Keywords

1 Introduction

Nowadays, specificity is a necessity because of the increased knowledge. The unique surgery, anesthesia, and nursing services team that will be created for breast cancer treatment will minimize the error rate and will achieve the desired success more easily. This situation will also minimize the medical error rate due to possible lack of communication, time loss, and cost ratio. The multidisciplinary tumor council tries to reach the best result by evaluating the patients’ condition individually and also discussing treatment recommendations. The core of this council consists of two breast surgeons, a radiation oncologist, a medical oncologist, two radiologists, two pathologists, two nurses dealing with cancer patients, and a secretary. The addition of an obstetrician, a plastic surgeon, a nuclear medicine specialist, a physical therapist, a psychiatrist, and, if possible, a sociologist will significantly increase the accuracy of the decisions made. Due to its complexity, correct communication between team members plays a key role in success.

It is not possible to specialize in many subjects in today’s medical science. It is very important to choose a specific subject and to work with different medical disciplines that are unique in this regard. The deeper the subject is known, the easier it is to professionalize on it. The correctness, cost, and effectiveness of the treatment; whether there are any alternatives and the solution of the problems that can be encountered is only possible by having detailed information. In this regard, every healthcare worker, whether in the operating room or the clinic, should be trained to meet this goal. In addition, it is extremely important for healthcare providers to be compatible with each other in order to prevent medical errors. To facilitate this, the preparation of checklists and the development of teamwork training programs provide an opportunity to minimize preventable errors. Again, preparation of the security checklist ensures that team dynamics are maintained. To prevent possible conflicts, it is important to develop communication skills, to do teamwork effectively, and to provide hierarchical order.

A multidisciplinary approach is necessary in order to decrease the mortality rate and achieve success by effective survival in breast cancer patients. Thus, the chance of choosing the right treatment rate increases, the cost rate decreases, and the morbidity and mortality rates that may occur decrease. Undoubtedly, this process includes both the preoperative decision-making stage, the surgical procedure in the operating room, and the solution of the complications that may occur in the postoperative period.

The factors affecting the teamwork are the professionalism, clinical performance, level of consciousness, and communication skills of the surgeon. As in all people, the professional culture of the surgeon determines his thoughts, beliefs, and behaviors. Sacks et al. stated that surgical culture has three main components: teamwork, communication, and a safe working environment [1].

In order to provide health service effectively and successfully, clinical cultural accumulation must be sufficient. The surgeon must be familiar with all aspects of the work. He should know the accuracy, cost, effectiveness, the availability of alternatives, and the solution of the problems, follow-up of the disease, and get help from the necessary people. Every healthcare professional, whether in the operating room or in the clinic, must be trained to meet this goal. To overcome such difficulties requires a long, patient, and conscious education process. Of course, providing a safe working environment to the surgical team that completes the process should be the primary task of management. Donabedian emphasized that clinical performance depends on knowledge, skills, technical capacity, and communication [2]. Rigorous, ambitious work is required to develop the technique. The important thing is that easily neglected communication is just as effective as technical skills. Gawande et al., with the participation of 38 surgeons, observed 146 unintentional events after surgery, and while 60% of them occurred in the operating room, the direct role of communication failure was found in 43%. What is striking in this study is the high number of undesirable problems due to lack of communication. In this study, the factors that play a role in the formation of undesirable errors in surgery are indicated.

These are:

  • Distraction during surgery, division of surgery

  • Ergonomic problems (environment, light, noise, etc.)

  • Inadequate technological infrastructure

  • Fatigue

  • Excessive workload

  • Lack of communication between staff

  • Improper treatment protocols

  • Inadequate training of surgical or operating room staff

  • Inexperience

  • Administrative confusion, bureaucratic chaos

  • Ability to perform surgical treatment elective

  • Hours of surgical treatment during the day

  • Failure to ensure adequate alertness

  • Memory fatigue

  • Incorrect decision making [3]

Important factors that directly affect the success rate in the operating room are the awareness of teamwork and the development of communication skills. In the study conducted in the late 1970s, it was reported that adverse events were found in 4.6% of the medical practices [4]. In another study conducted in 1991, this rate was observed at similar levels with 3.7% [5, 6]. Both studies concluded that more than half of medical errors were preventable and most of these were related to surgical care [3, 7].

