Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 8 • Adrenals—Anterior, Posterior (Open and Laparoscopic) 105

STEP 5: PEARLS AND PITFALLS

◆ The appropriate preoperative preparation of the patient with a pheochromocytoma cannot

be overstated. Failure to follow the sequence of alpha blockade followed by beta blockade

can lead to hemodynamic catastrophe.

◆ Even with the appropriate preparation, patients with pheochromocytomas may have wide

ﬂ uctuations in blood pressure as the adrenal gland is manipulated intraoperatively. Early

control of the adrenal vein and appropriate hemodynamic monitoring and intervention are

keys to minimizing this complication. Careful attention to ﬂ uid management should con-

tinue into the postoperative period.

◆ Manipulation should be by grasping the tissue around the adrenal glands or pushing it to

the side, and dissection of the adrenal glands should be extracapsular. Lacerations of the

gland will cause bleeding, which compromises adequate visualization and/or causes spillage

of potentially malignant cells.

SELECTED REFERENCES

1. Bravo EL: Pheochromocytoma: Diagnosis, localization and management. N Engl J Med 1984;311:

1298-1303.

2. Gagner M: Laparoscopic adrenalectomy. Surg Clin North Am 1996;76:523-537.

3. Prinz A: A comparison of laparoscopic and open adrenalectomies. Arch Surg 1995;130:489-492.

108

STEP 1: SURGICAL ANATOMY

◆ The breast is an organ that is composed of lobes, ducts, ﬁ brous stroma, ligaments, adipose

tissue, nerves, blood vessels, and lymphatics. The nipple-areolar complex is a specialized struc-

ture containing elements of skin epithelium, sweat and sebaceous appendages, and ductal

epithelium with a nerve supply from branches of the second to sixth intercostal nerves.

◆ The breast parenchyma is organized into lobes that have a central duct, peripheral branch-

ing ducts, and glandular tissue.

◆ The lobes are variable in size, shape, and extent of branching.

◆ Ducts from different lobes are not constructed in wedge-like radial fashion but may lie over

or under one another in an overlapping manner like intertwining roots.

◆ Most experts believe that ducts from one lobe do not anastomose with ducts of another

lobe, but this is still an area of investigation.

◆ The nonuniform distribution of lobe anatomy inﬂ uences the ability to map the breast

parenchyma and has implications for surgical resection. Most tumors are localized and

limited in extent, with a smaller percentage distributed segmentally and a minor number

coursing in an irregular intertwined pattern.

◆ The peripheral ducts terminate in ﬁ ve to nine central ductal oriﬁ ces in the nipple.

◆ Breast cancer is primarily a disease that begins in the terminal duct lobular units.

◆ Deﬁ nition of terms for breast conservation:

◆ Lumpectomy, tylectomy, wide local excision, partial mastectomy, or segmental

mastectomy are roughly synonymous terms referring to the removal of a cancer through

a small incision on the breast with a rim of normal healthy breast tissue, leaving the

majority of normal breast tissue undisturbed. In most cases the nipple-areolar complex is

left intact.

CHAPTER

Wide Local Excision

Baiba J. Grube

◆ Quadrantectomy usually refers to a wider excision that resects a quadrant of breast

tissue, sometimes associated with the resection of redundant skin.

◆ Lumpectomy is combined with sentinel node biopsy and/or axillary dissection for an

invasive cancer (see Chapters 10 and 11).

◆ Lumpectomy is usually followed by radiotherapy.

◆ Randomized trials have demonstrated that patients who undergo lumpectomy, axillary stag-

ing, and radiotherapy have the same overall survival as those who have modiﬁ ed radical

mastectomy.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ In a well-screened population, breast cancer is commonly identiﬁ ed as a nonpalpable

mammographic abnormality. Interval cancers may occur in a well-screened population,

especially in patients who are BRCA1 and BRCA2 gene mutation carriers. A clinician

experienced in breast disease may also palpate small breast cancers.

◆ Preoperative evaluation of a screen-detected nonpalpable abnormality or palpable lesion

requires diagnostic mammograms. Additional images may include magniﬁ cation and

exaggerated and medial-lateral views. Other imaging modalities such as ultrasound and

magnetic resonance imaging (MRI) may provide detailed information to map the area

involved with tumor.

◆ A pathologic diagnosis of an image-detected abnormality or a palpable abnormality is

obtained by ﬁ ne needle aspiration, core biopsy, or excisional biopsy. The preferred method

is a core biopsy, which allows for receptor analysis and permits discussion of

treatment options.

◆ Selection of a surgical option for local control of breast cancer is a complex decision, based

on the tumor features, breast size, location, associated medical problems, and individual

choice. Interdisciplinary discussion with radiation oncologists, medical oncologists, and

plastic surgeons in addition to the oncologic surgeon provides a comprehensive under-

standing of the options available to the patient.

◆ Lumpectomy with axillary staging may be an alternative procedure to a modiﬁ ed radical

mastectomy for many women, especially in the current era of mammographic screening,

identiﬁ cation of earlier stage disease, and the use of induction chemotherapy to reduce the

size of the primary tumor.

