Use of technetium-99m-labeled colloid albumin for preoperative and intraoperative localization of nonpalpable breast lesions

Combined radioguided occult lesion and sentinel node localization for breast cancer

INTRODUCTION

The incidence of non-palpable breast lesions requiring intraoperative localization has greatly increased, particularly because of the widespread use of mammographic screening. These lesions have previously been localized preoperatively using hook-wire or carbon track techniques. In the era of increasing acceptance of sentinel node biopsy (SNB) a separate procedure would be required for sentinel node localization (SNL). The present study describes an experience with ultrasound guided radionucleotide occult lesion localization (ROLL) as a reliable alternative that enables SNL synchronously.

METHODS

Twenty-two patients with proven breast malignancy on core biopsy were enrolled in the present study. Preoperatively, technetium-99m was injected around the lesion under radiological guidance. A gamma-probe was then used to locate the lesion and guide its surgical removal. Complete excision was then confirmed immediately by verifying minimal residual radioactivity in the cavity wall tissue. Appropriate SNB then proceeded.

RESULTS

The primary breast lesion was identified in all cases except in one, where the radiotracer was injected into the wrong site, giving a miss rate of 1/22 (4.5%). The average size of the tumour was 13 mm (range 6-22 mm) and the closest margins ranged from 0 (1 patient) to 22 mm (mean 7 mm). Two patients had inadequate margins and required further excision giving a re-excision rate of 2/21 (9.5%). SNB specimens included a median of 3.7 nodes/patient.

CONCLUSION

Radionucleotide occult lesion localization/SNL is a simple, accurate and reliable method of combining localization of impalpable breast lesions with the localization required for SNB. The miss and re-excision rates compare favourably with the needle-wire systems and carbon tracking techniques. There are significant resource efficiency and time advantages.

Radio-guided occult lesion localization in patients undergoing breast-conserving surgery and sentinel node biopsy

BACKGROUND

The objective of the study was to evaluate the feasibility of radio-guided occult lesion localization (ROLL) in breast-conserving surgery for nonpalpable breast cancer.

METHODS

Altogether 215 breast cancer patients were included in a prospective study. Ultrasonographically guided intratumoral injection of radioactive tracer was used for tumor localization in 64 patients with nonpalpable tumors, visible in breast ultrasonography (the ROLL group). Nonpalpable tumors, visible only in mammography, were localized with a help of a guidewire in 14 patients (the WGR group). The remaining 137 patients had palpable tumors.

RESULTS

The proportion of specimens with close or involved margins (0 to 3 mm) was the same in the ROLL group (6%) and among cases with palpable tumors (5%). In addition the median length of the closest margin did not differ significantly between the groups.

CONCLUSIONS

The results of ROLL for nonpalpable breast cancer are comparable with those for resection of palpable tumors.

Novel techniques in sentinel lymph node mapping and localization of nonpalpable breast lesions: the Moffitt experience

The concept of lymphatic mapping has helped to redefine the clinical significance of lymph nodes with respect to breast cancer. The combination technique using both blue dye and radiocolloid is the most effective method of lymphatic mapping. The data in the literature support the concept that all patients undergoing lumpectomy or especially mastectomy should undergo lymphatic mapping if a diagnosis of invasive cancer is remotely possible. The low morbidity, high sensitivity, and specificity of mapping indicate its use for increasing numbers of patients thought initially not to be candidates for the procedure.

Radio-guided surgery improves outcome of therapeutic excision in non-palpable invasive breast cancer