The American Institute of Medicine published the first public report on medical errors in 1999, To Err is Human, and in 1997, 33.6 million applications to hospitals in the United States, 44,000–98,000 deaths were caused by medical errors, and most of them were preventable errors caused by lack of communication it is [8]. In another study published by the US Center for Disease Control and Prevention, it was emphasized that medical errors were eighth among the causes of death and that they were above the deaths due to breast cancer, traffic accidents, and AIDS, and the cost of health expenditures was 17–29 billion dollars. In the latest publication, it is underlined that the frequency of deaths due to medical errors is in the third place in the United States [9].

2 Multidisciplinary Tumor Council

The treatment process begins with the decision-making process for which the patient is to be treated. Teamwork is almost a necessity in order to make the right decision for the patient. This is the purpose of establishing a multidisciplinary tumor council. The multidisciplinary tumor council seeks to achieve the best results by addressing the patient’s situation individually and discussing treatment recommendations. This certainly benefits the patient. Because after understanding breast cancer biology, breast cancer is not only a disease, it has heterogeneous features, and in this respect, it is necessary to make a patient-based treatment plan. The treatment process has gained a complex dimension (Fig. 22.1).

Fig. 22.1
figure 1

Scheme of a multidisciplinary approach in the treatment of breast cancer. The main purpose of the multidisciplinary approach is to determine the best-individualized treatment for the patient. This requires effective communication and collaboration among team members

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Definition of the multidisciplinary approach in the United Kingdom is “meetings of a group of people from different disciplines to discuss the diagnosis and treatment of patients” [10]. The core of this council consists of two breast surgeons, radiation oncologists, medical oncologists, two radiologists, two pathologists, two nurses dealing with cancer patients, and one secretary. Nowadays, the obstetrician should be invited to the council in order to perform effective management of the ovulation/embryo freezing process, the posttreatment procedure of pregnancy, and the follow-up of the BRCA-positive patient. In addition, the inclusion of a plastic surgeon, a nuclear medicine specialist, a physical therapist, a psychiatrist, and, if possible, a sociologist will significantly increase the accuracy of the decisions made. In a systematic review published in 2010, a significant relationship was found between multidisciplinary approach and survival [11]. In Scotland, approximately 13,000 female patients were evaluated between 1990 and 2000. As a result, while the mortality was 11% higher in the non-multidisciplinary approach, it was 18% lower in the multidisciplinary approach [12].

In these studies, patients who underwent at least 30 breast cancer surgeries per year with a multidisciplinary approach and treatment plans were investigated. As a result, it was shown that patients underwent less mastectomy and more breast-conserving surgery. In addition, this group of patients had a higher chance of adjuvant treatment [12,13,14]. Evaluation among approximately 2000 cancer health professionals has shown that a multidisciplinary approach contributes to clinical decision-making, better patient care, higher evidence-based treatment rates, and a positive contribution to mean survival. Ninety percent of the participants confirms that approach [15]. The multidisciplinary approach is also effective in the logical use of resources. Taylor et al. emphasized that the cost of treatment plans for breast cancer ranged from 14–643 pounds, and in this respect, the multidisciplinary approach directly contributed to the reduction of costs [16]. As in the decision-making stage, there is a multidisciplinary approach in the operating room. The operating room is an environment in which both genders coexist in a hierarchical order, often encountered in conflict with work-related stress.