◆ Lumpectomy is followed by breast radiotherapy.

◆ Whole breast irradiation may be given with or without a boost to the site of the tumor.

◆ Accelerated partial breast radiotherapy is a recent approach that limits the radiation to a

smaller ﬁ eld, delivering a higher dose over a shorter period of time.

CHAPTER 9 • Wide Local Excision 109

110 Section II • The Breast

◆ Evaluation of the primary lesion and the planned procedure should be reviewed with

the radiologist and the radiation therapist.

◆ Palpable tumors may be initially treated with neoadjuvant chemotherapy to downsize

them if they are too large to result in a good cosmetic outcome.

◆ Nonpalpable tumors will require preoperative ultrasound-guided, stereotactically placed,

or on rare occasions, MRI-directed needle localization.

◆ Size and extent of lesion relative to breast size will dictate the ability to perform breast-

conserving surgery and the cosmetic outcome.

◆ Centrally located tumors may require resection of the nipple-areolar complex.

◆ Multifocality is the presence of satellite tumors within the index quadrant. If they are

close enough together to permit resection through a single incision, breast conservation

remains an option.

◆ Multicentricity, the presence of tumors in different quadrants of the breast, is usually

taken as a contraindication to breast conservation.

◆ Calciﬁ cations that are associated with a malignancy may be treated with breast conserva-

tion unless they involve too extensive an area for a good cosmetic outcome or if they

involve the entire breast.

◆ Breast conservation may not be an option:

◆ When extensive resection would lead to poor cosmesis

◆ Large tumor size relative to breast size

◆ Diffuse suspicious calciﬁ cations

◆ Multicentric disease

◆ Inﬂ ammatory carcinoma

◆ Locally advanced disease

◆ When medical contraindications are present

◆ Previous chest wall irradiation

◆ Active collagen vascular disease

◆ Presence of a pacemaker

◆ Signiﬁ cant cardiac disease

◆ Signiﬁ cant pulmonary disease

◆ When the patient is pregnant

◆ Radiotherapy is contraindicated in pregnancy but may be delayed until after delivery

if other treatment is ongoing.

STEP 3: OPERATIVE STEPS

1. ANESTHESIA

◆ Monitored anesthesia care with local anesthetic is usually sufﬁ cient for a small lumpectomy.

◆ Larger resection or resection in the vicinity of the nipple-areolar complex may require a

general anesthetic.

◆ General anesthesia is usually preferable for lumpectomy combined with sentinel node

biopsy and axillary dissection.

CHAPTER 9 • Wide Local Excision 111

2. INCISION

◆ The curvilinear incision is placed along Langer’s lines over a palpable mass in the upper

hemisphere (Figures 9-1 and 9-2). Some surgeons prefer a radial incision in the inferior

hemisphere, particularly if skin must be removed. Shortening the distance between the

nipple and inframammary crease gives much poorer cosmesis than medial/lateral narrowing

of the breast.

Incision lines

Tumor

FIGURE 9 –1

Incision and

underlying tumor

medial to areola

FIGURE 9 –2

112 Section II • The Breast

◆ When a nonpalpable lesion is localized with a wire, review of the mammogram with atten-

tion to the lesion and the wire tip dictates the placement of the incision. The entrance point

of the wire may be far removed from the lesion, and an incision placed at the entry point of

the wire may lead to extensive unnecessary dissection of normal breast tissue. Multiple

bracketing wires may be used for extensive calciﬁ cations.

◆ Some radiologists inject a small amount of methylene blue at the tip of the wire to aid the

surgeon.

◆ Skin excision is usually unnecessary unless the tumor is too close to achieve a clear margin.

3. DISSECTION

◆ Dissection of the area of interest may be performed with sharp dissection (Figure 9-3) or

electrocautery.

◆ If electrocautery is used, the skin edges are at risk from thermal injury, and there may be

signiﬁ cant cautery artifact of the specimen, making histopathologic evaluation of the margins

difﬁ cult for the pathologist.

◆ Sharp dissection is an alternative and requires meticulous hemostasis once the lesion is removed.

◆ When the tumor is located, a 1-cm margin of normal tissue may be grasped with Allis forceps

(Figure 9-4). If the glandular tissue is almost completely replaced with adipose tissue, trac-

tion with instruments on the friable fatty tissue can damage the surrounding normal margin

and preclude accurate margin assessment. In these cases, gentle pressure should be applied to

separate the area of interest from the remaining breast. The incision may need to be larger for

better visibility.

◆ The pectoralis fascia is removed in cases in which the tumor approaches the chest wall.

◆ When the specimen is resected, it is oriented for the pathologist with marking sutures so

that the medial, lateral, superior, inferior, posterior, and anterior margins can be evaluated

for proximity of the tumor cells.

◆ The presence of the lesion is placed on a grid, and the location of the lesion is conﬁ rmed by

specimen mammogram. The radiologist can place marking needles in the specimen for the

pathologist to identify the lesion.

◆ The submission of separate shaved margins from the cavity is a technique that provides

additional information about margins.