Intratumoral injection of a radiocolloid for lymphatic mapping enables the therapeutic excision of clinically occult breast cancer with the aid of a gamma-ray detection probe. The aim of this study was to determine the success rate of radio-guided tumour excision in addition to a guide wire and to identify factors predicting clear margins. Sixty-five consecutive patients underwent radio-guided tumour excision after intratumoral injection of 99mTc-nanocolloid guided by ultrasound or stereotaxis. A localization wire was inserted after scintigraphy had been performed (group 1). The results were compared with retrospective data from 67 consecutive patients who underwent therapeutic wire-directed excision alone (group 2). Factors predicting clear margins (> or = 1 mm) were determined in a logistic regression model. Adequate margins were obtained in 83% of group 1 and in 64% of group 2 (P = 0.014). The invasive component was incompletely excised in two patients in group 1 and in 14 patients in group 2. Further surgery was performed in four patients in group 1 and in 14 patients in group 2. Factors predictive of clear margins were decreasing pathological tumour diameter (P = 0.035), increasing weight of the specimen (P = 0.046), absence of microcalcifications (P = 0.004) and absence of carcinoma in situ component (P = 0.024). Radio-guided excision was an independent predictor of complete excision of the invasive component (P = 0.012). The application of radio-guided surgery combined with wire localization seems to improve the outcome of therapeutic excision of non-palpable invasive breast cancer compared with wire-directed excision alone.

The future of surgery in the treatment of breast cancer

The role of surgery cannot be discussed independently, but in relationship to the other modalities of treatment. Sentinel lymph node mapping and biopsy has revolutionized the role of surgery in axillary staging. Techniques of sentinel node mapping, the timing relative to chemotherapy, possible contraindications, and the necessity of completion axillary dissection are all under active investigation. The next few years will see continued changes in this important technique. Techniques of localizing clinically occult tumors are numerous and under study. These are not yet at the level of Phase III comparative trials. Induction chemotherapy has long been standard care for women with locally advanced breast cancer. It has not become standard care for Stage I or II breast cancers that meet criteria for adjuvant therapy. The ability to significantly downsize 80% of breast cancers is reason enough to make it usual practice for women who are certain to receive chemotherapy, if only for the cosmetic advantage that would accrue. Much has been made of the use of thermal ablation of small breast cancers by small probes introduced by skin puncture. In initial trials the lesions were excised after being heated or frozen. Current studies are leaving the destroyed tissue in place and following for evidence of control or recurrence. The value of this approach in terms of cosmesis is unproven, and the timing of its introduction when small tumors are being evaluated for margins and genetic markers, make it difficult to imagine broad acceptance. Finally, the role of prophylactic surgery for women at increased risk remains a difficult equation, compounded of alternatives such as chemoprevention, availability and effectiveness of surveillance techniques, and the level of fear and anxiety of the patient.

Advances in the Diagnosis and Excision of Breast Cancer

Until recently little advance in the diagnosis and excision of breast cancer has been made since the inception of needle localization breast biopsy (NLBB). Stereotactic core needle breast biopsy (SCNBB) can avoid most NLBB especially for calcifications. However, when open biopsy is necessary NLBB has been the standard of care. As many as 50 per cent of nonpalpable lesions can be seen by ultrasound (US) to avoid the unpleasantness and complications associated with NLBB. Further SCNBB leaves a blood-filled cavity that can be easily seen by US. Intraoperative US can be used to direct the excision while improving margin negativity. MRI has improved sensitivity in detecting suspicious breast lesions and techniques such as hematoma-directed US-guided breast biopsy can facilitate excision of such masses. Clearly new technologies have improved the ability to diagnosis and excise breast cancer. The onus on the surgeon is to incorporate them into standard practice to improve outcomes.

Sentinel Lymph Node Metastasis in Microinvasive Breast Cancer

BACKGROUND

Ductal carcinoma in situ with microinvasion (DCISM) is a separate pathological entity, distinct from pure ductal carcinoma in situ (DCIS). DCISM is a true invasive breast carcinoma with a well-known metastatic potential. Currently, there is controversy regarding the indication for complete axillary dissection (CAD) to stage the axilla in patients with DCISM. The role of CAD is questioned given its morbidity and reported low incidence of axillary involvement. Sentinel lymph node biopsy (SLNB) may obviate the need for CAD in these patients without compromising the staging of the axilla and the important prognostic information.

METHODS

From March 1996 to December 2002, 4602 consecutive patients with invasive breast carcinoma underwent SLN biopsy. Of these, 41 patients with DCISM were selected.

