overview

General

Tumor ablation is defined as the removal of a breast tumor surrounded by normal breast tissue, as shown in the figure below.

Usually, a lumpectomy is done only to diagnose a lump in the breast. However, this procedure may be performed as part of definitive management of a breast malignancy or previously diagnosed benign lesions with a needle biopsy.

Point

Indications for tumor resection can be diagnostic or therapeutic.

Indications for the diagnosis of tumor resection include:

• Suspicious pathology obtained on core needle biopsy or fine-needle aspiration cytology of a suspected breast tumor on radiographic imaging.
• A tumor classified as type 3 or 4 according to the Breast Imaging Reporting and Data System is located near the pectoralis major, which makes radiographically guided biopsies difficult.

Indications for tumor ablation therapy include:

• Benign tumors in the breast, such as fibroadenomas or melanoma.
• Non-invasive ductal carcinoma or invasive breast cancer is likely to have safe breast surgery based on the size of the lesion.

Contraindications

A lumpectomy should not be performed without prior confirmation of the nature of the breast mass by a needle biopsy.

For proven cancers, surgical removal of the tumor may be contraindicated because of the size of the tumor or contraindication to radiation therapy.

When lumpectomy will involve removal of more than 30% of breast tissue, lumpectomy is not recommended. In general, 3-4 cm is considered a safe threshold for resection of medium and large breast tumors.

Patients undergoing surgery to remove the tumor for cancer must have postoperative radiation therapy to the chest wall to reduce the risk of local recurrence. Tumor resection should not be performed in patients with severe psoriasis, granulomatosis, or prior chest wall radiation.

Preparing for surgery

Equipment

A basic surgical kit is required to perform a tumor resection.

Important tools include:

• Littlewood forceps, Lahey clamps or skin hooks for breast tissue separation
• Langenbeck ball (medium and small)
• Small artery forceps
• Toothless and toothed clamps
• Monopolar Metzenbaum Electrotherapy

Prepare for the Patient

Anesthetize

Tumor excision can be performed under local or general anesthesia. Small lumps, especially those distal to the nipple, are suitable for local anesthesia, as long as the patient is cooperative.

Posture

The patient lies supine on the table.

The right arm should be in line with the shoulder on the hand. This is especially helpful for tumors in the upper quadrant.

For lumps in the upper half of the breast, the head of the table can be tilted up 30-40 degrees.

For tumors in the outer half of the breast, tilt the patient to the side opposite the surgical mass.

Complications

Tumor resection is a safe procedure without many complications. Common complications after surgery include:

• Congestion
• Infection
• Loss of aesthetics
• Re-cutting

Although resection is not a complication, it is something that should be clearly explained to the patient prior to surgery. A second surgery to remove more breast tissue is needed in two cases:

• If tumor cells are found near the edge of the tumor excision specimen when the procedure was done for a breast cancer.
• If the final pathology indicates an incompletely resected malignancy or a borderline phyllodes tumor.

Skill

Approach considerations

Mark the tumor with an indelible pen on the skin before making an incision.

With lumpectomy to remove a benign tumor, too much breast tissue must not be separated. Apply scissors or electrotherapy to the surface of the lump and remove it. Blood vessels can be controlled if any arise.

With melanectomy, separate the breast tissue and pull it out at least 1 cm from the palpable tumor. Orient the resected tumor with sutures or forceps. Always reconstruct the breast by spacing out the walls of the cavity with surgical sutures. The placement of a drain is not recommended because it compromises the aesthetics.

Removal of a palpable tumor

Make an incision

The location of the incision is determined by the location of the tumor.

For central tumors, a periosteal incision is most appropriate and heals quickly with minimal scarring.

For tumors in the outer half of the breast, a curved incision over the tumor following the natural crease of the breast is aesthetically pleasing.

Breast tissue separation

Using a skin hook and an opening spatula or Littlewood forceps, lift one side of the skin incision.

If a lumpectomy is performed for a benign tumor or for diagnostic purposes, do not separate the breast tissue but cut straight down to the surface of the tumor. Dissect around it, control bleeding if any, and remove the tumor.

When surgically removing a malignant tumor, it is important to separate the breast tissue around the tumor as is done with a mastectomy. Use scissors or electrotherapy to separate the breast tissue. Be careful not to thin the tissue too much. The breast tissue should be separated around the tumor and at least 1 cm away from it. Remove the tumor with a sufficient margin down the pectoralis major.

A newly reported method for predicting the intraoperative margin status of tumor resection, in which the margin of the scraping cavity is assessed by micro-X-ray tomography (micro-CT); This technique appears to show great promise in intraoperative determination of marginal tumor involvement and reduction in resection rates. The researchers reported that positive predictive value 83.3%, negative predictive value 94.7%, sensitivity 83.3%, and specificity 94.7% for micro-CT in the evaluated for resection of the margin of the tumor cavity. More recently, a systematic review and meta-analysis of cavity scraping plus lumpectomy versus excision alone in patients undergoing safe breast surgery found that extra cavity scraping is effective for reduce the percentage of positive margins and avoid resection with excessive volume of tissue removed compared with tumor resection alone.

Close the compartment

When surgically removing benign tumors, the cavity tends to be small. This is because benign tumors push out the stroma around the breast, which will return to its normal position once the tumor is removed. Surgical sutures may be used to create space before the skin sutures are placed.

Malignant lumps tend to grow into surrounding breast tissue; therefore, they leave a larger cavity when resected. This should be accounted for by taking advantage of the surrounding breast tissue to create aesthetics.

Abnormal tumor that cannot be palpated

Conducted ablation is performed for undetectable abnormalities. The radiologist inserts a wire through or near the abnormal mass. For lesions visible on ultrasound, the wire is inserted under ultrasound guidance. For parts that cannot be seen on ultrasound, this is done under stereotactic surgery.

The wire may be inserted one day before surgery.

After the wire is inserted, another mammogram is taken and used as a guide during surgery.

In the operating room, the surgeon removes the bandage through the wire and determines the sitting position of the incision, based on the spatial orientation of the lesion according to the original and determined mammography. The incision is usually placed close to the wire entry point if it is just anterior to the lesion.

If the wire entry point is far from the actual site of the lesion, an incision is made closer to the lesion.

When the breast tissue is lifted, the wire is pulled through the skin into the wound.

Once the lesion is excised, radiographs are required to ensure complete resection.

Breast-conserving surgery

Recent years have seen the introduction and growing use of laparoscopic breast surgery, which allows surgeons to remove larger volumes of breast tissue without sacrificing aesthetics. This post-operative breast defect is filled with tissue displacement techniques or replaced with fat or muscle grafts.

Source: Medscape – Lumpectomy

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