary vein and the muscles of the axil-

la (I = low axilla, II = midaxilla, III = apex of axilla).26



below the lowest extension of hair-bearing skin, either as an ini-

tial maneuver or after the initial identification of key structures.

The key to axillary dissection is obtaining and maintaining

proper orientation with respect to the axillary vein, the thora-

codorsal bundle, and the long thoracic nerve. After the incision

has been made, the dissection is extended down into the true axil-

lary fat pad through the overlying fascial layer.The fat of the axil-

lary fat pad may be distinguished from subcutaneous fat on the

basis of its smoother, lipomalike texture.There may be aberrant

muscle slips from the latissimus dorsi or the greater pectoral

muscle; in addition, there may be an extremely dense fascialencasement around the axillary fat pad. It is important to divide

these layers early in the dissection.The borders of the greater pec-

toral muscle and the latissimus dorsi are then exposed, which

clears the medial and lateral borders of the dissection.

The axillary vein and the thoracodorsal bundle are identified

next.As discussed (see above), the initial identification of the axil-

lary vein should be made medially, under the greater pectoral

muscle, to prevent injury to low-lying branches of the brachial

plexus. Sometimes, the axillary vein takes the form of several

small branches rather than a single large vessel. If this is the case,

all of the small branches should be preserved.

The thoracodorsal bundle may be identified either distally at

its junction with the latissimus dorsi or at its junction with the

axillary vein.The junction with the latissimus dorsi is within theaxillary fat pad at a point two thirds of the way down the hair-

bearing skin of the axilla, or approximately 4 cm below the infe-

rior border of the axillary vein. Occasionally, the thoracodorsal

bundle is bifurcated, with separate superior and inferior branch-

es entering the latissimus dorsi; this is particularly likely if the

entry point appears very high. If the bundle is bifurcated, both

branches should be preserved.The thoracodorsal bundle may be

identified at its junction with the latissimus dorsi by spreading

within axillary fat parallel to the border of the muscle and look-

ing for the blue of the thoracodorsal vein. The identification is

also facilitated by lateral retraction of the latissimus dorsi. The

long thoracic nerve lies just medial to the thoracodorsal bundle

on the chest wall at this point and at approximately the same

anterior-posterior position. It may be identified by spreading tis-

sue just medial to the thoracodorsal bundle and then running the

index finger perpendicular to the course of the long thoracic

nerve on the chest wall to identify the cordlike nerve as it moves

under the finger. Once the nerve is identified, axillary tissue may

be swept anteriorly away from the nerve by blunt dissection along

the anterior serratus muscle; there are no significant vessels in this

area.

The junction of the thoracodorsal bundle with the axillary vein

is 1.5 to 2.0 cm medial to the point at which the axillary vein

crosses the latissimus dorsi.The thoracodorsal vein enters the pos-terior surface of the axillary vein, and the nerve and the artery pass

posterior to the axillary vein.There are generally one or two scapu-

lar veins that branch off the axillary vein medial to the junction

with the thoracodorsal vein.These are divided during the dissec-

tion and should not be confused with the thoracodorsal bundle.

The axillary vein and the thoracodorsal bundle having been

identified, the greater pectoral muscle is retracted medially at the

level of the axillary vein, and the latissimus dorsi is retracted lat-

erally to place tension on the thoracodorsal bundle. Once this

exposure is achieved, the axillary fat and the nodes are cleared

away superficial and medial to the thoracodorsal bundle to the

level of the axillary vein. Superiorly, dissection proceeds medially

along the axillary vein to the point where the fat containing level

II nodes crosses the axillary vein.To improve exposure, the fasciaoverlying the level II extension of the axillary fat pad should be

incised to release tension and expose the lipomalike level II fat.As

noted [see Structures to Be Preserved, above], the medial pectoral

nerve passes onto the underside of the greater pectoral muscle in

this area and should be preserved. One or more small venous

branches may pass inferiorly from the medial pectoral bundle;

particular attention should be paid to preserving the nerve when

ligating these venous branches.

