Breast Conserving Surgery and Sentinel Lymph Node Biopsy under Local Anesthesia for Breast Cancer

doi:10.4236/jct.2012.325102

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Journal of Cancer Therapy, 2012, 3, 810-813

http://dx.doi.org/10.4236/jct.2012.325102 Published Online October 2012 (http://www.SciRP.org/journal/jct)

Breast Conserving Surgery and Sentinel Lymph Node

Biopsy under Local Anesthesia for Breast Cancer

Shinichiro Kashiwagi*, Naoyoshi Onoda, Tsutomu Takashima, Yuka Asano, Naoki Aomatsu,

Masanori Nakamura, Hidemi Kawajiri, Tetsuro Ishikawa, Kosei Hirakawa

Department of Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan.

Email: *[email protected]

Received August 21st, 2012; revised September 23rd, 2012; accepted October 8th, 2012

ABSTRACT

Background: Breast conserving surgery and sentinel lymph node biopsy has become the standard operation for early

breast cancer. This operation has been performed under local anesthesia for patients that would like short-term admis-

sion or for those not indicated for general anesthesia due to complications. This report presents the outcomes of breast

conserving surgery and sentinel lymph node biopsy under local anesthesia. Patients and Methods: The study included

61 patients with breast cancer that were all definitely diagnosed before surgery. The indications were preoperatively

diagnosed localized DCIS, invasive carcinoma measuring less than 3 cm in tumor diameter on ultrasound, and tumors

with negative axillary lymph nodes. The surgical procedures included breast conserving surgery associated with sentinel

lymph node navigation biopsy. Results: The surgery could be performed under local anesthesia in all 61 patients, and

no patient was converted to general anesthesia. Four patients had sentinel lymph node metastasis. Surgical stumps were

positive in 18 patients (29.5%). Ten Gy of boost irradiation of the tumor bed was added to the conventional breast irra-

diation for these patients. There were no serious complications associated with surgery. Conclusion: Breast conserving

surgery and sentinel lymph node biopsy for early breast cancer can be performed safely under local anesthesia. This

procedure contributes to shortening the length of hospitalization and thereby saving medical resources without deceas-

ing the quality of treatment.

Keywords: Breast Cancer; Local Anesthesia; Breast Conserving Surgery

1. Introduction

There is a trend towards more frequently performing

breast conserving surgery for breast cancer, and partial

breast resection (Bp) combined with sentinel lymph node

biopsy (SNB) has became one of the standard treatment

methods for early-stage breast cancer [1-5]. The inci-

dence of breast cancer is increasing among Japanese

women, as well as in the other countries in the world.

The enlightenments for the well-arranged management of

breast cancer have been gradually but continuously ac-

cepted in public. There is an increasing demand of the

integrated and standard systematic treatment in the pa-

tients with breast cancer. Therefore, less invasive and

less time or cost consuming treatments became necessary

and acceptable widely as ever before. Bp combined with

SNB has been performed under local anesthesia in the

out-patient setting mainly for elderly patients, requesting

surgery without admission. Although the technique and

significance of SNB under local anesthesia has been re-

ported and discussed enthusiastically, there had been few

reports concerning those of performing Bp at the same

time with SNB [6,7]. The advantages of breast conserve-

ing surgery for breast cancer under local anesthesia are

avoiding risks due to general anesthesia, and treatment

without a hospital stay is therefore possible [6-11]. On

the other hand, there remain several critical drawbacks of

this procedure, such as the limitations in the pain control

during operation and in the extent of resectable areas.

This study reviewed the results of breast conserving sur-

gery for breast cancer under local anesthesia in this de-

partment, and discussed its feasibility.

2. Patients and Methods

This study evaluated a total of 61 patients, with a pre-

operative diagnosis of breast cancer established based on

a core needle biopsy between April 2006 and March

2011. The extent of infiltration of the lesion was evalu-

ated using ultrasonography and MRI. The axillary lymph

nodes were evaluated with ultrasonography, CT as well

as palpation. The main indication was a diagnosis of

ductal carcinoma in situ (DCIS) or invasive carcinoma

*Corresponding author.

