Lumpectomy with Sentinel Lymph Node Biopsy
Right/left breast carcinoma [invasive ductal/lobular carcinoma / DCIS]
Same
Right/left lumpectomy (partial mastectomy) with sentinel lymph node biopsy
[***, MD/DO]
[Resident/PA name]
General endotracheal / local with MAC
The patient is a [age]-year-old female with [right / left] breast cancer [measuring ___ cm, located in the ___ quadrant] presenting for breast-conserving lumpectomy with sentinel lymph node biopsy. The risks, benefits, and alternatives including total mastectomy were discussed with the patient, and informed consent was obtained. [Wire/seed/SAVI SCOUT localization was performed preoperatively.]
[A palpable mass / wire-localized / SAVI SCOUT-localized] lesion was identified in the [___] quadrant of the [right / left] breast. [___ sentinel lymph nodes] were identified with [isosulfan blue dye and/or gamma probe]. Sentinel lymph node frozen section was [negative / positive for metastasis]. Specimen radiograph confirmed the [target / clip / device] was removed. Final margins are pending pathology. [No other significant findings were noted.]
The patient was brought to the operating room and placed supine with the ipsilateral arm abducted on an arm board. [Anesthesia type] was induced. A surgical timeout was performed confirming patient identity, procedure, operative site (right vs. left), allergies, and administration of prophylactic antibiotics.
[Sentinel lymph node mapping: Isosulfan blue dye was injected [periareolar (1 mL intradermal) / peritumoral (5 mL)].] [Technetium-99m sulfur colloid had been injected by nuclear medicine the day of/prior to surgery.] The breast and axilla were prepped and draped.
An axillary incision was made at the hair-bearing skin of the lower axilla. The axillary contents were inspected with the gamma probe. Blue-staining and/or hot lymph nodes were identified; [___ sentinel node(s) were removed]. Each node was confirmed as hot (ex vivo counts > 10x background). The axilla was surveyed with the gamma probe after excision. [Residual axillary tissue counting >= 10% of the hottest node was excised as an additional sentinel node.] The nodes were sent for frozen section; result: [negative / positive].
A curvilinear/radial incision was made over the tumor site in the [___] quadrant. [The wire/SAVI SCOUT device was used to guide excision.] Electrocautery dissection was carried through the subcutaneous tissue to the breast parenchyma. The tumor with a margin of surrounding breast tissue was excised with care to achieve a gross tumor-free margin on all sides. The specimen was oriented with [sutures/clips: long = lateral, short = superior, medium = medial / posterior]. Specimen radiograph [confirmed localization target removed / showed margin closest to tumor at ___]. [Re-excision of the ___ margin was performed and sent as a separate specimen.]
Cavity hemostasis was achieved with electrocautery. Oncoplastic closure was performed by reapproximating the breast parenchyma with [2-0 Vicryl] interrupted sutures to minimize deformity. The skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
Lumpectomy specimen (oriented) and [___ sentinel lymph nodes] sent to pathology
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 carcinoma
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: *** lumpectomy with sentinel lymph node biopsy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: ***
INDICATIONS: The patient is a .PTAGE-year-old female with *** breast cancer, *** quadrant. *** localization preoperatively. Informed consent obtained.
FINDINGS: *** lesion identified. *** sentinel nodes removed; frozen section ***. Specimen margins ***. *** margin re-excision.
DESCRIPTION OF PROCEDURE:
Supine, arm abducted. *** anesthesia. Surgical timeout; laterality confirmed.
Sentinel node biopsy: blue dye injected periareolar. *** blue/hot nodes removed; ex vivo counts confirmed. Nodes to frozen section: ***.
Axillary incision. Breast incision over *** quadrant. *** localized excision performed. Specimen oriented (long=lateral, short=superior) and sent for specimen radiograph: ***. *** margin re-excision performed.
Cavity hemostasis. Parenchymal closure with 2-0 Vicryl. Skin with 4-0 Monocryl.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Lumpectomy specimen (oriented) and *** sentinel nodes 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
Intraoperative frozen section of the sentinel lymph node(s) returned positive for [macrometastasis / micrometastasis]. [Per Z0011 criteria (cT1-2, 1-2 positive sentinel nodes, planned whole breast radiation): no axillary lymph node dissection was performed and the patient will be treated with adjuvant radiation.] [Alternatively: an axillary lymph node dissection (levels I-II) was performed, clearing the axillary contents from the axillary vein to the long thoracic nerve medially and the thoracodorsal nerve laterally.]
Oncoplastic Closure
Given the volume of tissue removed and the breast size, an oncoplastic closure was performed to minimize deformity. [A local tissue rearrangement / reduction mammaplasty pattern / therapeutic mammoplasty] was used to reapprox the breast parenchyma. The nipple-areola complex was repositioned as needed. Skin was closed with subcuticular sutures.
Palpable Mass: No Localization
The tumor was palpable intraoperatively. No preoperative localization was needed. The mass was excised by palpation guidance with a [1-cm] gross margin on all sides. The specimen was oriented and sent for radiographic and pathologic margin assessment.
Charting Tips
- Specimen orientation must be documented explicitly. State the orientation convention used (e.g., long = lateral, short = superior, medium = medial) and that the specimen was submitted oriented for margin assessment. This enables targeted re-excision if margins are positive.
- Document axillary counts quantitatively. State the ex vivo count of each sentinel node and the background count. 'Hot node removed' without counts is insufficient. The ratio confirms SLN identity.
- For positive sentinel nodes, document the specific intraoperative decision-making (proceed with ALND vs. Z0011/AMAROS criteria for omission). This is an evolving area of practice and your intraoperative decision must be explicitly supported in the note.
Documentation & Reimbursement Considerations
- Primary service: Report Lumpectomy with Sentinel Lymph Node Biopsy as the primary service when it is the definitive operation performed.
- Use for any excision of breast lesion with margins. Oncoplastic closure does not change this reporting option.
- Document depth of dissection, number of nodes identified, hot/blue status, ex vivo counts, and pathologic result.
- If immediate re-excision of margins is performed at the same setting, this may be billable as a separate service. Check with your coding team as bundling rules vary by payer.
- 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.