A sense of responsibility and professional care for the patients leads to an effort to increase the level of care provided. Over the last decade, the common working area of surgery and anesthesia teams have increased considerably. The high level of harmony between these two teams and the increasing technological advances have led the way of treatment towards minimally invasive methods. As the interventional procedure moves towards a minimally invasive level, the complexity of the decisions to be made increases, and the necessity of working together becomes more common. Of course, the common mind will increase the accuracy of the decisions to be in favor of the patient. If an effective success is to be achieved, it is essential that communication is done properly and that the culture of the multidisplinary approach is developed. Poor teamwork results in more side effects and an increased complication rate. Similarly, piloting is an important profession where the slightest mistake can cause hundreds of people to die. It is a business area that needs to be carefully examined in order to emphasize the importance of teamwork and communication in our age.

Nowadays, the way a pilot can obtain a license is to prove his/her technological knowledge as well as show his/her teamwork awareness and communication ability [17]. It is remarkable that it is quite parallel with surgery. The need for professionalization arises, especially when the risk ratio for the service provided increases. This is the reason for the creation of specialized subgroups of work or services. In the face of the increasing burden of information in our age, authenticity is a necessity. The more specific the study, the higher the success rate. The surgical, anesthesia, and nursing services team for breast cancer treatment will minimize the error rate and will make the desired success easier. This will also minimize the medical error rate due to a possible communication defect and minimize the loss of time and cost.

3 Teamwork Training and Control Lists

In line with this information, it is very important that healthcare providers are compatible with each other in order to prevent medical errors. To facilitate this, the preparation of checklists and the development of teamwork training programs provide the opportunity to minimize preventable errors. In a study by the Veterans Health Administration (VHA), the group that was trained in teamwork was compared with the group that was not trained, and a 50% reduction in preventable mortality was observed in the group trained [18]. The preparation of the safety checklist also reduces communication errors and maintains team dynamics. In this way, it has been shown that surgical complications and mortality rate are reduced. Its widespread use was initiated in 2008 by WHO. After the WHO study conducted between 2007 and 2008, it has been shown that hospital mortality and complication rates have decreased significantly with the use of checklists [19]. Haynes et al. demonstrated that surgical treatment can prevent one of two deaths within the first 30 days by using a surgical checklist [20]. Again, improving communication skills, effective teamwork, effective hierarchical order, and awareness are very important.

4 What to Do in the Treatment Process of a Breast Cancer Patient

Effective treatment of the patient whose treatment type has been determined in the tumor council starts with hospitalization. The patient is admitted to the room before the surgery, information is given about the surgery, and written and verbally informed medical consent is given to her/his at least 1 day before the consent. The person is asked to mark the breast to be operated on. This stage is observed by the assistant health personnel in terms of being an objective eye, and the checklist is noted. Likewise, intravenous vascular access from the appropriate site and arm is important. The patient is then delivered to the operating room. Many health professionals are involved in all these processes. Patient care personnel should be very careful while moving the patient to the operating room and giving the appropriate position on the operating room table (Fig. 22.2).

Fig. 22.2
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Effective cooperation in the operating room is necessary for the patient’s safety

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In order to ensure proper follow-up in the preoperative period, an adequate number of vascular access is provided to the patient by the anesthesia team. If necessary, nerve blockage is performed to the appropriate area. If an analgesic is needed in the postoperative period, an appropriate catheter is inserted. Mechanical and medical premedication is applied during and after surgery to prevent possible deep vein thrombosis. Before surgical intervention, antibiotic prophylaxis is applied especially to patients who will have a prosthesis. If there is a long-term surgical treatment plan such as reconstruction with flap, a bladder catheter is placed. Proper wiping and covering of the surgical field and appropriate intervention are very important. The presence of the radiologist, nuclear medicine specialist, and, most importantly, the pathology specialist in the operating room is important for effective treatment. In these stages, effective communication and proper teamwork are extremely important. Details in preoperative evaluation are shown in Table 22.1. The questions that should be asked in the operating room are discussed in Table 22.2.

