Lumpectomy with Sentinel Lymph Node Biopsy
[Right / Left] breast [invasive ductal carcinoma / invasive lobular carcinoma / ductal carcinoma in situ], clinically node negative
Same
[Right / Left] partial mastectomy (lumpectomy) with [wire / magnetic seed / radar reflector / radioactive seed] localization and sentinel lymph node biopsy
[***, MD/DO]
[Resident/PA name]
General anesthesia via [laryngeal mask airway / endotracheal tube]
The patient is a [age]-year-old [female / male] with biopsy-proven [right / left] breast [invasive carcinoma / ductal carcinoma in situ] [measuring [X cm] on imaging], clinically node negative, presenting for breast-conserving surgery with sentinel lymph node biopsy. Image-guided localization of the [lesion / biopsy clip] was performed preoperatively. The risks, benefits, and alternatives, including mastectomy, were discussed, and informed consent was obtained.
The localized lesion was excised from the [clock position] position of the [right / left] breast. Specimen radiograph confirmed the [lesion, biopsy clip, and localizer / biopsy clip and localizer] within the specimen. [number] sentinel lymph node(s) were removed. The hottest ex vivo count was [X counts], and the residual axillary bed count was [X counts]. [No palpably suspicious axillary nodes were identified.]
The patient was brought to the operating room and placed supine with the ipsilateral arm abducted on an arm board. General anesthesia was induced. A surgical timeout was performed confirming patient identity, procedure, operative site and laterality, allergies, and administration of prophylactic antibiotics.
Technetium-99m sulfur colloid had been injected [on the day of surgery / the day before surgery]. [Isosulfan blue dye, [5 mL], was injected in the [subareolar / peritumoral] tissue, and the breast was massaged for 5 minutes.] The breast and axilla were prepped and draped in sterile fashion.
The gamma probe was used to localize the area of highest axillary counts, and a transverse incision was made in the lower axilla over this area. Dissection was carried through the subcutaneous tissue and the clavipectoral fascia. [number] sentinel lymph node(s) were identified with the gamma probe [and blue dye] and excised, with lymphatics controlled with [clips / electrocautery]. The ex vivo count of each node was recorded. The axillary bed was resurveyed with the gamma probe and palpated. All nodes with counts of at least 10% of the hottest ex vivo node were removed, along with any [blue-stained or] palpably suspicious nodes. The nodes were sent for [permanent / frozen section] pathology. Hemostasis was confirmed, and the axillary incision was closed in layers with [3-0 Vicryl] deep dermal and [4-0 Monocryl] subcuticular sutures.
A [curvilinear / radial / periareolar] incision was made overlying the localized lesion. Guided by the localizer, the lesion was excised with a rim of grossly normal breast tissue[, carrying the dissection to the pectoralis fascia]. The specimen was oriented with a short suture marking the superior margin and a long suture marking the lateral margin. Specimen radiograph confirmed the [lesion, biopsy clip, and localizer / biopsy clip and localizer] within the specimen. [Additional cavity shave margins were excised from the [superior, inferior, medial, and lateral] walls, each marked on the new margin surface and sent separately.]
The cavity was irrigated, and hemostasis was achieved with electrocautery. [Titanium clips were placed in the cavity walls for radiation planning.] [Oncoplastic tissue rearrangement was performed by mobilizing the adjacent breast parenchyma and reapproximating it with [2-0 Vicryl] sutures to fill the defect.] The incision was closed in layers with [3-0 Vicryl] deep dermal and [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
[Right / Left] partial mastectomy specimen, oriented (short suture superior, long suture lateral)[; separate cavity shave margins, labeled by orientation]; [number] sentinel lymph node(s), labeled with ex vivo counts
Minimal (less than 20 mL)
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** breast ***, clinically node negative
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** partial mastectomy (lumpectomy) with *** localization and sentinel lymph node biopsy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General anesthesia via ***
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with biopsy-proven *** breast *** measuring *** cm on imaging, clinically node negative, presenting for breast-conserving surgery with sentinel lymph node biopsy. Image-guided localization was performed preoperatively. The risks, benefits, and alternatives, including mastectomy, were discussed, and informed consent was obtained.
FINDINGS: The localized lesion was excised from the *** position of the *** breast. Specimen radiograph confirmed the *** and localizer within the specimen. *** sentinel lymph node(s) were removed. Hottest ex vivo count ***; residual axillary bed count ***.
DESCRIPTION OF PROCEDURE:
Supine, arm abducted. General anesthesia. Surgical timeout performed; laterality confirmed.
Technetium-99m sulfur colloid injected preoperatively.[ Isosulfan blue dye injected ***.] Breast and axilla prepped and draped.
