LUMPECTOMY

PROCEDURE
Background
• Lumpectomy is defined as an excision of a breast lump with a
surrounding rim of normal breast tissue
• Traditionally, a lumpectomy was performed only to diagnose a
breast mass.
• this procedure can be performed as part of the definitive
management of a breast malignancy or benign lesions that
have previously been diagnosed by needle biopsy. [2, 3]
Indications
• The indications for performing a lumpectomy may be
diagnostic or therapeutic.
• Indications for a diagnostic include :
– Equivocal pathology obtained on core biopsy or fine
needle aspiration cytology of a radiologically suspicious
breast lump
– A lump classified as category 3 or 4 by the Breast Imaging-
Reporting and Data System that is close to the pectoral
muscle, which makes biopsy under radiological guidance
difficult
• Indications for a therapeutic include :
– Benign breast lumps, such as fibroadenoma or
phyllodes [4]
– Ductal carcinoma in situ or invasive breast cancer
that is amenable for breast conservation based on
the size of the lesion [5, 6]
 Contraindications
• A lumpectomy is not recommended without prior needle
biopsy confirmation of the nature of the breast mass.
• For proven cancers, a lumpectomy may be contraindicated
because of the size of the lump or contraindications to
radiotherapy.
• When excision of the lump would involve removing more than
30% of the breast tissue, a lumpectomy is not recommended.
Generally speaking, 3-4 cm is considered to be the safe cutoff
for lumpectomy in medium to large breasts.
• Patients undergoing lumpectomy for cancer must undergo
postoperative radiotherapy to the chest wall to reduce the
risk of local recurrence.
• A lumpectomy must not be performed for patients with
severe psoriasis, sarcoidosis, or previous chest wall
radiotherapy.
 PERIPROCEDURAL CARE
Equipment
• A basic surgical set is required
• Important instruments include:
– Littlewood forceps, Lahey forceps, or skin hooks
for lifting the flaps
– Langenbeck retractors (medium and small size)
– Small artery forceps
– Nontoothed and toothed forceps
– Metzenbaum scissors
– Unipolar diathermy
 Patient Preparation
Anesthesia
• It can be performed under local or brief
general anesthetic.
• Small lumps, particularly those that are away
from the nipple, are suitable for local
anesthetic provided the patient is cooperative.
Positioning
• The patient is positioned supine on the table.
• The arms should be stretched out in line with the
shoulder on an armboard. This is particularly helpful
for upper outer quadrant lumps.
• For lumps in the upper half of the breast, the head
end of the table can be tilted up by 30-40 degrees.
• For tumors in the outer half of the breast, tilt the
patient towards the opposite side to the one being
operated upon.
 Complications
• Lumpectomy is a safe procedure that does not
have many complications.
• Routine postoperative complications include :
– Hematoma
– Infection
– Poor cosmesis
– Re-excision
• Although re-excision is not a complication per se, it is
something that needs to be explained clearly to the
patient before surgery.
• A second operation to excise more breast tissue is
needed in two circumstances:
– If tumor cells are found close to the margin of the excised
lumpectomy specimen when the procedure has been
performed for a diagnosed breast cancer [7, 8]
– If the final pathology reveals incompletely excised
malignant or borderline phyllodes
 Technique
Approach Considerations
• Mark the lump with an indelible marker on the skin prior to
making the skin incision.
• With lumpectomy for a benign lump, do not raise flaps.
• Go down onto the surface of the lump with scissors or
diathermy and excise it.
• Bleeding vessels can be managed as they arise.
• With lumpectomy for a malignant lump, raise flaps all around
the lump and extend them to at least a centimeter beyond
the palpable lump.
• Orient the excised lump with sutures or clips.
• Always reconstruct the breast by approximating the walls of
the cavity with absorbable sutures.
• Drain placement is not recommended as it leads to poor
cosmetic results.
Lumpectomy for Palpable Lumps
• Making the Incision
• The placement of the incision is determined by the
location of the lump. [9]
• For central lumps, a periaerolar incision is best suited and
heals well with minimal scarring.
• For lumps in outer halves of the breast, a curvilinear
incision over the lump along the natural crease lines of
the breast gives the best cosmetic result.
• Incision sites for lumpectomy.
Raising the Flaps
• Using skin hooks and cat's paws retractors or Littlewood
forceps, lift up one side of the skin incision.