RESULTS

Metastasis in the SLN were detected in 4 of 41 (9.7%) patients. Two of the 4 patients had only micrometastasis in the SLN. In three patients, the SLN was the only positive node after CAD.

CONCLUSIONS

SLN biopsy should be considered as a standard procedure in DCISM patients. SLNB can detect nodal micrometastasis and accurately stage the axilla avoiding the morbidity of a CAD. Complete AD may not be mandatory if only the SLN contains micrometastatic disease. Informed consent is very important in the decision not to undergo CAD.

Gamma probe-assisted brain tumor microsurgical resection: a new technique

OBJECTIVES

The pioneering performance of gamma probe-assisted surgery (GPAS) for brain tumors, aiming not only an improvement of tumor detection, but mainly assurance of its complete removal and the study of the usual distribution of the 99mTc-MIBI in the brain SPECT of normal individuals.

METHOD

Patient's informed consent and demonstration of the tumor by the preoperative MIBI SPECT were the inclusion criteria adopted for GPAS, which was performed in one patient with a right parietal lobe metastatic tumor. The radiotracer (99mTc-MIBI) was injected in a peripheral vein 5 hours before the operation. A tumor to-normal tissue count ratio equal to or greater than 2/1 was considered indicative of tumor. MIBI SPECT was performed in five normal individuals in a pilot study.

RESULTS

The gamma probe greatly facilitated intraoperative tumor detection (tumor to-normal brain count ratio was 5/1) and indicated a small piece of residual tumor after what was thought to be a complete tumor removal, allowing its resection, which, otherwise, would have been left behind. Postoperative CT confirmed complete tumor resection. The MIBI SPECT in normal individuals showed an increased uptake by the hypophisis, choroid plexus, skull, scalp and salivary glands and absence of uptake by the normal brain tissue. There were no complications.

CONCLUSION

GPAS proved to be, in this single case, a safe and reliable technique to improve brain tumor detection and to confirm the presence or absence of residual tumor.

Innovation in early breast cancer surgery: radio-guided occult lesion localization and sentinel node biopsy

The surgical management of non-palpable breast lesions remains controversial. At the European Institute of Oncology we have introduced a new technique, radio-guided occult lesion localization (ROLL) to replace standard methods and overcome their disadvantages. Regarding axillary dissection, probe-guided biopsy of the sentinel node (SN) is easy to apply, and the whole procedure is associated to a low risk of false negatives. We suggest that the SN technique should be widely adopted to stage the axilla in patients with breast cancer with clinically negative lymph nodes. Large-scale implementation of the sentinel node technique will reduce the cost of treatment as a result of shorter hospitalization times.

Intraoperative localization after stereotactic breast biopsy without a needle

BACKGROUND

Needle localization breast biopsy (NLBB) is the standard for the removal of breast lesions after vacuum-assisted breast biopsy (VABB). Disadvantages include a miss rate of 0% to 22%, risk of vasovagal reactions, and scheduling difficulties. We hypothesized that the hematoma resulting from VABB could be used to localize the VABB site with intraoperative ultrasonography (US) for excision.

METHODS

Twenty patients had VABB followed by intraoperative US-guided excision.

RESULTS

The previous VABB site in 19 patients was successfully visualized with intraoperative US and excised at surgery. One patient had successful removal of the targeted area under US guidance, but failed to show removal of the clip on initial specimen mammogram.

CONCLUSION

This study demonstrates the effectiveness of US in identifying hematomas after VABB for excision. This technique, which can be performed weeks after VABB, improves patient comfort and allows easier scheduling.

Single intralesional tracer dose for radio-guided excision of clinically occult breast cancer and sentinel node

BACKGROUND

The purpose of this study was to determine the feasibility of both lymphatic mapping and probe-guided primary tumor excision by use of intralesional tracer administration in clinically occult breast cancer.