Breast Conserving Surgery and Sentinel Lymph Node Biopsy under Local Anesthesia for Breast Cancer 811

(tumor diameter < 3 cm) made preoperatively, without a

clinical suspicion of axillary lymph node metastasis. Pa-

tients who met these criteria received a full explanation

regarding the merits and demerits of systemic and local

anesthesia, as well as the risk of recurrence following

breast-sparing surgery. Written informed consent was

obtained from each patient. Breast conserving surgery for

breast cancer was performed under local anesthesia

through outpatient visits for those that gave their in-

formed consent. Local anesthesia was conducted with

lidocaine (0.5% to 1.0%) containing 5 μg/ml epinephrine

(Figure 1). Bp and SNB were performed, and RI and dye

were used to identify the sentinel nodes. Tc-99 m phytate

colloid (1 mCi) was injected the day before surgery in-

tracutaneously right above the tumor, subcutaneously,

and near the tumor, followed by lymphoscintigraphy to

identify the sentinel nodes, explore those in the axilla,

and locate sentinel nodes during surgery (Figure 2(a)).

Four ml of ICG solution containing 1.0 ml lidocaine (1%)

was injected subcutaneously through the affected areola

of the breast to form a swelling, light massage was ap-

plied to the injection site, and a skin incision was then

made approximately 10 minutes later to identify the

lymph nodes dyed green as the sentinel nodes (Figure

2(b)). A parapapillary 3 cm arch-wise skin incision was

made, a skin flap was created and finally the tumor was

excised with a margin of 1 cm according to its extension.

Tumors in the upper lateral quadrant required an ap-

proximately 5 cm axillary incision for both Bp and SNB

(Figure 3(a)). Tumors in other locations required an ap-

proximately 2 cm axillary incision for SNB. A half-circle

incision around the areola was made for Bp (Figure

3(b)). No drains were placed. A total of 60 Gy of exter-

nal radiation was applied to the conserved breast. Pa-

tients with positive surgical margins received an addi-

tional 10 Gy of boost irradiation (60 Gy in total) instead

of additional resection.

3. Results

A total 61 cases were surgically treated at this institute.

Figure 1. Local anesthesia: Local anesthesia was conducted

with lidocaine (0.5% to 1.0%) containing 5 μg/ml epinephrine.

(a)

(b)

Figure 2. Sentinel Node Navigation: Radioisotope (99 m Tc

phytate): Peritumoral injection one day before surgery (a);

Dye (indocyanine green): Intradermal injection to areola

(b).

(a)

(b)

Figure 3. Surgery: Tumor in upper lateral quadrant: about

5 cm length axillary incision is made for both Bp and SNB

(a); Tumor in the other locations: about 2 cm axillary inci-

sion for SNB. 1/2 circle incision around the areola for Bp

(b).

Breast Conserving Surgery and Sentinel Lymph Node Biopsy under Local Anesthesia for Breast Cancer

812

All of the patients underwent surgery with local anesthe-

sia (100% of the cases). The average age of the patients

was 62. The tumor stage was: Tis (n = 5), T1 (n = 42),

and T2 (n = 14). The total volume of lidocaine required

for surgery was less than 7.0 mg/kg. Surgery could be

completed under local anesthesia in all patients, and no

patients had to be converted from local to general anes-

thesia. No hematomas of the resected site, which would

require needle drainage, were observed postoperatively.

SNB was performed in 44 patients, and metastasis was

confirmed in four of them, and all of those patients un-

derwent lymphadenectomy under general anesthesia at a

later date. The proportion of patients with positive closed

margins in this study (n = 18) was equivalent to that pre-

viously reported in breast-sparing surgery under general

anesthesia (Figure 4). The postoperative observation

period ranged from two to 36 months (average: 25 months),

and local recurrence developed in four patients, that sub-

sequently underwent breast total resection (Bt) under

general anesthesia. No distant organ recurrences were

detected. The patients with positive closed margins

showed no significant difference in the in the DFS (dis-

ease-free survival; Figure 5).

4. Discussion

Breast resection under general anesthesia and partial

Figure 4. Treatment Schedule: Treatment is undergone 2

nights admission or ambulatory day surgery as patient’s

preference.