Table 22.1 Stages and details of preoperative evaluation
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Table 22.2 Questions to be asked by the operating room team
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A mastectomy incision is classified as a clean wound. Because it is far from the possibility of contamination from the gastrointestinal system, genitourinary system, and respiratory system. However, the rate of wound infection after modified radical mastectomy (MRM) varies between 2 and 15%. The most frequently isolated bacteria are Staphylococcus aureus and Staphylococcus epidermidis [21]. Therefore, cephalosporin or ampicillin, which has antistaphylococcal activity, is given intravenous as appropriate. Prophylactic antibiotics should be discussed with the infectious diseases specialist considering the flora of the hospital, and the most appropriate one should be done. Studies have shown that wound infection rate decreases with a single-dose prophylactic antibiotic. This reduces the possibility of delayed wound healing and the inability to start the chemotherapy process [22].

Depending on individual and tumor factors such as tumor site, tumor size, and breast tumor size ratio, achieving these goals can often be challenging or even limiting for the surgeon. In breast-conserving surgery (BCS), the most important reason affecting the cosmetic outcome is volume loss. The removal of more than 20% of breast volume has been shown to produce poor cosmetic results [23]. The detection of cancer foci at a distance of less than 3–4 cm in the same quadrant is called multifocal breast cancer, whereas multicentric breast cancer is the presence of breast cancer in two different quadrants (away from 4 cm). In such cases, oncoplastic breast surgery has proven to be effective and has been successfully applied. Oncoplastic breast surgery (OPS) describes the fusion of surgical oncology and plastic reconstructive surgical techniques. Breast tumor excised with oncological principles leaves a defective area behind. This area should be closed according to the rules of reconstructive breast surgery. Thus, both effective treatment and cosmetic satisfactory results are obtained. There are two different approach techniques for reconstruction after BCS. These are volume-displacing and volume-replacing techniques [24, 25]. Volume displacement techniques involve glandular flap mobilization to fill the defect area. Because of this technique that results in a loss of breast volume, simultaneous reduction in the contralateral breast to achieve symmetry would be necessary. Tumor resection can be performed with different techniques such as glandular remodeling, inferior and superior pedicle technique, batwing technique, paddle mammoplasty, round-block technique, and vertical scar technique.

On the other hand, in volume replacement techniques, autologous tissues are used for the reconstruction of the defected area to excise the breast tissue volume. Although different methods are described, the latissimus dorsi flap is generally used. Volume replacement is preferred in patients with small- and medium-sized breasts, who do not allow or do not want to lose volume. It is also generally more suitable for patients who do not prefer surgery to the contralateral breast. Volume displacement has better results in medium-large and large breasts and ptotic breasts.

Complications of replacement techniques include glandular necrosis, nipple necrosis, and donor site complications. As experience increases, the complication rate decreases. The multidisciplinary approach in OPS is indispensable for achieving the desired level of aesthetic success on both the short- and long-term outcome, as well as achieving oncologically acceptable recurrence and survival rates.

OPS and BCS serve basically two purposes. These are the removal of the tumor with an intact surgical margin and an acceptable cosmetic outcome. The absence of ink on the tumor after BCS and OPS is considered as a negative surgical margin. If the tumor is close to the skin, it should be removed with the skin. Cosmetic results should be acceptable after tumor removal. Re-excision is required in 20–30% of patients undergoing lumpectomy [26]. Of those who have re-excision, 40–70% had residual tumors [27]. Intraoperative ultrasonography increases the success of incision selection and the management re-excision if necessary. Marking the excised breast with a hemoclip would be a guide for the radiation oncology after breast-conserving surgical treatment.

