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Krekel N, Zonderhuis B, Muller S, Bril H, van Slooten HJ, de Lange de Klerk E, van den Tol P, Meijer S. Excessive resections in breast-conserving surgery: a retrospective multicentre study. Breast J 2012; 17:602-9. [PMID: 22050281 DOI: 10.1111/j.1524-4741.2011.01198.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The main determinant of cosmetic outcomes following breast-conserving surgery (BCS) for breast cancer is the volume of resection. The importance of achieving optimal oncological control may lead to an unnecessarily large resection of breast tissue. The aim of this study is to evaluate excess resection volume in BCS for cancer by determining a calculated resection ratio (CRR). This retrospective study was conducted in four affiliated institutions and involved 726 consecutive patients with T1-T2 invasive breast cancer treated by BCS between January 2006 and 2009. The pathology reports were reviewed for tumor palpability, tumor size, surgical specimen size, and oncological margin status. The optimal resection volume (ORV) was defined as the spherical tumor volume with an added 1.0 cm margin of healthy breast tissue. The total resection volume (TRV) was defined as the ellipsoid volume of the surgical specimen. CRR was determined by dividing the TRV by the ORV. Of all tumors, 72% (525/726) were palpable, and 28% (201/726) were nonpalpable. The tumor stage was T1 in 492 patients (67.8%) and T2 in 234 patients (32.2%). The median CRR was 2.5 (0.01-42.93). Margin status was positive or focally positive in 153 patients (21.1%). Lower tumor stage was associated with a higher CRR (factor 0.61 [p < 0.0001] and a lower positive margin rate [p = 0.064]). Accordingly, the median CRR of the nonpalpable lesions was higher than that of the palpable lesions (3.1 and 2.2, respectively; p < 0.01), and the involved margin rate was lower (17.4% and 22.5%, respectively; p = 0.13). Of patients with a CRR >4.0, 10.7% still had tumor involved margins. This study clearly shows that BCS is associated with excessive resection of healthy breast tissue while clear margins are not assured. Surgical factors should be modified to improve surgical accuracy.
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Affiliation(s)
- Nicole Krekel
- Surgical Oncology, VU University Medical Center, Amsterdam, The Netherlands.
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102
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Postma EL, Witkamp AJ, van den Bosch MA, Verkooijen HM, van Hillegersberg R. Localization of nonpalpable breast lesions. Expert Rev Anticancer Ther 2012; 11:1295-302. [PMID: 21916583 DOI: 10.1586/era.11.116] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The introduction of mammography screening and improvements in diagnostic tools resulted in a major increase of breast cancers detectable as small, nonpalpable lesions suitable for breast-conserving treatment. Accurate preoperative localization of these cancers is a necessity. Several methods are available for localization, of which wire-guided localization is considered the current gold standard. Promising techniques are radio-guided occult lesion localization, radioactive seed localization and ultrasound-guided surgery. In this article, an overview of the various localization techniques is provided, describing advantages, shortcomings and effectiveness.
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Affiliation(s)
- Emily L Postma
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, The Netherlands.
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103
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Krekel NMA, Lopes Cardozo AMF, Muller S, Bergers E, Meijer S, van den Tol MP. Optimising surgical accuracy in palpable breast cancer with intra-operative breast ultrasound--feasibility and surgeons' learning curve. Eur J Surg Oncol 2011; 37:1044-50. [PMID: 21924854 DOI: 10.1016/j.ejso.2011.08.127] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 08/04/2011] [Accepted: 08/22/2011] [Indexed: 12/19/2022] Open
Abstract
AIMS To evaluate if intra-operative guidance with ultrasonography (US) could improve surgical accuracy of palpable breast cancer excision, and to evaluate the performance of surgeons during training for US-guided excision. MATERIALS AND METHODS Thirty female patients undergoing breast-conserving surgery for palpable T1-T2 invasive breast cancer were recruited. Three individual breast surgeons, assisted by US, targeted and excised the tumours. The main objective was to obtain adequate resection margins with optimal resection volumes. The specimen volume, tumour diameter and histological margin status were recorded. The specimen volume was divided by the optimal resection volume, defined as the spherical tumour volume plus a 1.0-cm margin. The resulting calculated resection ratio (CRR) indicated the amount of excess tissue resected. RESULTS All tumours were correctly identified during surgery, 29 of 30 tumours (96.7%) were removed with adequately negative margins, and one tumour was removed with focally positive margins. The median CRR was 1.0 (range, 0.4-2.8), implying optimal excision volume. For all breast surgeons, CRR improved during the training period. By the 8th procedure, all surgeons showed proficiency in performing intra-operative breast US. CONCLUSION Surgeons can easily learn the skills needed to perform intra-operative US for palpable breast tumour excision. The technique is non-invasive, simple, safe and effective for obtaining adequate resection margins. Within the first two cases, resections reached optimal volumes, thereby, presumably resulting in improved cosmetic outcomes. In a multicentre, randomised, clinical trial, intra-operative US guidance for palpable breast tumours will be evaluated for oncological and cosmetic outcomes.
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Affiliation(s)
- N M A Krekel
- Department of Surgical Oncology, VU University Medical Centre, De Boelelaan 1117, Amsterdam, The Netherlands.
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104
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Fisher CS, Mushawah FA, Cyr AE, Gao F, Margenthaler JA. Ultrasound-guided lumpectomy for palpable breast cancers. Ann Surg Oncol 2011; 18:3198-203. [PMID: 21861232 DOI: 10.1245/s10434-011-1958-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND We sought to determine the re-excision rate following lumpectomy for palpable breast cancers using intraoperative ultrasound (US). A secondary aim was to investigate the impact on surgical decision-making. METHODS We identified 73 women who underwent US-guided lumpectomy for palpable breast cancer between 2006 and 2010. A cohort of 124 women who underwent palpation-guided lumpectomy was used for a comparison group. Data included patient demographics, tumor characteristics, intraoperative findings, and pathologic outcomes. Descriptive statistics were used for data summary and compared by chi-square or t test, as appropriate. RESULTS A total of 73 women underwent US-guided lumpectomy, and 124 women underwent palpation-guided lumpectomy (median age 55 years). Patients undergoing palpation-guided lumpectomy had smaller tumors that were more likely to be HER2/neu amplified compared with patients undergoing US-guided lumpectomy (P < 0.05 for each). There were no differences between the 2 groups with respect to patient age, tumor grade, and estrogen/progesterone receptor status (P > 0.05 for each). Re-excision rates were similar in both groups [17 (23%) in the US group versus 31 (25%) in the palpation group; P > 0.05]. In the US group, 45 patients (62%) had additional shave margins taken based on US interrogation of the specimen, and 12 patients (16%) were spared a 2nd procedure based on the use of intraoperative US. CONCLUSIONS Although palpable breast cancers can be excised based on direct palpation or needle localization, we believe that US guidance provides an excellent tool to aid the breast surgeon. Only 10% of patients had a positive margin on final pathology as a result, and the overall re-excision rate was acceptable.