◆ The cavity is demarcated with metal clips for the radiation oncologist, unless partial breast

irradiation with a MammoSite balloon catheter is anticipated. The balloon is susceptible to

rupture from the sharp metallic clips.

CHAPTER 9 • Wide Local Excision 113

FIGURE 9 –3

FIGURE 9 –4

114 Section II • The Breast

4. CLOSING

◆ Surgeons vary in their recommendation for closure of the partial mastectomy defect. In

most cases, the defect in the breast can be closed by approximating the fascia of the

superﬁ cial subcutaneous adipose tissue and the skin (Figure 9-5). The cavity is allowed

to accumulate a ﬁ brinous seroma, which helps maintain the natural shape of the breast.

◆ Some surgeons are concerned that lack of cavity closure will leave a dimple in the contour

and therefore elect to close the parenchyma. The goal in breast conservation is to remove

the tumor with a healthy margin to reduce risk of recurrence, minimize deformity, and

preserve the location of the nipple.

◆ Oncoplastic advancement ﬂ aps may be helpful when a large cavity remains but should be

applied only by individuals experienced in the techniques. When applying oncoplastic pro-

cedures that shift tissues around, the surgeon must be reasonably certain that the margins

are free of tumor.

◆ Reapproximation of the subcutaneous fat with an absorbable suture leads to better skin

closure (see Figure 9-5).

◆ Skin closure may be performed with absorbable or nonabsorbable sutures or Dermabond,

according to individual preference.

Closure done with

subcuticular running

suture pattern

FIGURE 9 –5

5. PROCESSING OF RESECTED SPECIMEN

◆ Orientation of the specimen is the responsibility of the surgeon, and any concerns should

be communicated to the pathologist.

◆ The specimen may not be a perfect sphere or rectangle but rather an irregular specimen

that requires detailed orientation.

◆ Specimen mammography aids the surgeon who can perform additional resections at the

time of lumpectomy.

◆ Specimen mammography aids the pathologist who can process the areas of interest in greater

depth.

◆ Pathologic processing is most helpful when multicolor inking of the specimen margins is

performed.

6. REEXCISION LUMPECTOMY

◆ If the margins demonstrate transected tumor, discussion for reexcision lumpectomy or mas-

tectomy must be undertaken.

◆ If reoperation is desired by the patient, the same incision may be used.

◆ Multicolored inking of the initial lumpectomy specimen can identify a speciﬁ c margin that

is positive, and re-resection may be limited to the affected margin.

STEP 4: POSTOPERATIVE CARE

◆ A variety of dressings can be used, from Opsite alone to ﬂ uffs and a specialized postsur-

gical bra.

◆ Showers may be taken in 48 hours.

◆ Tub baths and swimming are avoided until the wound is completely healed.

◆ Strenuous exercise should be avoided in the ﬁ rst week to prevent bleeding.

◆ Silicone-based sheets, such as Biodermis, may be applied to reduce scarring by direct pressure.

◆ A sports bra worn 24 hours a day may be comfortable for some, whereas others ﬁ nd any

form of bra uncomfortable.

CHAPTER 9 • Wide Local Excision 115

116 Section II • The Breast

STEP 5: PEARLS AND PITFALLS

◆ Discussion with the interdisciplinary team will sequence treatment in the most appropriate

manner.

◆ Surgical planning preoperatively with the radiologist is critical to achieve negative margins

the ﬁ rst time.

◆ Complex resections may require input from a plastic surgeon, especially when contralateral

symmetry may be an issue.

◆ Large excisions may require oncoplastic techniques to rearrange the remaining breast

parenchyma.

◆ Maintenance of the nipple-areolar complex in the native position results in the best

cosmetic outcome.

◆ Specimen orientation by the surgeon and communication with the radiologist and

pathologist is critical.

◆ Specimen mammography and communication of the ﬁ ndings to the surgeon and

pathologist are essential to take additional margins at the ﬁ rst operation.

◆ Specimen multicolor inking aids in determining the location of a close margin, so re-

resection is limited to the area of residual tumor and not on the negative margins.

SELECTED REFERENCES

1. Anderson BO, Masetti R, Silverstein MJ: Oncoplastic approaches to partial mastectomy: An overview of

volume-displacement techniques. Lancet Oncol 2005;6:145-157.

2. Fisher B, Anderson S, Bryant J, et al: Twenty-year follow-up of a randomized trial comparing total mastec-

tomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J

Med 2002;347:1233-1241.

3. Schwartz GF, Veronesi U, Clough KB, et al: Consensus conference on breast conservation. J Am Coll Surg

2006;203:198-207.

4. Veronesi U, Cascinelli N, Mariani L, et al: Twenty-year follow-up of a randomized study comparing breast-

conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347:1227-1232.

5. Iglehart JD, Kaelin CM: Diseases of the breast. In Townsend C Jr, Beauchamp R, Evers B, Mattox K (eds):

Sabiston Textbook of Surgery. Philadelphia, Elsevier Saunders, 2004, pp 867-927.