• If the lumpectomy is being performed for a benign lump
or for diagnostic purposes, do not lift flaps but cut down
straight onto the surface of the lump.
• Dissect around it, take care of bleeders as they occur, and
excise the lump.
• When the lumpectomy is being performed for a
malignant lump, it is important to raise flaps around
the lump as one would do for a mastectomy.
• Lift the flap up using scissors or diathermy. Be careful
not to thin the flap too much.
• The flap should be raised all around the dimensions
of the lump and at least a centimeter beyond.
• Excise the lump with a sufficient margin down to the
pectoral muscle.
Closure of the Cavity
• When a lumpectomy is performed for a benign lump, the
cavity tends to be small.
• A few absorbable sutures may be placed to approximate
the cavity before placing the skin sutures.
• Malignant lumps tend to grow into the surrounding
breast tissue; therefore, they leave a bigger cavity when
excised.
• This should be approximated by mobilizing the
surrounding breast tissue to allow for good cosmesis.
 Lumpectomy for Impalpable Abnormalities
• Wire-guided excision is performed for impalpable
abnormalities.
• The radiologist inserts a wire either through or in close
proximity to the abnormality.
• For lesions visible on ultrasonography, the wire is inserted
under ultrasonographic guidance. [11]
• For those that are not visible on ultrasonography, this is done
under stereotactic control.
• The wire can be inserted up to a day prior to the actual
surgery.
• Another mammogram after inserting the wire is taken and
used as a guide during surgery.
• in the operating room, the surgeon removes the dressing
over the wire and determines the sitting of the incision,
confirming mammograms.
• The incision is generally placed close to the entry point of
the wire if it is just anterior to the lesion.
• If the entry point of the wire is at a distance from the
actual position of the lesion, then the incision is made
closer to the lesion.
• Once the skin flaps are raised, the wire is pulled through
the skin into the wound.
• Once the lesion is excised, a radiograph is performed to
ensure complete excision.
 References
• Vo T, Xing Y, Meric-Bernstam F, Mirza N, Vlastos G, Symmans WF, et al. Long-term outcomes in
patients with mucinous, medullary, tubular, and invasive ductal carcinomas after lumpectomy. Am J
Surg. 2007 Oct. 194(4):527-31. [Medline].
• Morrow M. Trends in the surgical treatment of breast cancer. Breast J. 2010 Sep-Oct. 16 Suppl
1:S17-9. [Medline].
• Kumar S, Sacchini V. The surgical management of ductal carcinoma in situ. Breast J. 2010 Sep-Oct.
16 Suppl 1:S49-52. [Medline].
• Guillot E, Couturaud B, Reyal F, Curnier A, Ravinet J, Laé M, et al. Management of phyllodes breast
tumors. Breast J. 2011 Mar-Apr. 17(2):129-37. [Medline].
• Motwani SB, Goyal S, Moran MS, Chhabra A, Haffty BG. Ductal carcinoma in situ treated with
breast-conserving surgery and radiotherapy: a comparison with ECOG study 5194. Cancer. 2011
Mar 15. 117(6):1156-62. [Medline].
• Goyal S, Vicini F, Beitsch PD, Kuerer H, Keisch M, Motwani S, et al. Ductal carcinoma in situ treated
with breast-conserving surgery and accelerated partial breast irradiation: comparison of the
Mammosite registry trial with intergroup study E5194. Cancer. 2011 Mar 15. 117(6):1149-55.
[Medline].
• Jacobson AF, Asad J, Boolbol SK, Osborne MP, Boachie-Adjei K, Feldman SM. Do additional shaved
margins at the time of lumpectomy eliminate the need for re-excision?. Am J Surg. 2008 Oct.
196(4):556-8. [Medline].
• Landercasper J, Whitacre E, Degnim AC, Al-Hamadani M. Reasons for re-excision after lumpectomy
for breast cancer: insight from the American Society of Breast Surgeons Mastery(SM) database. Ann
Surg Oncol. 2014 Oct. 21(10):3185-91. [Medline].
• Fisher CS, Mushawah FA, Cyr AE, Gao F, Margenthaler JA. Ultrasound-Guided Lumpectomy for
Palpable Breast Cancers. Ann Surg Oncol. 2011 Aug 23. [Medline].
Thank You