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Affiliation(s)
- Carla S Fisher
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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105
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Chan BKY, Jois RHS, Wiseberg JA, Audisio RA. Localization techniques for guided surgical excision of non-palpable breast lesions. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd009206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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106
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Davis KM, Hsu CH, Bouton ME, Wilhelmson KL, Komenaka IK. Intraoperative Ultrasound Can Decrease the Re-excision Lumpectomy Rate in Patients with Palpable Breast Cancers. Am Surg 2011. [DOI: 10.1177/000313481107700627] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Positive margins occur in 15 to 69 per cent of patients undergoing lumpectomy. The current study was performed to evaluate intraoperative ultrasound in patients undergoing lumpectomy for palpable breast cancer. A retrospective chart review was performed of patients with palpable cancer who underwent lumpectomy with intraoperative ultrasound from 2004 to 2009. Each patient was matched with two patients who underwent lumpectomy alone over the same time period. Matching criteria included tumor size, clinical stage, body mass index, age at diagnosis, and lymphovascular invasion or extensive intraductal component. Twenty-two consecutive patients who underwent lumpectomy with intraoperative ultrasound were matched with 44 patients who underwent lumpectomy without intraoperative ultrasound. In addition to matching criteria, the patients were similar with respect to ethnicity, insurance status, weight, predominant histology, estrogen receptor, progesterone receptor, and Her2 status. Patients who underwent lumpectomy with intraoperative ultrasound were significantly less likely to have an involved margin (41 vs 9%, P = 0.01) and less likely to require a re-excision (34 vs 9%, P = 0.04). The lumpectomy volumes in the intraoperative ultrasound group were smaller than the volumes in the lumpectomy alone group. Intraoperative ultrasound can decrease the rate of positive margins and re-excision lumpectomy in patients with palpable breast cancers.
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Affiliation(s)
- Karole M. Davis
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona
| | - Chiu-Hsieh Hsu
- Arizona Cancer Center, University of Arizona, Tucson, Arizona
- Mel and Enid Zuckerman Arizona College of Public Health, University of Arizona, Tucson, Arizona
| | - Marcia E. Bouton
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona
| | | | - Ian K. Komenaka
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona
- Arizona Cancer Center, University of Arizona, Tucson, Arizona
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Sheikh F, Pockaj B, Wasif N, Dueck A, Gray RJ. Positive margins after breast-conserving therapy: localization technique or tumor biology? Am J Surg 2011; 202:281-5. [PMID: 21600556 DOI: 10.1016/j.amjsurg.2010.06.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 06/09/2010] [Accepted: 06/09/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND The relative contributions of patient and tumor factors versus radiologic localization technique to the rates of inadequate margins of excision in breast-conserving therapy have not been defined. METHODS Patients undergoing breast-conserving therapy were studied. Margins less than 2 mm from tumor were considered inadequate. RESULTS Of 539 patients, 31% were guided by palpation and 69% were guided by preoperative radiologic localization. The palpation-guidance patients had larger tumors (P < .0001) and more nodal metastases (P = .0005). The rates of inadequate margins were 10% for palpation-guided patients and 11% for radiologic-localization patients (P = .53). The 3-year rates of local recurrence were .7% for palpation-guided patients and 1.8% for radiologic-guided patients (P = .5). CONCLUSIONS Patient, tumor, and intraoperative pathologic factors, not just localization device shortcomings, produce inadequate margins of excision in breast-conserving therapy. A reasonable expected rate of inadequate margins owing to patient and tumor factors is 10%. Quality improvement for margin management must focus on intraoperative assessment of margins, especially for patients with identified risk factors, in addition to improving localization technique.
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Affiliation(s)
- Fariha Sheikh
- Section of Surgical Oncology, Department of Surgery, Mayo Clinic in Arizona, Phoenix, AZ 85054, USA
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108
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109
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Krekel NMA, Zonderhuis BM, Schreurs HWH, Cardozo AMFL, Rijna H, van der Veen H, Muller S, Poortman P, de Widt L, de Roos WK, Bosch AM, Taets van Amerongen AHM, Bergers E, van der Linden MHM, de Lange de Klerk ESM, Winters HAH, Meijer S, van den Tol PMP. Ultrasound-guided breast-sparing surgery to improve cosmetic outcomes and quality of life. A prospective multicentre randomised controlled clinical trial comparing ultrasound-guided surgery to traditional palpation-guided surgery (COBALT trial). BMC Surg 2011; 11:8. [PMID: 21410949 PMCID: PMC3069937 DOI: 10.1186/1471-2482-11-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 03/16/2011] [Indexed: 11/10/2022] Open
Abstract
Background Breast-conserving surgery for breast cancer was developed as a method to preserve healthy breast tissue, thereby improving cosmetic outcomes. Thus far, the primary aim of breast-conserving surgery has been the achievement of tumour-free resection margins and prevention of local recurrence, whereas the cosmetic outcome has been considered less important. Large studies have reported poor cosmetic outcomes in 20-40% of patients after breast-conserving surgery, with the volume of the resected breast tissue being the major determinant. There is clear evidence for the efficacy of ultrasonography in the resection of nonpalpable tumours. Surgical resection of palpable breast cancer is performed with guidance by intra-operative palpation. These palpation-guided excisions often result in an unnecessarily wide resection of adjacent healthy breast tissue, while the rate of tumour-involved resection margins is still high. It is hypothesised that the use of intra-operative ultrasonography in the excision of palpable breast cancer will improve the ability to spare healthy breast tissue while maintaining or even improving the oncological margin status. The aim of this study is to compare ultrasound-guided surgery for palpable tumours with the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumour-free margins, cosmetic outcomes and quality of life. Methods/design In this prospective multicentre randomised controlled clinical trial, 120 women who have been diagnosed with palpable early-stage (T1-2N0-1) primary invasive breast cancer and deemed suitable for breast-conserving surgery will be randomised between ultrasound-guided surgery and palpation-guided surgery. With this sample size, an expected 20% reduction of resected breast tissue and an 18% difference in tumour-free margins can be detected with a power of 80%. Secondary endpoints include cosmetic outcomes and quality of life. The rationale, study design and planned analyses are described. Conclusion The COBALT trial is a prospective, multicentre, randomised controlled study to assess the efficacy of ultrasound-guided breast-conserving surgery in patients with palpable early-stage primary invasive breast cancer in terms of the sparing of breast tissue, oncological margin status, cosmetic outcomes and quality of life. Trial Registration Number Netherlands Trial Register (NTR): NTR2579
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Affiliation(s)
- Nicole M A Krekel
- Department of Surgical Oncology, VU University Medical Centre, Amsterdam, the Netherlands.