The next step in the dissection is to reflect the axillary fat pad

inferiorly by dividing the medial attachments of the axillary fat

pad along the anterior serratus muscle. Care must be taken to

preserve the long thoracic nerve.Because there are no significant

vessels or structures in the tissue anterior to the long thoracic





LatissimusDorsi Muscle

ThoracodorsalNerve

ThoracodorsalArtery

2nd Rib

ThoracodorsalVein

Long ThoracicNerve

Figure 7 Axillary dissection. Shown is a view of the structures

of the axilla after completion of axillary dissection.26



nerve, this tissue may be divided sharply, with small perforating

vessels either tied or cauterized. Finally, the axillary fat is freed

from the tail of the breast with the electrocautery or a knife.

There is no need to orient the axillary specimen for the pathol-

ogist, because treatment is not affected by the anatomic level of

node involvement. A surgical clip is placed at the apex of the dis-

section to assist the radiation oncologist in planning radiation

fields. A closed suction drain is placed through a separate stabwound. (Some practitioners prefer not to place a drain and sim-

ply aspirate postoperative seromas as necessary.) The use of fibrin

sealants may reduce the incidence of seromas. A long-acting local

anesthetic may be instilled into the axilla—a particularly helpful

practice if the dissection was done as an outpatient procedure.

Mastectomy

The goal of a mastectomy is to remove all breast tissue, includ-

ing the nipple and the areola, while leaving well-perfused, viable

skin flaps for primary closure or reconstruction.This is the case

whether the mastectomy is performed for treatment of breast

cancer or for prophylaxis in high-risk patients. Proper skin inci-

sions and good exposure throughout the procedure are the keycomponents of a well-performed mastectomy.The borders of dis-

section extend superiorly to the clavicle, medially to the sternum,

inferiorly to where breast tissue ends (on the costal margin,below

the inframammary fold), and laterally to the border of the latis-

simus dorsi.The fascia of the greater pectoral muscle forms the

deep margin of the dissection and should be removed with the

specimen.

Mastectomy usually calls for general anesthesia, but it may be

performed with thoracic epidural anesthesia supplemented by

local anesthesia as needed. When a simple mastectomy is to be

performed in a frail patient for whom general anesthesia poses

unacceptable risks (particularly if the patient is elderly and has a

narrow-based, pendulous breast), local anesthesia with sedation

is appropriate.

OPERATIVE TECHNIQUE

Skin-sparing mastectomy performed in conjunction with

immediate reconstruction is discussed elsewhere [see Breast

Reconstruction after Mastectomy, below]. In a modified radical or

simple mastectomy without reconstruction, the goal is to leave a

smooth chest wall that permits comfortable wearing of a bra and

a prosthesis. It is important to remove a sufficient amount of skin

to ensure that no dog-ears or lateral skin folds are left on the ante-

rior chest wall. This undesirable result can be prevented by

extending the incision far enough medially and laterally to

remove all skin that contributes to the forward projection of

breast skin envelope.

The incision may be either transverse across the chest wa

angled upward toward the axilla as necessary to include the

ple-areola complex and any incisions from previous biops

Care should be taken to make the upper and lower skin flap

similar length so that there is no redundant skin on either flap

Figure 8 ]. The boundaries of the incision can be determinethe following five steps: (1) the lateral and medial end point

the incision are marked,(2) the breast is pulled firmly downw

(3) the upper incision is defined by drawing a straight line f

one end point to the other across the upper surface of the bre

(4) the breast is pulled firmly upward, and (5) the lower inci

is defined by drawing a straight line from one end point to

other across the lower surface of the breast.The outlined inci

is then checked to ensure that it can be closed without ei

undue tension or redundant skin. The closure should be f

snug intraoperatively, when the patient’s arm is positioned

pendicular to the torso for exposure, because a signifi

amount of slack is created when the arm is returned to a m

normal position at the patient’s side.The medial and lateral

points of the incision may be adjusted upward or downwardinclude any previous biopsy incisions in the specimen.

