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.
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.
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