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110
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Nonpalpable breast lesions: preoperative radiological guidance in radioguided occult lesion localisation (ROLL). Radiol Med 2011; 116:564-74. [DOI: 10.1007/s11547-011-0654-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Accepted: 07/30/2010] [Indexed: 10/18/2022]
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111
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Ocal K, Dag A, Turkmenoglu O, Gunay EC, Yucel E, Duce MN. Radioguided occult lesion localization versus wire-guided localization for non-palpable breast lesions: randomized controlled trial. Clinics (Sao Paulo) 2011; 66:1003-7. [PMID: 21808866 PMCID: PMC3129952 DOI: 10.1590/s1807-59322011000600014] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 02/01/2011] [Accepted: 03/04/2011] [Indexed: 11/22/2022] Open
Abstract
AIM This prospective randomized clinical study was conducted to compare radioguided occult lesion localization (ROLL) with wire-guided localization to evaluate optimum localization techniques for non-palpable breast lesions. METHODS A total of 108 patients who were undergoing an excisional biopsy for non-palpable breast lesions requiring pathologic diagnosis were randomly assigned to the ROLL group (n = 56) and wire-guided localization group (n = 52). In the study, patients' characteristics, radiological abnormalities, radiological technique of localization, localization time, operation time, weight of the excised specimen, clearance margins, pathological diagnosis and perioperative complications were assessed. RESULTS There were no differences between the two groups in terms of age, radiological abnormalities and localization technique (p = non-significant for all). ROLL techniques resulted in 100% retrieval of the lesions; for the wire-guided localization technique, 98%. Both localization time and operation time were significantly reduced with the ROLL technique (p = significant for all). The weight of the specimen was significantly lower in the ROLL group than in the wire-guided localization group (p = significant). The overall complication rate and pathological diagnosis were similar for both groups (p = non-significant for all). Clear margins were achieved in 91% of ROLL patients and in 53% of wire-guided localization patients, and the difference was significant. CONCLUSIONS The present study indicated that the ROLL technique is as effective as wire-guided localization for the excision of non-palpable breast lesions. In addition, ROLL improved the outcomes by reducing localization and operation time, preventing healthy tissue excision and achieving clearer margins.
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Affiliation(s)
- Koray Ocal
- Department of General Surgery, Medical Faculty, Mersin University, Mersin, Turkey
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112
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Krekel NMA, Zonderhuis BM, Stockmann HBAC, Schreurs WH, van der Veen H, de Lange de Klerk ESM, Meijer S, van den Tol MP. A comparison of three methods for nonpalpable breast cancer excision. Eur J Surg Oncol 2010; 37:109-15. [PMID: 21194880 DOI: 10.1016/j.ejso.2010.12.006] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 11/17/2010] [Accepted: 12/06/2010] [Indexed: 12/14/2022] Open
Abstract
AIMS To evaluate the efficacy of three methods of breast-conserving surgery (BCS) for nonpalpable invasive breast cancer in obtaining adequate resection margins and volumes of resection. MATERIALS AND METHODS A total of 201 consecutive patients undergoing BCS for nonpalpable invasive breast cancer between January 2006 and 2009 in four affiliated institutions was retrospectively analysed. Patients with pre-operatively diagnosed primary or associated ductal carcinoma in situ (DCIS), multifocal disease, or a history of breast surgery or neo-adjuvant treatment were excluded from the study. The resections were guided by wire localisation (WL), ultrasound (US), or radio-guided occult lesion localisation (ROLL). The pathology reports were reviewed to determine oncological margin status, as well as tumour and surgical specimen sizes. The optimal resection volume (ORV), defined as the spherical tumour volume with an added 1.0-cm margin, and the total resection volume (TRV), defined as the corresponding ellipsoid, were calculated. By dividing the TRV by the ORV, a calculated resection ratio (CRR) was determined to indicate the excess tissue resection. RESULTS Of all 201 excisions, 117 (58%) were guided by WL, 52 (26%) by US, and 32 (16%) by ROLL. The rate of focally positive and positive margins for invasive carcinoma was significantly lower in the US group (N = 2 (3.7%)) compared to the WL (N = 25 (21.3%)) and ROLL (N = 8 (25%)) groups (p = 0.023). The median CRRs were 3.2 (US), 2.8 (WL) and 3.8 (ROLL) (WL versus ROLL, p < 0.05), representing a median excess tissue resection of 3.1 times the optimal resection volume. CONCLUSION US-guided BCS for nonpalpable invasive breast cancer was more accurate than WL- and ROLL-guided surgery because it optimised the surgeon's ability to obtain adequate margins. The excision volumes were large in all excision groups, especially in the ROLL group.
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Affiliation(s)
- N M A Krekel
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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113
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Sheikh F, Rebecca A, Pockaj B, Wasif N, McCullough AE, Casey W, Kreymerman P, Gray RJ. Inadequate margins of excision when undergoing mastectomy for breast cancer: which patients are at risk? Ann Surg Oncol 2010; 18:952-6. [PMID: 21080087 DOI: 10.1245/s10434-010-1406-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND We analyzed the margin status and risk factors for inadequate margins among patients who underwent skin-sparing mastectomies (SSM) and traditional total mastectomies (TM). MATERIALS AND METHODS Patients undergoing mastectomies from 2003 to 2009 were included. Margins of excision were considered positive if carcinoma was at an inked margin and were considered close if such disease was within 2 mm of an inked margin. RESULTS A total of 426 patients were identified. The mean age was 60 years and 90% were white. Mean tumor size was 2.6 cm and 44% had multiple ipsilateral carcinomas. Of 426 patients, 177 (42%) underwent SSM with reconstruction and 249 (58%) TM. The rate of positive or close margins on the initial specimen was 29% for SSM vs. 12% for TM (P < 0.01), and the rate of reoperation for margins was 7% for SSM vs. 2% for TM (P < 0.01). Logistic regression analysis revealed that independent risk factors for initial close or positive margins included SSM (odds ratio 2.36, 95% confidence interval [95% CI] 1.05-5.30), multiple ipsilateral tumors (OR 2.12, 95% CI 1.05-4.24), and upper-inner quadrant location (OR 2.58, 95% CI 1.07-6.19). Mean follow-up time was 28 months, and the local recurrence rate was 0.9%. Local recurrence rates were not different for those undergoing SSM (1.1%) vs. TM (0.8%, P = NS). CONCLUSIONS Mastectomy patients undergoing SSM, with multiple ipsilateral tumors, and/or upper-inner quadrant disease are at significantly higher risk for inadequate margins of excision. These patients warrant more vigilant intraoperative attention to margin status to ensure adequate margins at the end of the first operation.