BCS and OPS are generally contraindicated in locally advanced and T4 tumors, presence of diffuse malignant microcalcification on mammography, and inflammatory breast carcinoma. When preparing the upper and lower flaps during mastectomy, the skin and underlying fat tissue and the vessels feeding it should be preserved to a thickness of about 5 mm. The flaps should be prepared above the clavicle, below the initial portion of the rectus muscle fascia and internal sternum, and externally to the m. latissimus dorsi. Complications such as wound infection, seroma, bleeding, pneumothorax, tissue necrosis, and local recurrence may occur after mastectomy. Drains can be taken when the 24-h flow rate drops below 25–30 mL. Generally, patients who are hospitalized for 1 day should be given verbal and written information about their activities and nutrition at home when they are discharged. The probability of seroma is 30% [28]. Seroma is directly associated with postoperative edema in the arm [29]. The bleeding rate after mastectomy is between 1 and 4% [30]. In patients undergoing subcutaneous bilateral prophylactic mastectomy with nipple and/or areola protection, the risk of breast cancer is reduced by an average of 85–100% [31, 32].

In patients who undergo bilateral prophylactic mastectomy with nipple-areola removal, this risk is further reduced. However, risk-reducing mastectomy can never reduce the risk of breast cancer to zero [33, 34].

The material that can be used as an implant in the breast must be chemically inert and not carcinogenic. In recent years, breast implant-related anaplastic large cell lymphomas (ALCL) have been reported as case reports, but there has not been a definite connection between them. The silicone implants are important because they are not physically modified by tissue fluids. Silicone prevents them from deteriorating and rupturing over time. Implants should be easy to apply, sterilize, and resistant to mechanical stress. In order to perform breast reconstruction with a simultaneous prosthesis in patients undergoing mastectomy, it is necessary to have breast implants of the appropriate size and quality in the operating room.

Chronic diseases in the patient and conditions affecting skin nutrition adversely affect wound healing. It can cause complications such as exposing, infection, and loss of the implanted implant. Particular care should be taken especially in elderly patients with a history of smoking, diabetes, poor skin quality, or autoimmune disease involving the skin. In these patients, placing the implant under the pectoral muscle does not affect the outcome. The necessity of radiotherapy (RT) is an important factor in the adjuvant treatment of the disease. Postoperative RT may cause loss of the implants up to 50%. The possibility of infection and exposition increases with the skin burn. Cosmetic appearance and capsule formation rate increases due to fibrosis that may occur after RT. The experience of the surgeon is important in implant reconstruction. The presence of a plastic surgery specialist in the multidisciplinary team is important. This may vary depending on the clinical procedure and experience. The surgeon who plans reconstruction with an implant should be familiar with breast cancer surgery and reconstruction techniques. They should be experienced in patient factors and management of possible complications. The most important advantages of implant reconstruction are the fact that it allows shorter surgery, which does not require additional tissue.

It always reserves the right to return to an autologous method, without additional morbidity to the patient. The need for adjuvant RT is not considered as a contraindication. Thanks to the advanced RT devices and experienced radiation oncologists, the desired results are possible. At this stage, consultation with the radiation oncologist is of great importance. Breast reconstruction with an implant can be performed in the same session following mastectomy in the early period. It can also be performed in two sessions using tissue expander implants in the late period. Reconstruction with implant should ensure patient and physician satisfaction. For the patient, achieving symmetry by replacing the lost tissue is important. In terms of the physician, symmetrical and well-formed inframammarian folds are important.

In addition, an adequate medial and lateral fullness, an adequate ptosis, and a volumetric symmetry should be provided. The cosmetically desired surgical success is achieved by obtaining an appropriate position on the thoracic wall. The advantage of implant reconstruction is that it is easier to perform compared with an autologous reconstruction. It also extends the operation time from half an hour to an hour.

It does not require any additional incision, and the same incision can be used for the reconstruction when planning a mastectomy. Hyperpigmentation in the skin of the tissue carried in autologous reconstruction is not seen in implant reconstruction. It does not prolong hospital stay and has a morbidity similar to mastectomy. It does not cause additional scarring or tissue distortion. If reconstruction with a subpectoral implant is planned, surgical technique during mastectomy should be considered for the flap thickness and preservation of the subcutaneous tissue plexus. It is necessary to avoid removing excess skin. The quality and tension of the skin flaps are important. It is important to preserve the integrity and innervation of the pectoral muscle. There are two different views on whether to protect the pectoral nerve. First, preservation of the pectoral nerve prevents the loss of pectoral muscle volume and prevents atrophy. This is argued to be beneficial for the patient.

