LUMPECTOMY WITH SENTINEL

LYMPH NODE BIOPSY:

A BREAST CONSERVATION SURGERY

Shah Ahmed CC3
Learning Objectives
Recognize the risk factors for breast cancer
Understand the diagnostic work up and staging for breast
cancer
Understand the role for lumpectomy with a sentinel lymph
node biopsy (SLNB) in breast cancer treatment
Recognize the common complications of lumpectomy with
SLNB


Case presentation
JJ is a 66 yo F coming in for evaluation and treatment of a
possible right breast cancer.

She previously had breast cancer in the left breast which was
treated with breast conservation treatment in 2004. She had
no signs of recurrence since that time.

In January 2014 she had a screening mammogram which was
negative. In June 2014 she had screening MRI which was
positive for a new 8mm nodule at the 10 oclock position of
the right breast.
What risk factors for breast
cancer does JJ have?
Table 19-2. Lawrence PF, Bell RM, Dayton MT. Essentials of General Surgery. Lippincott Williams
& Wilkins; 2012.
Table 19-2. Lawrence PF, Bell RM, Dayton MT. Essentials of General Surgery. Lippincott Williams
& Wilkins; 2012.
What should we do for JJ now?
Work up
Breast Exam
inspection and palpation
Imaging
Mammography, US, MRI
guide wire placement
Fine needle aspiration
Cytological analysis of a non palpable lesion
Useful in cystic lesions
Core Biopsy
Analysis of breast tissue architecture and invasion
TNM staging
Degree of spread is the
most important prognostic
factor
it determines the
treatment options
*LUNG, LIVER, BONE, AND BRAIN
*
What features of a breast mass would make it
suspicious for cancer?
How about on mammography?
SPICULATED
LESION
Back to JJ
No palpable mass or palpable axillary lymph nodes
Core biopsy revealed invasive ductal carcinoma of the right breast
Lesion marked with needle localization and guide wire
LUMPECTOMY WITH SENTINEL LYMPH NODE
DISSECTION FOLLOWED BY CHEMOTHERAPY AND
RADIATION
Standard of care for stage I and stage II disease
There is no survival benefit or reduction in recurrence rates when comparing
complete mastectomy to lumpectomy with SLNB with adjuvant chemo/rad
X
AND
Technetium 99m-labled
sulfur colloid is injected
subdermally in proximity to
tumor site, either same day
or day before
Isosulfan blue dye is
injected in the breast
parenchyma
Hand held gamma counter
is used to determine the
location of sentinel nodes
Presence of blue dye
confirms node
Nodes are sent off to
pathology for frozen section
No cancer = proceed with
lumpectomy and attempt
to acquire negative margins
if negative margins are not
possible, mastectomy must
be performed
Cancer present in sentinel
lymph nodes = proceed
with axillary lymph node
dissection and lumpectomy
What Could go wrong?
wound infection
seroma
hematoma
transient lack of sensation to the skin due to damage
to cutaneous nerves
long thoracic nerve injury can lead to decreased
innervation to the serratus anterior muscle and a
subsequent winging of the scapula leading to an
inability to effectively raise the arm
lymphedema if axillary lymph node dissection is
performed

Follow up
adjuvant radiation therapy
adjuvant chemotherapy
hormonal therapy
Mammogram 6 months after radiation tx and
yearly thereafter

Sources
Blackbourne LH. Surgical Recall. Lippincott Williams &
Wilkins; 2011.
Hunt KK, Newman LA, Copeland EM, III, Bland KI.
Chapter 17. The Breast. In: Brunicardi F, Andersen DK,
Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock
RE. eds. Schwartz's Principles of Surgery, 9e. New York,
NY: McGraw-Hill; 2010.
Lawrence PF, Bell RM, Dayton MT. Essentials of General
Surgery. Lippincott Williams & Wilkins; 2012.
Stehr W. The Mont Reid Surgical Handbook. Saunders;
2008.