Figure 5. Disease free survival of patients with close margin:

Margin status was not concerned with disease free survival.

mastectomy combined with axillary lymph node dissect-

tion has been wildly conducted in the radical treatment of

breast cancer. Axillary lymph node dissection under local

anesthesia has been reported [8-11], but general anesthe-

sia is considered to be necessary in terms of the efficacy

and surgery-associated pain [12,13]. SNB, on the other

hand, is possible under local anesthesia, and, although

the observation periods were short in the present investi-

gation, no recurrences in the axillary lymph nodes were

observed. In this study, we could successfuy establish a

well-controlled pain relief by adding sufficient volume of

local anesthesia to retromammary space under the precise

ultrasound guidance before performing Bp. By adding

appropriate postoperative radiation therapy after breast-

conserving surgery, equivalent survival rate was obtained

in the patients undergone Bp in comparison to those un-

dergone mastectomy, and the permissible low-rate of

recurrence in the residual-breast could also be obtained

[1,2]. In addition, according to the well-known results of

the NSABP B-32 large-scale clinical trial, demonstrating

that completion surgical treatment by axillary lymph

node dissection did not affect the long-term prognosis of

the cases with negative SNB result, there is a growing

trend to omit axillary lymph node dissection in patients

with pathologically confirmed negative SNB result [14].

A recent study, ACOSOG-Z0011, demonstrated the pos-

sibility to omit salvage axillary dissection in certain

population of the cases with positive SNB under several

conditions by adding adjuvant therapies [15]. Further

evidences for the meaning to perform SNB will be re-

vealed in the near future. Currently, there is no doubt

performing SNB to obtain the accurate staging of the

patients with early breast cancer for conducting inte-

grated treatment. In other words, less invasive surgical

techniques can be applied in order to obtain the speci-

mens to confirm the pathological factors to establish an

individual treatment strategy. The extent of infiltration of

breast cancer tor partial mastectomy should be accurately

determined before surgery, in order to decrease the num-

ber of positive closed margins. Ultrasonography and

MRI are useful [16-19], and the resection range is deter-

mined based on these tests. The rate of positive closed

margins in the present study was equivalent to that ob-

tained in a previous study that investtigated breast-spar-

ing surgery under general anesthesia [20]. The patients

with positive surgical margins underwent boost irradia-

tion instead of additional resection, but no differences in

the DFS were seen, suggesting that boost irradiation is

effective. The tolerability of boost irradiation was con-

firmed, because no complications were observed either

during or after surgery.

5. Conclusion

It is necessary to accumulate further cases of breast-

Breast Conserving Surgery and Sentinel Lymph Node Biopsy under Local Anesthesia for Breast Cancer

813

sparing surgery under local anesthesia, in order to estab-

lish the precise criteria, and determine the efficacy as

well as tolerability. However, the current results sug-

gested that the above described surgical procedure is

useful as one type of minimally-invasive surgery.

REFERENCES

[1] U. Veronesi, et al., “Twenty-Year Follow-Up of a Ran-

domized Study Comparing Breast-Conserving Surgery

with Radical Mastectomy for Early Breast Cancer,” The

New England Journal of Medicine, Vol. 347, No. 16,

2002, pp. 1227-1232. doi:10.1056/NEJMoa020989

[2] B. Fisher, et al., “Twenty-Year Follow-Up of a Ran-

domized Trial Comparing Total Mastectomy, Lumpec-

tomy, and Lumpectomy Plus Irradiation for the Treatment

of Invasive Breast Cancer,” The New England Journal of

Medicine, Vol. 347, No. 16, 2002, pp. 1233-1241.

doi:10.1056/NEJMoa022152

[3] G. F. Schwartz, et al., “Proceedings of the Consensus

Conference on the Role of Sentinel Lymph Node Biopsy

in Carcinoma of the Breast April 19 to 22, 2001,

Philadelphia, Pennsylvania,” Human Pathology, Vol. 33,

No. 6, 2002, pp. 579-589.

doi:10.1053/hupa.2002.124117

[4] U. Veronesi, et al., “A Randomized Comparison of

Sentinel-Node Biopsy with Routine Axillary Dissection

in Breast Cancer,” The New England Journal of Medicine,

Vol. 349, No. 6, 2003, pp. 546-553.

doi:10.1056/NEJMoa012782

[5] U. Veronesi, et al., “Sentinel-Lymph-Node Biopsy as a

Staging Procedure in Breast Cancer: Update of a

Randomised Controlled Study,” Lancet Oncology, Vol. 7,

No. 12, 2006, pp. 983-990.

doi:10.1016/S1470-2045(06)70947-0

[6] A. Y. Joseph, et al., “Simple Anesthesia for Simple

Mastectomies,” Breast Cancer Research and Treatment,

Vol. 77, No. 2, 2003, pp. 189-191.

doi:10.1023/A:1021386722363

[7] G. W. Carlson , “Total Mastectomy under Local Anes-

thesia: The Tumescent Technique,” Breast Journal, Vol.