In the second view, it is considered that contraction occurs on the implant as a result of preservation of the pectoral nerve, which pushes the implant laterally and upwards. It is argued that the cosmetic result adversely affects. At this stage, the surgeon must decide according to his/her preference and experience. Care should be taken to protect the inframammarian sulcus when creating a subpectoral pocket. It is important to provide projection and ptosis. Breast reconstruction with tissue expanders can be selected if there is no adequate skin flap, a larger breast than the existing one is desired, and late reconstruction is planned. Inflating with tissue expanders is completed in 6–8 weeks. Permanent implant replacement is performed after 4 weeks and 6 months. In this process, the patient can complete adjuvant treatments. Wound healing problems and wound complications are seen at a higher rate with this technique. It also has the disadvantage of requiring a longer operation time and an additional operation. Ensuring symmetry can be difficult, and projection may be impaired. The most important advantage is that it does not interfere with subsequent reconstruction methods and does not require an additional incision scar.

There are many donor site options for immediate autologous breast reconstruction involving the abdomen, back, thigh, or waist.

These are:

  • Back: latissimus dorsi myocutaneous flap

  • Abdomen: transverse rectus abdominis myocutaneous flap

  • Abdomen: deep inferior epigastric perforator flap

  • Abdomen: superficial inferior epigastric perforator flap

  • Hip: superior gluteal artery perforator flap

  • Hip: inferior gluteal artery perforator flap

  • Hips: Ruben’s flap

  • Thigh: musculus gracilis flap

Among these rotating field options, the latissimus dorsi flap is one of the more easily applied and relatively less morbid back-based flaps. It can be applied more easily than other flaps, can be used in patients with RT, has a good vascularisation, and has a desired level of flap life. Although the microsurgical techniques are not needed in this surgery, they are useful after complications in other donor sites. It may be preferred in medium and moderate ptotic breasts. It can be used in combination with the implant in larger breasts or in reconstructions requiring more volume, and compatibility with the implant is near perfect. Regardless of the morphological structure of the patient, it does not cause problems in obese or weak patients. Its main contraindication is that the vascular structure feeding the flap is particularly damaged during axillary dissection. In patients undergoing anterior thoracotomy, this vascular nerve pack is strongly damaged. It should not be applied to patients who do not want additional incision on their back or who do not want different skin colors called “patch effect.” For such a surgery, the patient should be evaluated with plastic surgery beforehand.

In sentinel lymph node biopsy (SLNB), radioactive material, blue dye, or both can be used together. There are different approaches such as the choice of agents to be used, the location of the injection, the timing of the scintigraphy, whether or not to intervene in the extra axillary lymph nodes, and the axillary approach to be performed after examination of the removed lymph nodes. Regardless of the size and localization of the primary tumor, SLNB has been accepted as the standard approach in all cases of clinical node-negative breast cancer. In clinical N1 cases, it is assumed that tumor cells can infiltrate the lymph ducts, thus inhibiting the progression of dye or radiocolloid into the duct. This leads to the fact that the true sentinel lymph node cannot be detected and the false-negative rate increases. Forty percent of nodal positive patients can be diagnosed by preoperative USG and needle biopsy. When suspicious lymph nodes are palpated during the surgery, they should also be removed and sent to pathological examination, seperated from the sentinel nodes. Axillary lymph node dissection is performed if metastasis is detected in SLN or nonsentinel lymph node in intraoperative examination or paraffin. Blue paints are patent blue, isosulfan blue, and methylene blue. Isosulfan blue is the most commonly used agent, and it may cause anaphylactic reactions [35, 36]. Methylene blue does not bind to plasma proteins, and it makes a less anaphylactic reaction. But if it is done intradermally, it can cause skin necrosis. Approximately 2–5 mL of dye is injected peritumorally (1 cm around the tumor, four quadrants), subareolar, or into the cavity margins that were excised by the surgeon during surgery. Depending on the distance of the tumor to the axilla, a massage to the axilla is performed for 2–5 min. The axilla is then inserted through a 2–3 cm transverse incision that is made just below the hairline. The sentinel node is usually in the region where the intercostal nerve crosses this vein (axillary first level). The dissected duct is found, followed by the axillary region and the breast. The area is removed with fatty tissue and sent to pathology. If the blue dye was used for the staining of the lymph node, it should be discussed in detail with the pathology specialist whether the removed lymph node has been stained or not.