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Affiliation(s)
- Fariha Sheikh
- Section of Surgical Oncology, Department of General Surgery, Mayo Clinic in Arizona, Phoenix, AZ, USA
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114
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Kobbermann A, Unzeitig A, Xie XJ, Yan J, Euhus D, Peng Y, Sarode V, Moldrem A, Marilyn Leitch A, Andrews V, Stallings C, Rao R. Impact of routine cavity shave margins on breast cancer re-excision rates. Ann Surg Oncol 2010; 18:1349-55. [PMID: 21046260 DOI: 10.1245/s10434-010-1420-6] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Indexed: 11/18/2022]
Abstract
PURPOSE Breast-conserving therapy (BCT) is an accepted method of treating early breast cancer. We hypothesized that routine excision of additional cavity shave margins (CSM) at time of initial partial mastectomy reduces the need for additional surgery. METHODS A single-institution retrospective review was performed of women, 18 years or older, with a new diagnosis of breast cancer who underwent partial mastectomy between 1 January 2004 and 1 October 2009. Five hundred thirty-three charts were reviewed. Of those, 69 patients underwent CSM at time of initial operation. These 69 patients were matched with patients who had undergone partial mastectomy without CSM by tumor size, presence of extensive intraductal component, and primary histology. RESULTS The two groups were well matched for age, nuclear grade, associated lymphovascular invasion (LVI), receptor status, and multifocality. We found that 31.9% (44/138) required return to the operating room (OR) for re-excision of margins. Rate of return to the OR was 21.7% (15/69) in the CSM group and 42.0% (29/69) in the matched group (p = 0.011). Multivariate analysis found factors significantly associated with need for additional operation included lack of CSM (odds ratio 9.2, 95% CI 2.8-30.5, p = 0.0003), larger extent of intraductal component (odds ratio 7.0, 95% CI 1.8-27.0, p = 0.005), and lack of directed re-excision (odds ratio 6.4, 95% CI 1.7-25.1, p = 0.007). CONCLUSIONS CSM at time of initial partial mastectomy decreases rate of re-excision by as much as ninefold. CSM should be considered at time of initial operation to reduce the need for subsequent reoperation.
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Affiliation(s)
- Anne Kobbermann
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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115
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Giannotti GD, Ailabouni LD, Salti GI. Ultrasound-guided excision of nonpalpable malignant soft tissue tumors of the abdomen. Future Oncol 2010; 6:1513-5. [DOI: 10.2217/fon.10.98] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The use of intraoperative ultrasound to guide the excision of sonographically visible but nonpalpable lesions is a newer modality. Its use in intraoperative localization of recurrent malignant soft tissue tumors has not been reported. This report describes a technique of intraoperative localization by ultrasound to guide the excision of recurrent nonpalpable malignant soft tissue tumors of the abdominal wall in two patients. Tumors of both patients were successfully localized intraoperatively by ultrasonography and excised with adequate margins. This technique leads to reduced patient discomfort and anxiety, the avoidance of organizational requirements on the day of surgery, and allows for adequate margins of resection
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Affiliation(s)
- Giovanni D Giannotti
- Department of Surgical Oncology, University of Illinois at Chicago, 840 S Wood St (M/C 820), Chicago, IL 60612, USA
| | - Luay D Ailabouni
- Department of Surgical Oncology, University of Illinois at Chicago, 840 S Wood St (M/C 820), Chicago, IL 60612, USA
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Alderliesten T, Loo C, Paape A, Muller S, Rutgers E, Peeters MJV, Gilhuijs K. On the feasibility of MRI-guided navigation to demarcate breast cancer for breast-conserving surgery. Med Phys 2010; 37:2617-26. [PMID: 20632573 DOI: 10.1118/1.3429048] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE The aim of this study was to investigate the feasibility of image-guided navigation approaches to demarcate breast cancer on the basis of preacquired magnetic resonance (MR) imaging in supine patient orientation. METHODS Strategies were examined to minimize the uncertainty in the instrument-tip position, based on the hypothesis that the release of instrument pressure returns the breast tissue to its predeformed state. For this purpose, four sources of uncertainty were taken into account: (1) U(ligaments): Uncertainty in the reproducibility of the internal mammary gland geometry during repeat patient setup in supine orientation; (2) U(r_breathing): Residual uncertainty in registration of the breast after compensation for breathing motion using an external marker; (3) U(reconstruction): Uncertainty in the reconstructed location of the tip of the needle using an optical image-navigation system (phantom experiments, n = 50); and (4) U(deformation): Uncertainty in displacement of breast tumors due to needle-induced tissue deformations (patients, n = 21). A Monte Carlo study was performed to establish the 95% confidence interval (CI) of the combined uncertainties. This region of uncertainty was subsequently visualized around the reconstructed needle tip as an additional navigational aid in the preacquired MR images. Validation of the system was performed in five healthy volunteers (localization of skin markers only) and in two patients. In the patients, the navigation system was used to monitor ultrasound-guided radioactive seed localization of breast cancer. Nearest distances between the needle tip and the tumor boundary in the ultrasound images were compared to those in the concurrently reconstructed MR images. RESULTS Both U(reconstruction) and U(deformation) were normally distributed with 0.1 +/- 1.2 mm (mean +/- 1 SD) and 0.1 +/- 0.8 mm, respectively. Taking prior estimates for U(ligaments) (0.0 +/- 1.5 mm) and U(r_breathing) (-0.1 +/- 0.6 mm) into account, the combined impact resulted in 3.9 mm uncertainty in the position of the needle tip (95% CI) after release of pressure. The volunteer study showed a targeting accuracy comparable to that in the phantom experiments: 2.9 +/- 1.3 versus 2.7 +/- 1.1 mm, respectively. In the patient feasibility study, the deviations were within the 3.9 mm CI. CONCLUSIONS Image-guided navigation to demarcate breast cancer on the basis of preacquired MR images in supine orientation appears feasible if patient breathing is tracked during the navigation procedure, positional uncertainty is visualized and pressure on the localization instrument is released prior to verification of its position.
