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Lumpectomy Sentinel Lymph Node Biopsy Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left breast cancer.

POSTOPERATIVE DIAGNOSIS:  Left breast cancer.

PROCEDURES PERFORMED:
1.  Left needle localized lumpectomy.
2.  Sentinel lymph node biopsy with intraoperative frozen section.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

COMPLICATIONS:  None apparent.

DRAINS:  None.

ESTIMATED BLOOD LOSS:  Minimal.

SPECIMENS:
1.  Sentinel lymph node biopsy, 2 nodes sent.
2.  Left needle localized lumpectomy.
3.  Additional margins including anterior superior as a single and then separate medial, lateral, inferior and posterior.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old woman who presents with a nonpalpable biopsy-proven left breast cancer. After discussion, she elected to proceed with breast conservation with the needle localized lumpectomy and sentinel lymph node biopsy.

DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient was taken to the operating room and placed on the operating table in the supine position. Anesthesia was induced. The patient was intubated. The area involving the left breast and axilla were prepped with Betadine and draped sterilely. The localization films were viewed. Methylene blue was injected in the circumareolar position and was allowed to migrate to the axilla. A radiation detector was used to detect the hot spot in the left axilla. An incision was created along the anterior border of the left axilla and an obviously blue and radiative lymph node was identified with an adjacent node being mildly radiative. These 2 nodes were excised. Interrogation with radiation within the axilla showed no other hot spots, and no other blue nodes were detected. The nodes were forwarded to pathology where frozen section showed no evidence of metastatic disease. The wound was inspected for hemostasis, which was excellent. It was closed with interrupted 3-0 Vicryl and running 4-0 Monocryl. An incision was created over the inferior left breast excising the entrant site of the needle, which was located in the inframammary position and extending superiorly over the inferior portion of the breast in the 6 o'clock position. Incision was deepened with electrocautery. The underlying cord tissue surrounding the localization needle was excised. It was forwarded to radiology where specimen radiographs confirmed the presence of the mammographic abnormality and the previously placed clip within the specimen. It was from there forwarded to pathology. Additional margins were taken, marked separately, posterior, medial, lateral, inferior and a combined anterior superior. These were all forwarded, labeled separately, in formalin, to pathology for later analysis. The wound was inspected for hemostasis, which was excellent. It is noted that the deep margin was chest wall as the lesion was quite deep. The wound was closed with interrupted 3-0 Vicryl and running 4-0 Monocryl subcuticular stitch. Benzoin, Steri-Strips and sterile dressings were applied. The patient was awakened and returned to recovery in stable condition having tolerated the procedure well.