How is lumpectomy for palpable lumps performed?

Updated: Dec 24, 2019
  • Author: Kanchan Kaur, MBBS, MS (GenSurg), MRCSEd; Chief Editor: Erik D Schraga, MD  more...
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Answer

Answer

Making the incision

The placement of the incision is determined by the location of the lump. [10]

For central lumps, a periaerolar incision is best suited and heals well with minimal scarring.

For lumps in the outer halves of the breast, a curvilinear incision over the lump along the natural crease lines of the breast gives the best cosmetic result.

Raising the flaps

Using skin hooks and cat 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 the 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 the 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 1 centimeter beyond it. Excise the lump with a sufficient margin down to the pectoral muscle.

A novel method for predicting lumpectomy intraoperative margin status has been reported in which shaved cavity margins were evaluated with microcomputed tomography (micro-CT) scanning; this technique appears to show promise in the intraoperative identification of margin tumor involvement and reduction of reexcision rates. [11]  The investigators reported a 83.3% positive predictive value, a 94.7% negative predictive value, 83.3% sensitivity, and 94.7% specificity for micro-CT in assessing lumpectomy shaved cavity margins. [11]  More recently, a systematic review and meta-analysis of cavity shaving plus lumpectomy versus lumpectomy alone in patients undergoing breast-conserving surgery found additional cavity shaving was effective for reducing the positive margin rate and for avoiding reoperation, and it did not appear to have excessive excised tissue volume relative to lumpectomy alone. [12]

Closure of the cavity

When a lumpectomy is performed for a benign lump, the cavity tends to be small. This is because benign lumps push the surrounding breast stroma, which springs back to its normal place once the lump is excised. 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.


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