Novel surgical options in breast cancerMarch 6, 2019
Nipple-sparing mastectomy (NSM) in the United States was first described by Drs.
Joseph Crowe and Randall Yetman of the Cleveland Clinic (CCF) in 2004. Incision placement for the procedure can be inframammary, periareolar, lateral, upper outer quadrant, lateral with a periareolar extension, medial, and transareolar. When the tumour is superficial in location, preserving the skin anterior to the tumor can compromise the oncologic goal of clear margins. The technique of Tumour Ultrasound-guided Incision (TUGI) for NSM developed by Dr Stephen Grobmyer and colleagues at CCF overcomes this problem.
The technique employs intraoperative ultrasound to locate the tumour and delineate the skin overlying it. The incision is then based on the tumour location, removing the skin anterior to the tumour en bloc with the NSM. This approach balances oncologic safety and technical outcomes.
Lymphedema is the nemesis of axillary nodal surgery for breast cancer, impacting patient quality of life and resulting in significant functional, psychological, and social morbidity. Although the increased use of sentinel node biopsy, either when nodes are clinically negative, or following neo-adjuvant therapy (NAC), has resulted in lower lymphedema rates, the rates following full axillary dissection can be up to 77%.
Techniques to reduce lymphedema include axillary reverse mapping (ARM), meticulous dissection of arm lymphatics with loupe magnification, microsurgical lymphaticovenous bypass, and a triple mapping technique following NAC which incorporates Indocyanine Green (ICG) fluorescence for sentinel node bypass. Slides illustrating these techniques were shown.