• Oncologically equivalent.• Better aesthetic outcome.• Psychological advantage with breast preservation
Still require mastectomy….• Extensive calcification on mammography• Clear margins cannot be obtained.• C/I to irradiation • previous chest wall irradiation • Pregnancy • scleroderma / active lupus Patient preference to mastectomy / desire to avoid irradiation
• Curvilinear incision – above nipple.• Radial incision – below nipple.• If previous bx- scar to be included.• Adequate clearance.• Specimen orientation.• HPE–hormone status/HER-2neu
Treatment of axillary node donot alter disease free / overallsurvival.Helps to stage the disease,identify the prognosis and needfor adjuvant therapy.
Node negative by physical andimaging studies.Not recommended T3/T4 tumour inflammatory breast ca pregnancy DCIS without mastectomy prior axillary surgery after preop chemotherapyCan be done old age / obesity male breast ca prior excisonal bx before preop chemo
In the operating room , 3-5 ml of isosulphan blue injectedparenchyma or subareolar
• Hand held gamma counter to identify the location.• 3-4 cm curved transverse incision below hair line is made and deepened, identify blue lymphatic channels.• As sentinel lymph node is approached signal increases.• Frozen section / touch imprint / permanent HPE.
• 10 sec in vivo and 10 sec ex vivo count to be obtained.• All blue lymph nodes and those with >10% of 10 second ex vivo count are to be removed.• Entire surgical bed to be scanned.• Should be <10% 0f 10 sec ex vivo count.
• Complications : • Infection • Seroma • Hematoma • Axillary paresthesia • Dereased range of motion • Lymphedema of arm.• Pathologic processing of the sentinel nodes – requires standardisation.• Intraoperative assessment of node varies in each institution.
• Adverse prognostic factors • Blood vessel or lymph vessel invasion • High nuclear grade • High histologic grade • HER – 2 /neu over expression • Negative hormone receptors• Tamoxifen – hormone positive >1cm• Trastuzumab – HER-2/neu positive + node positive tumor.