In accordance with current evidence based guidelines [4
], we performed a partial mastectomy/quadrantectomy. Prior to surgery, patient was prepped by radiology for a sentinel lymph node biopsy with frozen section analysis approximately two hours before her operation with radioactive tracer. Isobars were marked on the axillary area and nuclear medicine mapping was used to locate the sentinel node. The sentinel node was identified in the midaxillary line, elevated, and removed. Nuclear scanning was retested over the area and shown to be negative. Pathologist confirmed lymphocytes in the node and did not note metastasis. If the sentinel node was located substernally, it would have been left in place and targeted for radiation therapy. If sentinel node along midaxillary line was positive, a partial mastectomy of the whole breast with axillary lymph nodes would have been removed. Since the sentinel node was negative, a partial mastectomy/quadrantectomy was performed without removal of any further lymph nodes.
Preceding surgery, the palpable mass was marked in the upper medial quadrant of the left breast via ultrasound with generous margins drawn with pen. The mass was removed using a paddle of ellipsed skin at approximately 7
cm × 4
cm widening down to the pectoralis fascia with subtraction of fascia as well. A bovie was used set at 20 degrees to remove the breast mass and cauterize perforating vessels. Clips were placed along the area where the removed fascia was to tag previous location of the tumor. Incision was closed using vicryl for deep dermis and monocryl for skin. Dermabond was spread along the closure site. Patient has well tolerated the procedure, and positive cosmetic results were noted. No drain was inserted, and the patient had one post-op day in the hospital.
Final pathology of the left axillary sentinel lymph node showed sinus histiocytosis with lymphoid hyperplasia without histologic evidence of malignancy. Anterior breast tissue showed adipose tissue with focal septal fibrosis lacking histologic malignancy. The lumpectomy illustrated poorly differentiated invasive ductal carcinoma with sarcomatous features. The Nottingham histologic grade: nuclear pleomorphism of 3, tubule formation of 3, and mitotic count of 3 (22/10HPF) made the combined Nottingham score 9. The breast lumpectomy size was 10.1 × 6.0 × 7.2
cm with irregular tumor mass measuring 2.3 × 2.0 × 1.8
cm at its greatest dimension. Tumor had no identified microcalcifications, lymphatic/vascular invasion, nor skin involvement. Venous vascular invasion was suspicious in one section on analysis. Surgical resection margins were free of tumor; tumor was approximately 1.5
cm of inferior resection margin, 3.0
cm on superior resection margin, 3.4
cm from peripheral resection margin, and 4.2
cm from medial resection margin. Pathologic state is IIA and TNM grading of pT2pN0pMX. Immunoperoxidase stains were performed and revealed a population of sarcomatous appearing cells with the tumor to be positive for actin; stains for estrogen and progesterone receptors were uniformly negative. Overlying skin and dermis was free of malignancy.
After surgery patient was referred to oncologist for followup. One year out from surgery patient is well with no signs of recurrence of sarcoma of the breast.