Flaps

In most patients, there is a fairly well defined avascular p

between subcutaneous fat and breast tissue.This plane is ide

fied by pulling the edges of the incision upward with skin ho

and beginning a flap that is 8 to 10 mm thick and exte

approximately 1 cm from the skin edge. After this initial rel

of the skin edge, the desired plane is developed by applying fi

tension to pull breast tissue downward and away from the ski

a 45° angle.The fine fibrous attachments between breast ti

and subcutaneous fat (Cooper’s ligaments) are then divided w

the electrocautery or a blade, and crossing vessels are coagul

or ligated as they appear. To protect both arterial supply to venous drainage from the skin flap, one must refrain from ex

sive ligation or cauterization of vessels on the flap.

Completed mastectomy flaps are perfused through the

work of fine subdermal vessels that remains after dissection.

viability of the flaps is determined by their length, the qualit

the vessels they contain, the damage sustained by the vessels d

ing the dissection, and the tension imposed by the final clos

For most women, flap viability is not an issue. It is, howeve

serious consideration for diabetics and other patients with dif

small vessel disease. In such patients, flaps should be caref

planned so that they are no longer than necessary and there is





Figure 8 Mastectomy. Shown are common incisions used for mastectomy.15 Any previous biopsy incisions should

have been done in such a way as to be included within the boundaries of the mastectomy incision.







excess tension,and extra care should be taken to preserve flap ves-

sels. Patients should be warned that even with these additional

efforts, there may be some necrosis along the edges of the inci-

sion. Such necrosis is best treated with gradual debridement of

the dark eschar that forms as epithelialization proceeds from

viable tissue.

Borders of Dissection

Flaps are raised superiorly to the clavicle, medially to the ster-

num, inferiorly to where breast tissue ends on the costal margin

(generally below the inframammary fold), and laterally to the bor-

der of the latissimus dorsi. The plane between breast tissue and

subcutaneous fat is followed down to the greater pectoral muscle

and through the pectoral fascia both superiorly and medially.

Inferiorly, the fascia of the abdominal muscles is not divided.The

greater pectoral muscle, the abdominal muscles, and the anterior

serratus muscle form the deep border of the dissection.The pec-

toral fascia is removed with the breast specimen and may be sep-

arated from the muscle with either the electrocautery or a blade.

To maintain the skin tension needed for the development of

skin flaps, an assistant holds the flaps taut manually with skin

hooks, dull-toothed rakes padded with damp sponges, or Deaverretractors. Care must be taken to obtain adequate tension and

exposure so that as much breast tissue as possible can be removed

without undue damage to the skin flaps.

Simple versus Modified Radical Mastectomy

Simple mastectomy is performed (1) to treat DCIS, (2) as a

prophylactic measure, (3) as a follow-up to lumpectomy and axil-

lary dissection if lumpectomy margins are positive for malignan-

cy, (4) to treat local recurrence of breast cancer after lumpectomy,

node dissection, and irradiation, and (5) in elderly patients in

whom coexisting medical conditions or other factors constitute

contraindications to axillary dissection.Simple mastectomy is also

indicated for treatment of sarcomas of the breast: lymphatic

spread to axillary nodes is not part of the natural history of thisdisease.

Modified radical mastectomy is performed to treat invasive

breast cancer when (1) there are contraindications to breast

preservation or (2) the patient or the physician prefers mastecto-

my. Simple mastectomy in conjunction with SLN biopsy is an

increasingly common alternative to modified radical mastectomy

for patients with clinically negative axillary nodes. If the nodes are

positive for tumor on pathologic examination, the surgeon may

then elect to perform a completion axillary dissection.