And the pathology specialist should also be informed if there are other lymph nodes that are thought to be pathological. Care should be taken during the excision of the lymph node. It should be removed without crushing and with its surrounding fatty tissue as far as possible. False negativity is 3% when a single lymph node is removed and decreases below 1% when three or more are removed [37, 38]. Blue dye allergy is seen in about 1–3% [39]. Vital dyes cause changes in oxygen saturation. Blue dye is not used during pregnancy due to its potentially fatal effects [40].

Lymphoscintigraphy is based on the transport of the injected radiopharmaceutical to the local lymph nodes by lymph flow and is used for the detection of the lymph nodes. With this method, regional lymph node mapping is performed, and preoperative images determine whether the SLN is axillary or extra-axillary. During surgery, SLN is found with the help of a gamma probe. The particle size of the radiopharmaceutical used is important in the detection of SLN. The distribution of the particles in the radiopharmaceutical is not homogeneous, and it must be filtered to achieve homogenization. Particles smaller than 100 nm in size enter the lymph stream and drain into the lymph node. Those between 500 and 2000 cannot enter the lymph flow and remain at the injection site. Those <4–5 nm escape into the capillary current and are not transported to the lymph node. Small particles allow SLNB to be managed 2 h after treatment. In patients scheduled for surgery in the following morning, larger particles must be present in the radiopharmaceutical. The fastest result is intradermal injection due to the rich lymphatic network [41]. In order to perform accurate counting in the surgery and to minimize background activity, the tumor mass containing the primary injection site is removed. The gamma probe is hovered over the skin in the axilla to determine the point at which the highest activity count is taken, and a small incision is introduced into the axilla. The gamma probe is inserted through the incision, and the lymph node with the highest activity is removed with the surrounding fatty tissue. The removed lymph node is examined separately for reactivity counting and then is sent to pathology after being sure that it is SLN. The axilla is re-evaluated. If there is still a high count, the other sentinel nodes are removed until they remain less than 10% of the count value of the first node. In all of these stages, nuclear medicine experts will be helpful to proceed with a common mind to minimize the error rate.

In the localization of non-palpable breast lesions (NPBL), techniques such as wire-assisted marking, radionuclide occult lesion localization, skin projection marking, carbon localization, blue dye marking, and intraoperative US may be used. Wire-guided localization is the most commonly used technique for marking non-palpable breast lesions (Fig. 22.3).

Fig. 22.3
figure 3

The teamwork for the treatment of the patient diagnosed with ductal carcinoma in situ. The margins of the calcification were marked by a radiologist on the day of surgery

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ROLL technique has been accepted in recent years. Since marking with wire is possible, the wire should be placed on the day of the surgery. In order to guide the operating surgeon, the craniocaudal and mediolateral positions should be schematically shown, showing the localization of the wire and the distance to the lesion schematically (Fig. 22.4). At this stage, he/she should be in contact with the radiologist and if possible, be with the radiologist during the procedure.