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Affiliation(s)
- Tanja Alderliesten
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (NKI-AVL), P.O. Box 90203, 1006 BE Amsterdam, The Netherlands
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Hayashi N, Tsunoda H, Abe E, Kikuchi M, Enokido K, Tsugawa K, Suzuki K, Nakamura S. Ultrasonography- and/or mammography-guided breast conserving surgery for ductal carcinoma in situ of the breast: experience with 87 lesions. Breast Cancer 2010; 19:131-7. [DOI: 10.1007/s12282-010-0218-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 07/14/2010] [Indexed: 11/25/2022]
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118
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Das K, Sarkar DK, Karim R, Manna AK. Preoperative ultrasound guided needle localisation for non-palpable breast lesions. Indian J Surg 2010; 72:117-23. [PMID: 23133221 DOI: 10.1007/s12262-010-0035-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Accepted: 05/20/2009] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Breast cancer is a major cause of cancer-related morbidity and mortality in Indian women. Most cases present late and thus survival in Indian patients is poor compared to the western world. In the absence of a screening, early detection of breast cancer is a challenge in Indian subcontinent. METHOD Though much is known about management of any palpable lump in breast, clear guidelines in dealing with non-palpable lesions of breast is still obscure. Careful imaging of breast followed by assignment of standard Breast Imaging Reporting and Data Systems (BIRADS) category to the finding can go in a long way to predict chances of malignancy in a non-palpable breast lesion (NPBL). Total 22 patients with impalpable lesions in the breast were localised with US guided needle and lesion excised. Applicability of Ultrasonography (USG) to detect early breast lesions and comparison with mammography in predicting malignancy was assessed by tests of proportions (z test). RESULTS Total of three early breast cancers and four borderline lesions were diagnosed by this method among 22 properly selected cases. Needle localisation of the lesion on sonographic guidance followed by lumpectomy can be both an accurate diagnostic and therapeutic method to deal with occult lesion in our scenario. CONCLUSION US guided lumpectomy is a feasible alternative to other methods and is effective in Indian scenario to diagnose early subclinical breast cancers.
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Affiliation(s)
- Kalyan Das
- Department of Surgery, RG Kar Medical College and Hospital, Kolkata, India
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van Riet YEA, Jansen FH, van Beek M, van de Velde CJH, Rutten HJT, Nieuwenhuijzen GAP. Localization of non-palpable breast cancer using a radiolabelled titanium seed. Br J Surg 2010; 97:1240-5. [DOI: 10.1002/bjs.7097] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Abstract
Background
Resection guided by a radiologically placed hookwire is the most common surgical technique for non-palpable breast cancer. This technique has several well described disadvantages such as incidental migration, kinking or fracture of the wire, and difficult logistics between the radiology, surgical and nuclear medicine departments. Use of an iodine-125-radiolabelled (I-125) seed for localization of non-palpable breast tumours could potentially prevent these problems.
Methods
Data on use of the I-125 seed localization technique in 325 consecutive women were collected prospectively between October 2003 and June 2009. All patients with screen-detected, histologically proven malignancy were included. Patients with a preoperative core biopsy showing either ductal carcinoma in situ or unclear pathology were excluded from this study.
Results
The mean(s.d.) age of the women was 59·5(11·9) years. Localization was guided ultrasonographically in 275 procedures, stereotactically in 45 and by both techniques in five. The I-125 seed was removed by surgery after a mean of 4(5) days. The mean duration of operation was 62·9(21·2) min. Complete tumour removal was achieved in 310 procedures (95·4 per cent).
Conclusion
Localization of impalpable breast cancer using a I-125 seed was safe and led to a high proportion of radical lumpectomies.
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Affiliation(s)
- Y E A van Riet
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - F H Jansen
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | - M van Beek
- Institute of Pathology, Eindhoven, The Netherlands
| | | | - H J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
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DeJean P, Brackstone M, Fenster A. An intraoperative 3D ultrasound system for tumor margin determination in breast cancer surgery. Med Phys 2010; 37:564-70. [PMID: 20229864 DOI: 10.1118/1.3290867] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
PURPOSE The purpose of this study was to analyze the clinical utility of a portable three-dimensional ultrasound (3DUS) system to be used for surgical guidance of lumpectomy surgeries. In 11%-60% of lumpectomy surgeries, a second surgery is required to fully resect the tumor. Previous studies have used 3DUS as a guidance tool with the hope of more accuracy in resecting the entire tumor during the first surgery. However, they utilized larger systems, which are not easily integrated into the operating room. METHODS The portable 3DUS scanning system we developed consisted of a motorized "tilt" scanner coupled to a Terason t3000 portable ultrasound machine (Terason Ultrasound, Burlington, MA). The 3DUS system was evaluated by measuring agar "tumor" phantoms of known volumes and acquiring and segmenting images from nine patients undergoing lumpectomy. RESULTS Experiments on simulated agar tumor phantoms have shown that our device could be used to measure objects with smooth, well-defined boundaries of known volume with an error of 3%. It was possible to view and segment estimated tumor margins from the clinical images in three dimensions. Correspondence between measurements obtained in the laboratory and the operating room varied with tumor geometry and the degree of spiculation in the ultrasound image. The measured values obtained by the system did not correspond closely with those obtained using histology. However, a more accurate histological measurement using 3D histology may provide a better basis for comparison. CONCLUSIONS The results of imaging simulated agar tumor phantoms indicate the system's consistency in measuring objects of known volume and geometry. The system could be used for segmenting the approximate boundary of lumpectomy patients' breast tumors relative to inserted guide wires. The potential advantages of this system are a reduction in the number of re-excision surgeries required and a reduction in the operative time with the patient under anesthesia.
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Affiliation(s)
- Paul DeJean
- Imaging Research Laboratories, Robarts Research Institute, The University of Western Ontario, London, Ontario N6A 5K8, Canada.