Simple mastectomy As described earlier (see above),a skin

incision is made, and thin flaps are raised to allow removal of all

breast tissue. Laterally, the dissection is extended to the border of

the latissimus dorsi, and breast tissue is removed anterior to thelong thoracic nerve. The dissection proceeds around the lateral

edge of the greater pectoral muscle but stops before entering the

axillary fat pad. If one wishes to sample the low axillary nodes (as,

for example, in a patient with extensive DCIS of comedo histol-

ogy), one may remove the lower portion of the axillary fat pad

between clamps. In so doing, one must avoid the long thoracic

nerve and the thoracodorsal nerve and keep the dissection low

enough to ensure that the intercostobrachial sensory nerve is not

damaged.The breast is then taken off the underlying muscles,and

the pectoral fascia is included with the specimen.

A single closed suction drain is placed through a separate stab

wound laterally to extend under the lower flap and a short dis-

tance upward along the sternal border of the dissection.The skin

is closed and a dressing applied according to the surgeon’s pref-

erence. Early arm mobilization is encouraged.

Modified radical mastectomy The incision is placed and

flaps are raised as for simple mastectomy.At the lateral edge of the

dissection, the border of the latissimus dorsi is exposed, as is the

lateral border of the pectoral muscle. Some surgeons prefer to

proceed with axillary dissection first, leaving the breast attachedto the chest wall, whereas others prefer to remove the breast from

the chest wall first and then use it to provide tension for the axil-

lary dissection. In either case, mechanical or manual retraction of

the latissimus dorsi and the greater pectoral muscle generally pro-

vides excellent exposure for axillary dissection.The landmarks of

the axillary dissection are identified as described earlier [see

Axillary Dissection, above]. The thoracodorsal bundle can often

be seen running along the latissimus dorsi as the muscle is retract-

ed laterally.

Once the axillary dissection has been completed and the breast

has been removed from the chest wall, the incision is irrigated and

two closed suction drains placed, one in the axilla and another

under the lower flap to the midline.The skin is closed and a dress-

ing applied according to the surgeon’s preference. Early armmobilization is encouraged.

Skin-sparing mastectomy An increasingly popular ap-

proach for women requiring mastectomy is skin-sparing mastecto-

my (SSM).27 This procedure consists of resection of the nipple-

areola complex, any existing biopsy scar, and the breast parenchy-

ma, followed immediately by breast reconstruction. It is somewhat

demanding technically, in that the effort expended in preserving

the skin makes it difficult for the oncologic surgeon to ensure

removal of as much breast tissue as possible. Because the infra-

mammary fold is preserved and a generous skin envelope remains

after SSM, cosmetic results after reconstruction are optimized.

SSM is oncologically safe and is not associated with an increased

incidence of local recurrence.The recurrences that do occur typi-cally develop below the skin flaps and thus are easily detectable;

deep recurrences beneath the reconstruction are comparatively

uncommon. Patients with locally advanced breast cancer are not

appropriate candidates for SSM with immediate reconstruction. In

general, immediate reconstruction should be reserved for patients

at low risk for postoperative adjuvant therapies.

Breast Reconstruction after Mastectomy

Advances in reconstructive techniques have made breast recon-

struction increasingly popular. Reconstruction may be done either

at the time of the mastectomy (immediate reconstruction) or later

(delayed reconstruction). It is well recognized that immediate breast

reconstruction after mastectomy is safe, does not significantly delaysubsequent administration of chemotherapy or radiation therapy,

and does not prevent detection of recurrent disease.Either implants

or autologous tissue may be used in reconstruction.

In most cases, the option of breast reconstruction is presented

to the mastectomy patient by her breast surgeon during preoper-

ative discussion of mastectomy or, in the case of delayed recon-

struction, during follow-up after an earlier mastectomy. The

patient, the plastic surgeon, and the oncologic or general surgeon

will decide among the several reconstruction options available—

implants with tissue expansion, the transverse rectus abdominis

myocutaneous (TRAM) flap, the latissimus dorsi myocutaneous

flap,and various free flaps—on the basis of patient preference and

lifestyle, the availability of suitable autologous tissue, and the







demands imposed by any additional cancer therapies required [see

Figure 9 ]. Familiarity with the strengths and drawbacks of these

reconstruction options facilitates this decision.