Transverse lower axillary incision over the area of highest counts, carried through the clavipectoral fascia. *** sentinel node(s) identified with the gamma probe [and blue dye] and excised. Ex vivo counts recorded. Axillary bed resurveyed and palpated. All nodes with counts of at least 10% of the hottest node, and any blue or palpably suspicious nodes, removed. Nodes sent for *** pathology. Layered closure.
*** incision over the localized lesion. Lesion excised with a rim of normal breast tissue under localizer guidance. Specimen oriented (short suture superior, long suture lateral). Specimen radiograph confirmed the *** and localizer. [*** cavity shave margins excised and sent separately.] [Titanium clips placed in the cavity for radiation planning.] Hemostasis. Closure with 3-0 Vicryl deep dermal and 4-0 Monocryl subcuticular sutures.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Partial mastectomy specimen (oriented), *** cavity shave margins, and *** sentinel lymph node(s) to pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Positive Sentinel Lymph Node
Frozen section of [number] sentinel lymph node(s) was positive for metastatic carcinoma. [Completion axillary lymph node dissection was not performed because the patient met ACOSOG Z0011 criteria (cT1-2, clinically node negative, 1-2 positive sentinel nodes, breast-conserving surgery with planned whole-breast radiation).] [A level I and II axillary lymph node dissection was performed. The axillary vein was identified as the superior border, and the long thoracic and thoracodorsal nerves were identified and preserved. The level I and II nodal tissue was excised en bloc and sent as a separate specimen. A closed suction drain was placed in the axilla.]
Oncoplastic Reconstruction
Because of the volume of tissue excised relative to breast size, oncoplastic reconstruction was performed using [glandular tissue rearrangement / a reduction mammaplasty pattern]. The adjacent breast parenchyma was mobilized and advanced to fill the defect, then reapproximated with [2-0 Vicryl] sutures. [The nipple-areola complex was recentralized on a [superomedial / superior / inferior] pedicle.] The skin was closed in layers with [3-0 Vicryl] deep dermal and [4-0 Monocryl] subcuticular sutures.
Palpable Mass: No Localization
The lesion was palpable, and no preoperative localization was performed. [Intraoperative ultrasound was used to confirm the lesion location.] The mass was excised by palpation with a [1-cm] gross margin of normal breast tissue on all sides. The specimen was oriented with a short suture marking the superior margin and a long suture marking the lateral margin. Specimen radiograph confirmed the lesion and biopsy clip within the specimen.
Charting Tips
- State the orientation convention (for example, short suture superior, long suture lateral) and label each cavity shave by its orientation. This allows a targeted re-excision of a single margin if final pathology is positive.
- Document that the specimen radiograph showed the target lesion or biopsy clip and the localizer. If a seed or reflector is not seen on the radiograph, document its retrieval from the cavity. Radioactive seeds also need chain-of-custody documentation per institutional radiation-safety policy.
- Record the ex vivo count of each sentinel node, the hottest node count, and the residual axillary bed count. The standard is removal of every node with counts of at least 10% of the hottest ex vivo node, plus any blue or palpably suspicious node. Stating that the axilla was cleared to this standard supports a reliable sentinel node result.
- Document cavity clip placement. Clips mark the tumor bed for radiation boost and partial-breast planning and for future imaging.
- For positive sentinel nodes, record the intraoperative decision (completion dissection vs. omission under ACOSOG Z0011 or AMAROS criteria) and the criteria the patient met. When nodes go to permanent pathology only, this decision is made postoperatively.
- Sentinel node biopsy is generally omitted for pure DCIS treated with lumpectomy and for patients aged 70 or older with early-stage, hormone receptor-positive, HER2-negative, clinically node-negative cancers (Choosing Wisely, SSO). Use the Partial Mastectomy (Lumpectomy) template for those cases.
Documentation & Reimbursement Considerations
- Primary service: Report Lumpectomy with Sentinel Lymph Node Biopsy as the primary service when it is the definitive operation performed.
- The partial mastectomy code (9.88 wRVU, 90-day global) covers any excision of a breast lesion with margins. Oncoplastic closure does not change the code.
- Intraoperative lymphatic mapping and sentinel node identification is reported with an add-on code (2.44 wRVU). It requires intraoperative injection of blue dye or radiocolloid with documentation of mapping.
- Sentinel node excision is billed separately from the lumpectomy and mapping, and code selection depends on depth. The deep axillary node code (6.27 wRVU, 90-day global) applies when dissection passes through the clavipectoral fascia, which covers most axillary sentinel nodes, and the superficial node code (3.70 wRVU, 10-day global) applies only when the node lies entirely superficial to that fascia. Document depth of dissection, number of nodes identified, hot/blue status, ex vivo counts, and pathologic result.
- Cavity shave margins taken at the same operation are included in the partial mastectomy and are not billed separately. A return to the operating room for margin re-excision is a separate procedure.
- 90-day global period: oncology follow-up, radiation planning, and wound checks are bundled for the surgical fee. Radiation oncology and medical oncology bill independently.