Fig. 22.4
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Mammography images of the patient. The limits of calcification were indicated by wire

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Mutually effective communication will increase the likelihood of successful excision. The distance to the lesion should be a maximum of 1 cm for wire marking to be accepted as successful. Specimen radiographs should be taken for lesions that can be seen on mammography, and pathological examination should be performed during the operation for lesions that are not seen. Wire marking may also have some complications. These are due to technical reasons, the location of the wire entry to the lesion, the difficulty of localization in patients with hard breast tissue, needle slippage or dislocation, and needle discomfort. And very rarely it can cause pneumothorax [42,43,44,45]. ROLL is a method of injection of Tc99m-labeled serum albumin macroaggregates into the lesion with imaging methods. The lesion is removed using a gamma probe during surgery. If the ROLL technique is used in combination with SLNB, it is called SNOLL. The ROLL is advantageous as it can be done 1 day before the wire marking [46]. In the wire marking method, the distance of the wire hook to the wire inlet may cause unnecessary dissection. In the non-palpable breast lesions, incisions parallel to the areola are preferred in the upper quadrants, whereas radial incisions parallel to the areola are preferred in the lesions located in the lower quadrant. Care should be taken to ensure that incisions are within the possible mastectomy line. The upper limit of the lesion is marked with two short strings, the lateral border with two long strings, and the anterior border with both a short and a long rope (Fig. 22.5).

Fig. 22.5
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The specimen was marked with silk for the pathologist to indicate the surgical margins. Effective communication is very important for success

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The edges are marked with a clip so that they can be seen on the specimen radiograph.

Specimen radiographs should be performed in patients with lesions seen on mammography, and the limits of microcalcification areas should be monitored. SLNB should be performed if there is an invasive focus on frozen examination. Blue dye injection can be performed subareolar-peritumorally in the inner quadrant and lateral to the lesion in the outer quadrant before the procedure. In patients with preoperative pathological diagnosis, SLN is first excised and sent for frozen examination. On the specimen mammography, the proximity of breast lesion to the edges and, if frozen examination is performed, the proximity of the tumor to the borders are examined. Accordingly, excision can be performed again. In all these processes, a thorough evaluation should be made with radiology, nuclear medicine, and pathology specialists before and after surgery. A proper communication is essential for an effective treatment.

While an accurate evaluation protects the patient from unnecessary breast resections, an inaccurate evaluation causes an incomplete treatment. Optimally, the team dealing with breast cancer should work together, be together, and do the evaluation in the operating room without wasting time. Communication plays a vital role in this process, which requires teamwork at every stage. Effective, adequate, and rational functioning of communication in a hierarchical order prevents potential conflicts. Neily et al. showed that the surgical mortality rate decreased with the training and the increasing communication of the team who works in the operating room. They found that the mortality rate decreased by 18% in 74 hospitals where such an education program was conducted. They made some suggestions based on this.

According to this, the health system needs to develop teamwork and skills. Presentations should be made to increase communication in the operating room at hospitals. All breast surgery specialists need to work together in a complementary way. It was emphasized that it is important to increase the effectiveness of teamwork and that this should be established during the residency period [47]. Undoubtedly, when the number of surgical teams, patients, and the complexity of surgical interventions in the health institution increases, mortality and morbidity rates would decrease [48].

5 Conclusion

Nowadays, knowledge about breast cancer biology has increased. The determination of details in this knowledge ensures success. The process becomes more challenging day by day. It is not possible to manage with individual effort. Absolute cooperation is required. Working on the same subject with different medical disciplines is the most rational solution. Every different perspective makes a great contribution to the patient’s best results. Therefore, it is extremely important for this team to meet at regular intervals and evaluate the matter together. Correct communication is essential for the right decision. Effective and correct communication between team members will improve their cooperation in the process. Cooperation with professionalism will bring the disease management to the desired level for both patients and decision-makers.

Tips and Tricks

  • Successful results in the diagnosis and treatment of breast cancer depend on team work.

  • The most important factor that determines success in teamwork is communication.

  • Cooperation can be made between team members after effective communication is provided.

  • Professionalism is required at all stages of this process.

  • Despite all kinds of precautions, checklists should be used to eliminate some deficiencies that may occur.

  • For the best results, it is necessary to create checklists with all health professionals involved in the process.

  • As the number of diagnosis and treatment increases, the error rate will decrease in the centers with these features.