11, No. 2, pp. 100-102.

doi:10.1111/j.1075-122X.2005.21536.x

[8] P. Fenaroli, et al., “Axillary Sentinel Node Biopsy under

Local Anaesthesia in Early Breast Cancer,” Annals of

Oncology, Vol. 11, No. 12, 2000, pp. 1617-1618.

doi:10.1093/oxfordjournals.annonc.a010407

[9] A. Luini, et al., “Sentinel Lymph Node Biopsy Performed

with Local Anesthesia in Patients with Early-Stage Breast

Carcinoma,” Annals of Surgery, Vol. 137, No. 10, 2002,

pp. 1157-1160.

[10] M. L. Smidt, et al., “Sentinel Lymph Node Biopsy

Performed under Local Anesthesia Is Feasible,” American

Journal of Surgery, Vol. 187, No. 6, 2004, pp. 684-687.

doi:10.1016/j.amjsurg.2003.09.009

[11] A. Luini, et al., “The Sentinel Node Biopsy under Local

Anesthesia in Breast Cancer: Advantages and Problems,

How the Technique Influenced the Activity of a Breast

Surgery Department; Update from the European Institute

of Oncology with More than 1000 Cases,” Breast, Vol.

16, No. 5, 2007, pp. 527-532.

doi:10.1016/j.breast.2007.04.003

[12] C. L. van Berlo, et al., “Ambulatory Sentinel Node

Biopsy under Local Anaesthesia for Patients with Early

Breast Cancer,” European Journal of Surgical Oncology,

Vol. 29, No. 4, pp. 383-385.

doi:10.1053/ejso.2002.1420

[13] N. Athey, et al., “Day-Case Breast Cancer Axillary

Surgery,” Annals of The Royal College of Surgeons of

England, Vol. 87, No. 2, 2005, pp. 96-98.

doi:10.1308/1478708051667

[14] D. N. Krag, et al., “Technical Outcomes of Sentinel-

Lymph-Node Resection and Conventional Axillary-

Lymph-Node Dissection in Patients with Clinically Node-

Negative Breast Cancer: Results from the NSABP B-32

Randomised Phase III Trial,” The Lancet Oncology, Vol.

8, No. 10, 2007, pp. 881-888.

doi:10.1016/S1470-2045(07)70278-4

[15] A. E. Giuliano, The Lancet Oncology Axillary Dissection

vs No Axillary Dissection in Women with Invasive

Breast Cancer and Sentinel Node Metastasis: A Ran-

domized Clinical Trial,” Journal of the American Medical

Association, Vol. 305, No. 6, 2011, pp. 569-575.

doi:10.1001/jama.2011.90

[16] C. A. Finlayson and T. A. MacDermott, “Ultrasound Can

Estimate the Pathologic Size of Infiltrating Ductal

Carcinoma,” Annals of Surgery, Vol. 135, No. 2, 2000, pp.

158-159.

[17] S. Akashi-Tanaka, et al., “Diagnostic Value of Contrast-

Enhanced Computed Tomography for Diagnosing the

Intraductal Component of Breast Cancer,” Breast Cancer

Research and Treatment, Vol. 49, No. 1, 1998, pp. 79-86.

doi:10.1023/A:1005986529910

[18] L. Esserman, et al., “Utility of Magnetic Resonance

Imaging in the Management of Breast Cancer: Evidence

for Improved Preoperative Staging,” Journal of Clinical

Oncology, Vol. 17, No. 1, 1999, pp. 110-119.

[19] G. Amano, et al., “Correlation of Three-Dimensional

Magnetic Resonance Imaging with Precise Histopatho-

logical Map Concerning Carcinoma Extension in the

Breast,” Breast Cancer Research and Treatment, Vol. 60,

No. 1, 2000, pp. 43-55. doi:10.1023/A:1006342711426

[20] Y. Komoike, et al., “Analysis of Ipsilateral Breast Tumor

Recurrences after Breast-Conserving Treatment Based on

the Classification of True Recurrences and New Primary

Tumors,” Breast Cancer, Vol. 12, No. 2, 2005, pp. 104-

111. doi:10.2325/jbcs.12.104