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Technical Notes

  1. Number of Resected Lymph Nodes: The average number of axillary lymph nodes resected is between 15 to 25.
  2. Postoperative Drainage: The Drains are left in place on the average of 5-6 days.
  3. Numbness at inferior aspect of Arm: In the majority of cases the intercostal brachial nerve and its branches, are frequently severed.
  4. Axillary Specimen Handling: The surgeon should always orient the specimen with silk sutures indicating LEVEL I and LEVEL III before sending it to the pathologist. 
  1. Axillary Sentinel Lymphadenectomy for Breast Cancer Q
    1. The theory behind this technique is, when a sentinel axillary lymph node (or first node in the lymphatic drainage path) can be identified,
    2. It correlates with the status of the rest of the lymph nodes of the axilla.
    3. An axillary lymph node can be identified in 92% of the patients with breast cancer using combined dye and scintigraphic mapping techniques.
    4. In addition, a sentinel lymph node will be found positive (with metastatic tumor) in all patients with axillary invasion, and a negative sentinel lymph node equates to an axilla negative for tumor invasion.
    5. One of the positive aspects of a sentinel lymphadenectomy is that it will eliminate most of the morbidity associated with standard axillary dissection. 
  2. The Technique There are two methods to identify an axillary sentinel lymph node.
    1. Vital Blue dye techniquenand
    2. Filtered technetium-lable sulfur colloid (scintigraphy). Q 
    3. Combined method - Prefered.
  3. Indications
    1. All patients requiring an axillary dissection for staging purposes.
    2. This includes patients requiring a lumpectomy with axillary dissection followed by radiation treatment or a patient requiring a standard modified radical mastectomy (Stage I, II and III).
    3. Patients with medial lesions of the breast should be excluded as well as patients whose lesions cannot be accurately diagnosed. 
  4. Performing the Lumpectomy or Total Mastectomy
    The total mastectomy or the lumpectomy should be then performed.
Contraindications For Breast Conservative Surgery:
Absolute contraindication – 
  1. Multicentric tumour
  2. Diffuse microcalcification involved in whole breast.
  3. T4 tumor.      

Relative contraindication -

  1. Pregnancy  
  2. Previous irradiation
  3. Collagen vascular disease
  4. Tumour > 4 cm in size.
  5. Pendulous breast.
  1. Breast Reconstruction After Mastectomy
    1. Common breast reconstruction techniques include synthetic implants and autologous tissue flaps (including the latissimus dorsi flap and the transverse rectus abdominis myocutaneous flap).
    2. Procedures may be implemented immediately following mastectomy or can be deferred until after adjuvant therapy is completed.
  2. Techniques of Reconstruction
    1. Implant Reconstruction

      1. Most common implant internal / external is silicone.
      2. An implant consists of a silicone shell that contains saline or silicone gel and is available in a variety of shapes and sizes.
    2. Autologous Tissue Flaps

      1. Of several autologous flap options, the most common are the latissimus dorsi flap and the TRAM flap. Q
      2. The latissimus dorsi flap
      3. The transverse rectus abdominis myocutaneous (TRAM) flap is currently considered the gold standard of breast reconstruction. This autologous tissue transfer is well suited for immediate reconstruction.
      4. The conventional TRAM flap or pedicle flap is supplied superiorly by the superior epigastric artery and vein.
      5. Free TRAM: In this procedure, the inferior blood supply, the deep inferior epigastric vessels, and the superior pedicle are divided, then the entire flap is brought up to the mastectomy site.
      6. Fine suturing is used to reattach or anastomose the inferior epigastric vessels microscopically into the recipient vessels -- in most cases, the thoracodorsal vessels.
      7. The gluteal free flap

A typical latissimus dorsi flap procedure, in which autologous tissue is rotated to the mastectomy defect.

A conventional transverse rectus abdominis myocutaneous (TRAM) flap procedure (A) and a free TRAM procedure (B), which improves blood supply to the flap.


Inflammatory vs. Noninflammatory Breast Cancer



Dermal lymph vessel invasion is present with or without inflammatory changes.

Inflammatory changes are present without dermal lymph vessel invasion.

Cancer is not sharply delineated.

Cancer is better delineated.

Erythema and edema frequently involve >33% of the skin over the breast.

Erythema is usually confined to the lesion, and edema is less extensive.

Lymph node involvement is present in >75% of cases.

Lymph nodes are involved in approximately 50% of the cases.

Distant metastases are present in 25% of cases.

Distant metastases are less common at presentation.

Distant metastases are more common at initial presentation.



  1. Biomarkers of breast cancer
    1. Prolifrative cell nuclear antigen PCNA, Ki-67, Br- Udr
    2. Indicator of apoptosis – Bcl – 2
                                          - Bax / bcl - 2
                                          - PRKCA
                                          - MXI
    3. Angiogeneesis factor - FGF-3, VEGF
    4. Cell addiesion molecular - CD-34, CDH1, CTNNB1, PECAM1, ITGB3
    5. Growth factors - BMP6, CSF1, CSF3, EGF, FGF18, FGF3, IGF1, IGF2, TGFA.
    6. DNA repair   - ATM, BRCA1, BRCA1, BRCA2, PCNA, RAD51, TP53, XRCC3


Treatment of choice for carcinoma breast with positive axillary lymph nodes with modified radical mastectomy done – (AIIMS May 08)

  1. Adriyamycin and tamoxifen if there is estrogen receptor positivity
  2. RT given if nodes are 4 in number
  3. Aromatase inhibitors given in premenopausal women
  4. Chemotherapy reduces recurrence risk and improves survival

Ans.    1. Adriyamycin and tamoxifen if there is estrogen receptor positivity




Axillary abscess is drained through which wall of axilla   (AIIMS MAY 2011)
A. Posterior wall                       
B. Lateral wall
C. Medial wall                   
​D. Floor of axilla


Ans. D. Floor of axilla

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