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121
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Eby PR, Calhoun KE, Kurland BF, Demartini WB, Gutierrez RL, Peacock S, Anderson BO, Byrd DR, Mann GN, Lehman CD. Preoperative and intraoperative sonographic visibility of collagen-based breast biopsy marker clips. Acad Radiol 2010; 17:340-7. [PMID: 20042350 DOI: 10.1016/j.acra.2009.10.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Revised: 10/02/2009] [Accepted: 10/12/2009] [Indexed: 11/18/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this study was to determine the sonographic visibility of implanted collagen-based breast biopsy marker clips in the clinic and operating room. MATERIALS AND METHODS Female patients aged > or =18 years who presented for preoperative surgical evaluation within 4 weeks of ultrasound-guided breast biopsy and collagen-based marker clip placement were eligible for this pilot study. The sonographic visibility of the marker clips was rated from 1 (not visible) to 5 (clearly visible) by surgeons at the preoperative appointment, by radiologists at wire localization, and by surgeons in the operating room. Visibility was considered inadequate for values of 1 or 2 and adequate for values of 3, 4, or 5. The data were compared using Wilcoxon's signed-rank test for paired differences across physician (radiologist vs surgeon), time (preoperative visit vs day of surgery), and target (lesion vs clip). RESULTS Twenty-five patients with 26 lesions were enrolled, and 19 patients returned for all imaging procedures. The mean lesion size was 12 mm (range, 5-24 mm). Adequate marker clip visibility assessed by the surgeons decreased from 80% (20 of 25) at the preoperative appointment to 65% (11 of 17) in the operating room, but the difference was not significant (P=.27). Visibilities of the lesions and clips were similar at the preoperative appointment (P=.61), but the clips were significantly less visible on the day of operation (P=.03). CONCLUSION The sonographic visibility of collagen-based marker clips is variable and likely decreases over time but may be adequate to guide intraoperative surgical excision in many cases.
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Affiliation(s)
- Peter R Eby
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA.
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Mascaro A, Farina M, Gigli R, Vitelli CE, Fortunato L. Recent advances in the surgical care of breast cancer patients. World J Surg Oncol 2010; 8:5. [PMID: 20089167 PMCID: PMC2828445 DOI: 10.1186/1477-7819-8-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 01/20/2010] [Indexed: 12/13/2022] Open
Abstract
A tremendous improvement in every aspect of breast cancer management has occurred in the last two decades. Surgeons, once solely interested in the extipartion of the primary tumor, are now faced with the need to incorporate a great deal of information, and to manage increasingly complex tasks. As a comprehensive assessment of all aspects of breast cancer care is beyond the scope of the present paper, the current review will point out some of these innovations, evidence some controversies, and stress the need for the surgeon to specialize in the various aspects of treatment and to be integrated into the multisciplinary breast unit team.
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Affiliation(s)
- Alessandra Mascaro
- Department of Surgery, Senology Unit, San Giovanni-Addolorata Hospital, Via Amba Aradam, 9, 00187 Rome, Italy.
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Romero P, Dauplat MM, Mishellany F, Gimbergues P, Le Bouëdec G, Penault-Llorca F. Chirurgie conservatrice du cancer du sein: évaluation des berges d’exérèse lors de la chirurgie première. ONCOLOGIE 2010. [DOI: 10.1007/s10269-009-1839-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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124
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Long-term outcomes after ROLL lumpectomy. Indian J Surg Oncol 2010; 1:47-51. [DOI: 10.1007/s13193-010-0011-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 09/14/2009] [Indexed: 11/26/2022] Open
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Massimo LP, Alessandra A, Valeria T, Renato A. Intraoperative Ultrasound in Excision of Breast Nonpalpable Lesions: The Experience of the Breast Unit of San Giovanni Hospital in Rome. Breast J 2009; 15:546-8. [DOI: 10.1111/j.1524-4741.2009.00781.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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126
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van Esser S, Peters NHGM, van den Bosch MAAJ, Mali WPTM, Peeters PHM, Borel Rinkes IHM, van Hillegersberg R. Surgical outcome of patients with core-biopsy-proven nonpalpable breast carcinoma: a large cohort follow-up study. Ann Surg Oncol 2009; 16:2252-8. [PMID: 19437077 PMCID: PMC2711911 DOI: 10.1245/s10434-009-0513-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 04/14/2009] [Accepted: 04/14/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Breast-conserving surgery (BCS) is the preferred treatment for nonpalpable breast carcinoma. The outcome, however, may be disappointing. In this study surgical outcome in a large cohort of patients diagnosed with nonpalpable breast carcinoma is evaluated. METHODS In 833 patients with 841 nonpalpable breast carcinomas the number of re-excisions and type of surgical procedures was calculated and summed per patient. Subsequently, the number of conversions to mastectomy and the number of days until complete tumor removal were analyzed. In a subgroup analysis the patients with an in situ carcinoma were compared with the patients with an invasive carcinoma. RESULTS The initial surgery consisted of BCS for 589 tumors (70%) and of mastectomy for 242 tumors (29%). For ten tumors (1%) the initial surgery was unknown. After BCS, 158/589 tumors (27%) required a re-excision: 116/337 (34%) for the in situ carcinomas and 63/504 (13%) for the invasive carcinomas (p = 0.0001). The number of conversions from BCS to mastectomy was 106/589 (18%): 66/241 (28%) in patients diagnosed with an in situ carcinoma versus 40/348 (11%) in patients with an invasive carcinoma (p = 0.0001). The median number of days until complete tumor removal was 28, being 38 days for the in situ carcinomas and 25 days for the invasive carcinomas (p = 0.0001). CONCLUSIONS There is room for improvement in the surgical treatment of nonpalpable breast carcinoma, especially the relatively favorable in situ carcinoma, as it requires significantly more excisions, mastectomies, conversions to mastectomy, and days for complete removal.
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MESH Headings
- Biopsy, Needle
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma in Situ/mortality
- Carcinoma in Situ/pathology
- Carcinoma in Situ/surgery
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Lobular/mortality
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/surgery
- Cohort Studies
- Female
- Follow-Up Studies
- Humans
- Mastectomy
- Middle Aged
- Neoplasm Invasiveness
- Neoplasm Staging
- Prognosis
- Survival Rate
- Treatment Outcome
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Affiliation(s)
- S van Esser
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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127
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Fine RE, Schwalke MA, Pellicane JV, Attai DJ. A novel ultrasound-guided electrosurgical loop device for intra-operative excision of breast lesions; an improvement in surgical technique. Am J Surg 2009; 198:283-6. [DOI: 10.1016/j.amjsurg.2009.01.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Revised: 01/06/2009] [Accepted: 01/06/2009] [Indexed: 11/26/2022]
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Pleijhuis RG, Graafland M, de Vries J, Bart J, de Jong JS, van Dam GM. Obtaining adequate surgical margins in breast-conserving therapy for patients with early-stage breast cancer: current modalities and future directions. Ann Surg Oncol 2009; 16:2717-30. [PMID: 19609829 PMCID: PMC2749177 DOI: 10.1245/s10434-009-0609-z] [Citation(s) in RCA: 247] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Accepted: 06/14/2009] [Indexed: 12/22/2022]
Abstract
Inadequate surgical margins represent a high risk for adverse clinical outcome in breast-conserving therapy (BCT) for early-stage breast cancer. The majority of studies report positive resection margins in 20% to 40% of the patients who underwent BCT. This may result in an increased local recurrence (LR) rate or additional surgery and, consequently, adverse affects on cosmesis, psychological distress, and health costs. In the literature, various risk factors are reported to be associated with positive margin status after lumpectomy, which may allow the surgeon to distinguish those patients with a higher a priori risk for re-excision. However, most risk factors are related to tumor biology and patient characteristics, which cannot be modified as such. Therefore, efforts to reduce the number of positive margins should focus on optimizing the surgical procedure itself, because the surgeon lacks real-time intraoperative information on the presence of positive resection margins during breast-conserving surgery. This review presents the status of pre- and intraoperative modalities currently used in BCT. Furthermore, innovative intraoperative approaches, such as positron emission tomography, radioguided occult lesion localization, and near-infrared fluorescence optical imaging, are addressed, which have to prove their potential value in improving surgical outcome and reducing the need for re-excision in BCT.