OPERATIVE TECHNIQUE

Placement of the incision for mastectomy with immediate

reconstruction is determined in discussion with the plastic sur-

geon. The goal is to preserve as much viable skin as possible for

the reconstruction without compromising complete resection of

breast and axillary tissue. The nipple and the areola mus

included in the resected skin, as must the biopsy inci

through which the malignancy was diagnosed [see Figure

(One option for removing biopsy incisions while leaving

maximal amount of unaffected skin is to place T-shaped i

sions that extend outward from the areola.) FNA and core-n

dle biopsy incisions are generally not included in the exc

skin segment; however, one may, if one wishes, excise a sm

amount of skin around a core-needle biopsy site. A linear i

Options for breast reconstruction after surgical therapy for breast cancer

Patient has undergone mastectomyPatient has undergonebreast conservation (localexcision and irradiation)

Management ofthe contralateralbreast

Reconstructionof the ipsilateralbreast

Patient has grave prognosisor cannot tolerate breastreconstruction surgery

Patient does not have graveprognosis and can toleratebreast reconstruction surgery

Do not consider breastreconstruction.

No treatment

No reconstruction

No reconstruction

Disease recurrence

Breastaugmentation

Breast reduction

Mastopexy

Consider breast reconstruction.

Patient has large or ptotic breastand does not wish to lift or reducethe contralateral breast; has hadprevious chest wall irradiation; ordesires autologous tissuereconstruction

Patient has good-quality,nonirradiated skin and soft tissueand small to medium-sized breastswith minimal ptosis or desiresimplant reconstruction

Consider autologous tissuereconstruction.

Consider implant reconstruction.

Tissue expander

Breast implant

Perform revisionaryprocedure, if necessary

Reconstruct the nippleand areola

Can be used whencreation of a breastmound with implants

alone is difficult.

Transverse rectusabdominis myocutaneoustissue is adequate forcreation of a pedicled flap

Consider transverse rectusabdominis myocutaneousflap.

Patient needs additionalcover for a breast implant,and tissue expansion iscontraindicated

Consider latissimus dorsi flap.

Patient is usually youngerthan 40 years and doesnot have adequate pedicled

flap site

Consider free gluteus flap.

Significant defect occurs

Figure 9 Breast reconstruction after m

tectomy. Shown is an algorithm outlinin

the major steps in breast reconstruction







sion should be made as far laterally as necessary to provide ade-

quate exposure for axillary dissection and complete excision of

breast tissue. A separate axillary incision may also be used when

axillary dissection or SLN biopsy is being performed [see Figure

10 ]. The extent of dissection should never be compromised in

any way for cosmetic reasons.

Reconstruction Options

Prosthetic implants Perhaps the simplest method of recon-

struction is to place a saline-filled implant beneath the greater

pectoral muscle and the anterior serratus muscle to recreate a

breast mound. Even after SSM, the greater pectoral muscle isusually so tight that unless the patient is small-breasted,expansion

of this muscle and the skin is necessary before an implant that

matches the opposite breast can be inserted.Serial expansions are

performed on an outpatient basis: saline is injected into the

expander every 10 to 14 days until an appropriate size has been

attained. A second operative procedure is then required to ex-

change the expander for a permanent implant. A nipple and an

areola are constructed at a later date.

