Table 1.

En Bloc Resection of BIA-ALCL with Key Oncologic Principles

Surgical management of BIA-ALCL with oncologic technique
• A preoperative PET/CT scan serves as a surgical road map for planning en bloc resection.
• Mark the patient preoperatively for breast anatomy as well as planned incisions for mastopexy if necessary, reconstruction, and need for skin excision.
• Intraoperative ultrasound or localization with radioactive or magnetic seeds can localize capsular masses or discrete lymph nodes to facilitate resection.
• For select patients, tumescence of skin flaps may facilitate ablation.
• Utilize existing breast incisions.
• Inframammary approach provides the best exposure for an en bloc resection.
• Establish dissection plane surrounding the capsule with elevation of overlying skin and parenchymal flaps.
• Complete capsulectomy should always include the posterior capsule.
• Tumescence hydrodissection aids in the elevation of the posterior capsule off of the chest wall.
• Excise suspicious and confirmed lymphadenopathy, avoid sentinel lymph node or full axillary dissection.
• Ensure meticulous hemostasis.
• Liberal drain placement.
• Change instruments for contralateral procedures.
• Specimen should be oriented for pathology evaluation.
• Surgical clips should be placed in the tumor bed particularly in an area where a mass is resected.
• Local anesthetic injection for intercostal blocks with lidocaine/Marcaine or Exparel.
• Reconstruction with smooth implants or autologous tissue based on stage of disease.
• Postoperative immobilization in surgical bra.