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Affiliation(s)
- Rick G Pleijhuis
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
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129
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James TA, Harlow S, Sheehey-Jones J, Hart M, Gaspari C, Stanley M, Krag D, Ashikaga T, McCahill LE. Intraoperative ultrasound versus mammographic needle localization for ductal carcinoma in situ. Ann Surg Oncol 2009; 16:1164-9. [PMID: 19267159 DOI: 10.1245/s10434-009-0388-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Revised: 01/26/2009] [Accepted: 01/27/2009] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ductal carcinoma in situ (DCIS) often requires some method of localization to achieve breast-conserving therapy. The purpose of this study was to compare the efficacy of intraoperative ultrasound versus mammographic needle localization (MNL) for partial mastectomy in DCIS. MATERIALS AND METHODS Data were collected from a Breast Cancer Surgery Database. All DCIS cases undergoing partial mastectomy (PM) were identified. Margin status, re-excision rates, and cost were determined for both groups. RESULTS A total of 155 patients undergoing PM for DCIS were identified from the database. In the 96 patients undergoing ultrasound-guided PM (Group 1), the positive margin rate was 10.4%, and close margins (<1 mm) were observed in 22.9% after initial surgery. There were 59 patients who underwent MNL (Group 2); the positive margin rate was 11.9%, and close margins were observed in 27.1%. The difference between positive and close margins in Group 1 versus Group 2 was not statistically significant. The rate of re-excision was 20.8% for Group 1 and 30.5% for Group 2, resulting in 1.23 and 1.37 operations per patient, respectively. The average cost of an intraoperative ultrasound at our institution was $933 and $1858 for MNL (excluding cost of radiologic interpretation), a difference of $925 per case. CONCLUSION Our study showed equivalent rates of positive margins and re-excision between intraoperative ultrasound and MNL when performing PM for nonpalpable DCIS. Considering the more invasive nature and increased cost of MNL, we consider surgeon-performed intraoperative ultrasound, when possible, the more cost-effective and practical procedure for patients with DCIS.
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Affiliation(s)
- T A James
- Department of Surgery, University of Vermont, Burlington, VT, USA.
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130
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Techniques préopératoires de repérage isotopique des lésions infracliniques mammaires (Trilim) dans les cancers du sein : techniques d’avenir ? ACTA ACUST UNITED AC 2009; 37:45-9. [DOI: 10.1016/j.gyobfe.2008.06.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2008] [Accepted: 06/18/2008] [Indexed: 11/19/2022]
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131
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Ramesh H, Anguille S, Chagla L, Harris O, Desmond S, Thind R, Audisio R. Recurrence after ROLL lumpectomy for invasive breast cancer. Breast 2008; 17:637-9. [DOI: 10.1016/j.breast.2008.05.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Accepted: 05/12/2008] [Indexed: 11/28/2022] Open
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132
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Van Esser S, Hobbelink M, Van der Ploeg I, Mali W, Van Diest P, Borel Rinkes I, Van Hillegersberg R. Radio guided occult lesion localization (ROLL) for non-palpable invasive breast cancer. J Surg Oncol 2008; 98:526-9. [DOI: 10.1002/jso.21143] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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133
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ADAMCZYK B, MURAWA P. Preoperative localization of nonpalpable breast nodules – which method to choose? Rep Pract Oncol Radiother 2008. [DOI: 10.1016/s1507-1367(10)60010-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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134
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van Esser S, Hobbelink MGG, Peeters PHM, Buskens E, van der Ploeg IM, Mali WPTHM, Rinkes IHMB, van Hillegersberg R. The efficacy of 'radio guided occult lesion localization' (ROLL) versus 'wire-guided localization' (WGL) in breast conserving surgery for non-palpable breast cancer: a randomized clinical trial - ROLL study. BMC Surg 2008; 8:9. [PMID: 18495027 PMCID: PMC2409294 DOI: 10.1186/1471-2482-8-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Accepted: 05/21/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With the increasing number of non palpable breast carcinomas, the need of a good and reliable localization method increases. Currently the wire guided localization (WGL) is the standard of care in most countries. Radio guided occult lesion localization (ROLL) is a new technique that may improve the oncological outcome, cost effectiveness, patient comfort and cosmetic outcome. However, the studies published hitherto are of poor quality providing less than convincing evidence to change the current standard of care. The aim of this study is to compare the ROLL technique with the standard of care (WGL) regarding the percentage of tumour free margins, cost effectiveness, patient comfort and cosmetic outcome. METHODS/DESIGN The ROLL trial is a multi center randomized clinical trial. Over a period of 2-3 years 316 patients will be randomized between the ROLL and the WGL technique. With this number, the expected 15% difference in tumour free margins can be detected with a power of 80%. Other endpoints include cosmetic outcome, cost effectiveness, patient (dis)comfort, degree of difficulty of the procedures and the success rate of the sentinel node procedure. The rationale, study design and planned analyses are described. TRIAL REGISTRATION (http://www.clinicaltrials.gov, study protocol number NCT00539474).
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Affiliation(s)
- Stijn van Esser
- Department of Surgical Oncology, University Medical Center Utrecht, Heidelberglaan 100, G04,228 3584 CX Utrecht, The Netherlands.