The major advantage of implant reconstruction is that there is

no need to harvest autologous tissue, and the patient thus is

spared the discomfort, scarring, and loss of muscle function that

would occur at the donor site. Accordingly, implant reconstruc-

tions are commonly performed in patients who require bilateral

mastectomies and reconstructions. The initial operating time issignificantly shorter for implant reconstruction than for autolo-

gous tissue reconstruction, and there is no need for autologous

blood donation or transfusion. Hospital stay and recuperation

time are also significantly shorter. The main drawbacks are the

prolonged time and the multiple office visits required to achieve a

symmetrical reconstruction if tissue expansion is required and the

necessity of a second surgical procedure to place the permanent

implant. In addition, the final cosmetic result often is not as good

as what can be achieved with autologous tissue reconstruction,

and it may deteriorate over time as a consequence of capsule for-

mation or implant migration.The implant-reconstructed breast is

DeepithelializedAreas

Flap Configured toForm Breast Mound

SuperiorEpigastricPedicle

RemainingAnteriorRectusSheathFascial

Resection

FascialClosure

AbdominalScar

MastectomyDefect

Skin andSubcutaneousTissue Resection

a b c

Figure 11 Breast reconstruction after mastectomy. Shown is autologous tissue reconstruction with a transverse rectus

abdominis myocutaneous (TRAM) flap. The infraumbilical flap is designed (a).The TRAM flap is tunneled subcuta-

neously into the chest wall cavity. Blood supply to the flap is maintained from the superior epigastric vessels of the rec-

tus abdominis. Subcutaneous fat and deepithelialized skin are positioned under the mastectomy flaps as needed to

reconstruct the breast mound (b). The fascia of the anterior rectus sheath is approximated to achieve a tight closure of

the abdominal wall defect and to prevent hernia formation.The umbilicus is sutured into its new position (c).

Figure 10 Breast reconstruction after mastectomy. Shown is

the recommended placement of incisions for skin-sparing mas-

tectomy. T-shaped incisions extending from the areola to remove

previous biopsy incisions may be used if necessary. A separate

axillary incision may be necessary when axillary dissection is

being done.



significantly firmer than the contralateral breast.The life expec-

tancy of currently available saline implants has not been estab-

lished, but it may be less than a decade, which means that many

patients who have received or are receiving implants may needreplacements at some point.

Patients who have previously undergone irradiation of the

breast or the chest wall may have tissue that cannot be adequate-

ly expanded and thus is unsuitable for implant reconstruction. If

the final pathologic evaluation of the mastectomy specimen indi-

cates that radiation therapy is needed for local control, one may

consider irradiating the chest wall before expansion with an

expander in place; however, this is not an ideal solution.

Autologous tissue A second approach to reconstruction is to

transfer vascularized muscle, skin, and fat from a donor site to the

mastectomy defect.The most commonly used myocutaneous flaps

are the TRAM flap [see Figure 11] and the latissimus dorsi flap [see

Figure 12]. Use of the free TRAM flap is advocated by certain cen-ters; other free-flap options,including the free gluteus flap,are used

in special circumstances, when other donor sites are unsuitable.

The major advantage of autologous tissue reconstruction is

that it generally yields a superior cosmetic result. Often, the size

and shape of the opposite breast can be matched immediately,

with no need for subsequent office or operative procedures.The

reconstructed breast has a soft texture that is very similar to that

of the contralateral breast. In addition, the cosmetic result is sta-

ble over time.The main drawbacks are the magnitude of the sur-

gical procedure required for the reconstruction (involving both a

prolonged operating time and longer inpatient hospitalization),

the potential need for autologous blood donation or transfusion,

and the pain, scarring, and loss of muscle function that arise at

the donor site. Smokers and patients with significant vascular

ease may not be ideal candidates for autologous tissue rec

struction. Partial necrosis of the transferred flap may create fi

areas; on rare occasions, complete necrosis and consequent of the flap can occur.

A number of factors are considered in choosing between

TRAM flap and the latissimus dorsi flap. In a TRAM flap rec

struction, the contralateral rectus abdominis is transferred al

with overlying skin and fat to create a breast mound.This pr

dure yields a flatter abdominal contour but calls for a long tra

verse abdominal incision and necessitates repositioning of

umbilicus. A major advantage of the TRAM flap is that it

provide enough tissue to match all but the largest contralat

breasts. Some patients, however, such as those who have un

gone an abdominal procedure that compromises the TRA

flap’s vascular supply, are not ideal candidates for TRAM

reconstruction. Postoperative discomfort is greater with TR

flap reconstruction than with other flap reconstructions becaof the extent of the abdominal portion of the procedure

young, healthy, and motivated patients who require bilat

reconstructions, it is often possible to perform two TRAM

procedures in the same operation.

