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DOI: 10.1055/s-0031-1281513
Immediate Microsurgical Breast Reconstruction and Simultaneous Sentinel Lymph Node Dissection: Issues with Node Positivity and Recipient Vessel Selection
Publication History
Publication Date:
29 June 2011 (online)
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ABSTRACT
Sentinel lymph node dissection (SLND) during mastectomy has been increasing given the decreased risk of lymphedema. Simultaneous reconstruction with a microsurgical breast reconstruction is often performed, but with node positivity a completion axillary lymph node dissection (ALND) must be performed subsequently. This study examines the potential risks especially in relation to microsurgical reconstruction. All patients undergoing microsurgical breast reconstruction at an academic institution from 2004 to 2010 were evaluated in a prospective database. Patients with immediate reconstruction and SLND were identified. Management of positive lymph node status was ascertained through extensive chart review. There were 610 reconstructions performed, 170 delayed and 440 immediate. From the immediate reconstructions, 110 patients (25%) had SLND and of these patients, 16 (14.55%) had a positive SLND. All 16 patients had internal mammary recipient vessels for free tissue transfer. Seven patients had intraoperative completion ALND, while nine patients had staged completion ALND at a later date. There were no adverse affects from completion ALND. Simultaneous mastectomy, SLND, and microsurgical reconstruction can be performed safely. The internal mammary vessels are preferred recipient vessels as node positive patients may require subsequent completion ALND. If a thoracodorsal anastomosis is performed, a potential risk exists for vessel injury and flap loss with completion ALND.
KEYWORDS
Breast reconstruction - sentinel lymph node biopsy - deep inferior epigastric perforator flap - microsurgical breast reconstruction - breast cancer
REFERENCES
- 1 Krag D, Weaver D, Ashikaga T et al.. The sentinel node in breast cancer—a multicenter validation study. N Engl J Med. 1998; 339 (14) 941-946
- 2 Wada N, Imoto S, Hasebe T, Ochiai A, Ebihara S, Moriyama N. Evaluation of intraoperative frozen section diagnosis of sentinel lymph nodes in breast cancer. Jpn J Clin Oncol. 2004; 34 (3) 113-117
- 3 Chao C, Wong S L, Ackermann D et al.. Utility of intraoperative frozen section analysis of sentinel lymph nodes in breast cancer. Am J Surg. 2001; 182 (6) 609-615
- 4 Giuliano A E, Jones R C, Brennan M, Statman R. Sentinel lymphadenectomy in breast cancer. J Clin Oncol. 1997; 15 (6) 2345-2350
- 5 Veronesi U, Paganelli G, Viale G et al.. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med. 2003; 349 (6) 546-553
- 6 McLaughlin S A, Wright M J, Morris K T et al.. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: patient perceptions and precautionary behaviors. J Clin Oncol. 2008; 26 (32) 5220-5226
- 7 Veronesi U, Paganelli G, Galimberti V et al.. Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes. Lancet. 1997; 349 (9069) 1864-1867
- 8 Weiser M R, Montgomery L L, Susnik B, Tan L K, Borgen P I, Cody H S. Is routine intraoperative frozen-section examination of sentinel lymph nodes in breast cancer worthwhile?. Ann Surg Oncol. 2000; 7 (9) 651-655
- 9 Turner R R, Hansen N M, Stern S L, Giuliano A E. Intraoperative examination of the sentinel lymph node for breast carcinoma staging. Am J Clin Pathol. 1999; 112 (5) 627-634
- 10 Kronowitz S J, Chang D W, Robb G L et al.. Implications of axillary sentinel lymph node biopsy in immediate autologous breast reconstruction. Plast Reconstr Surg. 2002; 109 (6) 1888-1896
- 11 Moran S L, Nava G, Behnam A B, Serletti J M. An outcome analysis comparing the thoracodorsal and internal mammary vessels as recipient sites for microvascular breast reconstruction: a prospective study of 100 patients. Plast Reconstr Surg. 2003; 111 (6) 1876-1882
- 12 Saint-Cyr M, Youssef A, Bae H W, Robb G L, Chang D W. Changing trends in recipient vessel selection for microvascular autologous breast reconstruction: an analysis of 1483 consecutive cases. Plast Reconstr Surg. 2007; 119 (7) 1993-2000
- 13 Grotting J C. Immediate breast reconstruction using the free TRAM flap. Clin Plast Surg. 1994; 21 (2) 207-221
- 14 Robb G L. Thoracodorsal vessels as a recipient site. Clin Plast Surg. 1998; 25 (2) 207-211
- 15 Arnez Z M, Bajec J, Bardsley A F, Scamp T, Webster M H. Experience with 50 free TRAM flap breast reconstructions. Plast Reconstr Surg. 1991; 87 (3) 470-478 discussion 479-482
- 16 Hefel L, Schwabegger A, Ninković M et al.. Internal mammary vessels: anatomical and clinical considerations. Br J Plast Surg. 1995; 48 (8) 527-532
- 17 Medina-Franco H, Vasconez L O, Fix R J et al.. Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg. 2002; 235 (6) 814-819
Bernard T LeeM.D. F.A.C.S.
Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center
Harvard Medical School, 110 Francis Street, Suite 5A, Boston, MA 02215
Email: blee3@bidmc.harvard.edu