METHODS

Sixty patients with a clinically occult breast lesion were prospectively included. Lymphoscintigraphy was performed after intratumoral injection of 99mTc-labeled nanocolloid guided by ultrasound or stereotaxis. A catheter over a localization wire was inserted for intraoperative blue dye administration by using the same imaging techniques. After sentinel node identification, the gamma-ray detection probe was used for radio-guided wide local excision in patients who underwent breast-conserving therapy.

RESULTS

A sentinel node was visualized on the scintigrams in 56 patients (93%) and could be identified intraoperatively in 58 patients (97%). A sentinel node contained tumor in 10 (17%) of these patients. Extra-axillary sentinel nodes were visualized in 43%, were collected in 38%, and contained metastasis in 7% of the patients. Complete excision of the primary tumor could be accomplished in 39 (87%) of 45 patients.

CONCLUSIONS

Both sentinel node biopsy and probe-guided excision of a nonpalpable breast cancer is feasible with the aid of intralesional tracer administration. Sentinel node metastasis was found in 17% of the patients. A remarkably high percentage of extra-axillary drainage (43%) was observed.

Randomized prospective evaluation of a novel technique for biopsy or lumpectomy of nonpalpable breast lesions: radioactive seed versus wire localization

BACKGROUND

Standard wire localization (WL) and excision of nonpalpable breast lesions has several shortcomings.

METHODS

Ninety-seven women with nonpalpable breast lesions were prospectively randomized to radioactive seed localization (RSL) or WL. For RSL, a titanium seed containing 125I was placed at the site of the lesion by using radiographical guidance. The surgeon used a handheld gamma detector to locate and excise the seed and lesion.

RESULTS

Both techniques resulted in 100% retrieval of the lesions. Fewer RSL patients required resection of additional margins than WL patients (26% vs. 57%, respectively, P = .02). There were no significant differences in mean times for operative excision (5.4 vs. 6.1 minutes) or radiographical localization (13.9 vs. 13.2 minutes). There were also no significant differences in the subjective ease of the procedures as rated by surgeons, radiologists, and patients. All WLs were carried out on the same day as the excision, whereas RSL was performed up to 5 days before the operative procedure.

CONCLUSIONS

RSL is as effective as WL for the excision of nonpalpable breast lesions and reduces the incidence of pathologically involved margins of excision. RSL also reduces scheduling conflicts and may allow elimination of intraoperative specimen mammography. RSL is an attractive alternative to WL.

Radioguidance for nonpalpable primary lesions and sentinel lymph node(s)

BACKGROUND

Radioguided surgery can also be used for the simultaneous guidance to a nonpalpable primary tumor and sentinel lymph nodes.

METHODS

Retrospective review of a prospective database. The surgeon used a gamma probe for guidance to an iodine-125 labeled titanium seed at the primary lesion and technetium-99 labeled sulfur colloid at the sentinel lymph node.

RESULTS

Forty-three patients with nonpalpable breast carcinoma underwent dual isotope radioguided surgery. The radioactive seed and primary lesion were retrieved in the first excision in all 44 patients (100%). Eleven patients (25%) had pathologically involved margins. Sentinel lymph node mapping was successful in 42 patients (98%). A mean of 2.4 sentinel nodes were excised and metastatic carcinoma was present in four patients (10%).

CONCLUSIONS

Dual isotopes can be effectively used in breast cancer patients for simultaneous radioguidance to both a nonpalpable primary lesion and sentinel lymph node and allows for improved logistics.

Sentinel node staging of early breast cancer using lymphoscintigraphy and the intraoperative gamma detecting probe

Lymphoscintigraphy combined with intraoperative gamma-probe detection of sentinel lymph nodes in patients with inoperable early primary breast cancers is effective for staging the disease. The clinical alternative is axillary lymph node dissection, which is a far more invasive procedure and is accompanied by significant morbidity. Accuracy of staging is enhanced by immunohistochemical staining of micrometastases, which pathologists can easily perform for one to three sentinel lymph nodes, but not for 20 to 30 nodes, using axillary dissection procedure. Optimum methodology is presented for performing sentinel lymph node imaging and is important for accurate identification of sentinel node(s).