In a latissimus dorsi myocutaneous flap reconstruction,

ipsilateral latissimus dorsi is transferred along with overlying

and fat to create a breast mound. Either a horizontal or a ver

donor site incision may be made on the back.The operative te

nique for the latissimus dorsi flap reconstruction is comp

requiring two intraoperative changes in patient position (f

supine to lateral decubitus and from lateral decubitus back

supine for mastectomy, muscle harvest, and final inset of

flap).Patients who have undergone irradiation of the breast,c





Thoracodorsal

Vessels

Skin Island

Latissimus Dorsi

Muscle

Latissimus

Dorsi Muscle

Pectoral Musc

Submuscular

Implant

a b

Figure 12 Breast reconstruction after mastectomy. Shown is autologous tissue reconstruction with a

latissimus dorsi myocutaneous flap in conjunction with a submuscular implant. (An implant is often

required to provide the reconstructed breast with adequate volume and projection.) The myocutaneous

flap is elevated; it is important to maintain the blood supply to the flap from the thoracodorsal vessels (a).

The flap is tunneled subcutaneously to the mastectomy defect (b). The latissimus dorsi is sutured to the

greater pectoral muscle and the skin of the inframammary fold, so that the implant is completely covered

by muscle.



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Acknowledgments

The authors wish to thank David Van Hook, M.D.,

Chief of Mammography, Department of Radiology,

Penn State Hershey Medical Center, Hershey,

Pennsylvania, for his assistance in preparing the section

on directional vacuum-assisted breast biopsy (mammo-

tomy).

Figures 1 through 8, 10 Kerry G. Nicholson.

Figure 9 Marcia Kammerer.

Figures 11 and 12 Tom Moore.

wall, or axilla (including irradiation of the thoracodorsal vessels)

may not be eligible for this procedure.

A major advantage of the latissimus dorsi flap is that its donor

site is associated with less postoperative discomfort than the

abdominal donor site of the TRAM flap. In addition,transfer of the

latissimus dorsi results in substantially less functional impairment

than transfer of the rectus abdominis.A drawback of the latissimus

dorsi flap is that in many women, the latissimus dorsi is not bulkyenough to provide symmetry with the contralateral breast. In such

cases, an implant must be added to the flap to match the size and

shape of the opposite breast, which means that the drawback of the

implant’s limited life span is added to the drawbacks already asso-

ciated with autologous tissue reconstruction.

Free-flap reconstruction options are utilized primarily when

other autologous and implant reconstruction options are not

available, do not provide sufficient tissue volume, or have failed.

They are more complex procedures, requiring microvascular

anastomoses and carrying a higher risk of total flap loss.The two

most commonly employed free-flap options are the free TRAM

flap and the free gluteus flap.

Donor site morbidity—including postoperative pain, wound-

healing complications,decreased abdominal muscle strength,and

hernia formation—is a prime disadvantage of pedicled or free

TRAM flap reconstruction. As a result, muscle-sparing alterna-

tives to autogenous breast reconstruction have been developed,such as the deep inferior epigastric perforator (DIEP) flap.28 In

this approach,free flaps are used that comprise skin and fat alone,

without the rectus abdominis. Avoidance of muscle sacrifice in

the abdomen ultimately translates into greater patient satisfac-

tion, but careful patient selection is essential to optimize out-

comes.The disadvantages of the DIEP flap include the consider-

able technical expertise and long operating time required, as well

as the greater potential for flap loss (because this flap has a more

tenuous blood supply than the standard TRAM flap).





References

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