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135
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Fortunato L, Penteriani R, Farina M, Vitelli CE, Piro FR. Intraoperative ultrasound is an effective and preferable technique to localize non-palpable breast tumors. Eur J Surg Oncol 2008; 34:1289-92. [PMID: 18248946 DOI: 10.1016/j.ejso.2007.11.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Accepted: 11/27/2007] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Non-palpable breast tumors represent an increasing management problem in modern Breast Units. Therefore, a simple and accurate procedure to localize these lesions is needed. To date, the most commonly used technique is wire localization, but there are some disadvantages. METHODS We conducted a prospective study on patients with malignant or benign non-palpable breast tumors who were surgically treated and underwent intraoperative ultrasound (IOUS) from May 2006 to June 2007. Margins of excision were inked and specifically assessed by the pathologist, and were considered positive if <or=1 mm. RESULTS There were 77 patients (60 malignant and 17 benign lesions), with a median age of 54 years (36-87), and a median diameter of 9mm (4-17). All lesions were correctly identified and localized by IOUS, and free margins of excision were obtained in 75/77 cases (97%). Only two patients required a re-excision, one for multifocal disease and one for margins of excision of 1mm. In the remaining cases, the median distance from the tumor to the closest margins of excision, with exclusion of the posterior (fascial) and anterior (skin) margins, was 1.3cm (0.3-3.2). CONCLUSIONS IOUS is a simple and accurate procedure that can be used to identify most non-palpable breast tumors, and has many advantages over the more commonly used wire-localization technique.
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Affiliation(s)
- L Fortunato
- Department of Surgery, S. Giovanni Addolorata Hospital, Via Amba Aradam 4, 00184 Rome, Italy.
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136
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Medina-Franco H, Abarca-Pérez L, García-Alvarez MN, Ulloa-Gómez JL, Romero-Trejo C, Sepúlveda-Méndez J. Radioguided occult lesion localization (ROLL) versus wire-guided lumpectomy for non-palpable breast lesions: A randomized prospective evaluation. J Surg Oncol 2008; 97:108-11. [DOI: 10.1002/jso.20880] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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137
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Bland KI. Editorial on “Radioguided occult lesion localization (ROLL) versus wire-guided lumpectomy for non-palpable breast lesions: A randomized prospective evaluation” by Medina-Franco H, et al. J Surg Oncol 2008; 97:101-2. [DOI: 10.1002/jso.20879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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138
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Cash CJC, Coles CE, Treece GM, Purushotham AD, Britton P, Sinnatamby R, Gee AH, Prager RW. Breast Cancers: Noninvasive Method of Preoperative Localization with Three-dimensional US and Surface Contour Mapping. Radiology 2007; 245:556-66. [PMID: 17890350 DOI: 10.1148/radiol.2452060906] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Formal ethical approval was granted by the local research ethics committee; all participants gave written consent. The purpose of the study was to prospectively evaluate the feasibility of a noninvasive method of breast tumor localization in 25 participants, based on the coregistration of three-dimensional (3D) ultrasonographic (US) data with surface contour data obtained by using a 3D laser camera. The tumor is segmented from the US data, and a surface-rendered 3D image of the tumor, in relation to the breast surface contour, is produced. From a personal computer in the operating room, the surgeon can dynamically view a 3D image of the tumor within the breast. This noninvasive method was equivalent to conventional techniques in 18 of 25 patients but was less successful in larger-breasted patients. In selected patients, this localization method could provide an alternative to conventional invasive techniques and can offer both spatial localization and tumor morphology.
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Affiliation(s)
- Charlotte J C Cash
- Department of Radiology, Cambridge University, Hills Road, Cambridge, UK.
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139
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Potter S, Govindarajulu S, Cawthorn SJ, Sahu AK. Accuracy of sonographic localisation and specimen ultrasound performed by surgeons in impalpable screen-detected breast lesions. Breast 2007; 16:425-8. [PMID: 17374484 DOI: 10.1016/j.breast.2007.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Revised: 01/30/2007] [Accepted: 02/01/2007] [Indexed: 11/23/2022] Open
Abstract
The National Breast Screening Programme had dramatically impacted surgical practice. Up to 50% of all newly diagnosed cancers are now impalpable creating increased demand for image-guided localisation. Wire-guided localisation (WGL) is the current gold standard, but USS-guided localisation by radiologists is a well-documented and effective technique. Increasing numbers of surgeons are proficient in using ultrasound and may be as accurate as radiologists in localising lesions intra-operatively. Of 68 patients with screen-detected impalpable lesions referred to one surgeon in our unit between January 2005 and February 2006, 32 had mass lesions, which were well seen on ultrasound and underwent intra-operative USS-guided localisation performed by a surgeon. All lesions were correctly identified and 87.5% (n=28) were fully excised. Those lesions not fully excised were lobular cancers. Intra-operative sonographic localisation performed by surgeons is an accurate and effective technique. It may produce less patient anxiety and discomfort than WGL and allow more effective and efficient use of resources and theatre time.
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Affiliation(s)
- S Potter
- Frenchay Hospital, Beckspool Road, Frenchay, Bristol, BS16 1JE, England, UK.
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140
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Medina-Franco H, Abarca-Pérez L, Ulloa-Gómez JL, Romero C. Radioguided Localization of Clinically Occult Breast Lesions (ROLL): A Pilot Study. Breast J 2007; 13:401-5. [PMID: 17593045 DOI: 10.1111/j.1524-4741.2007.00448.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Management of nonpalpable breast lesions requiring pathologic diagnosis has been with wire localization during the last few decades. Recently, radioguided localization (ROLL) became an alternative for this type of lesions. The objective of the present study was to evaluate the feasibility of this technique in a tertiary referral center in Mexico City. Consecutive patients requiring pathologic diagnosis from a nonpalpable breast lesion were included in the present study. On the same day of operation, all patients were injected with particles of human serum albumin. Localization of the lesion was performed in the operation theater with the aid of a hand-held gamma-probe. All lesions were identified in a control x-ray of the surgical specimen. Demographic, clinical, surgical and pathologic data were recorded. Forty patients with a mean age of 56.8 +/- 7.8 years were included. In 39 of the 40 patients (97.5%) the "hot spot" was identified easily. In all patients, the area of maximum radioactivity corresponded to the site of the lesion. Imaging confirmation of the lesion in the surgical specimen was done during the first excision in 37 patients (92.5%). In the remaining cases (7.5%), a wider excision was performed during the same procedure, finding the suspected lesion in all cases. Diagnosis of cancer was made in seven patients, (17.5%). There were no significant surgical complications. Our data suggest that ROLL offer a simple and reliable method to localize occult breast lesions, allowing complete removal of the lesion in 100% of the patients. Because of the small quantity of radioactivity, the procedure is safe for both patients and the medical staff, producing less discomfort in patients than wire localization.
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Affiliation(s)
- Heriberto Medina-Franco
- Department of Surgery, Section of Surgical Oncology, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico.
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141
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Haid A, Knauer M, Dunzinger S, Jasarevic Z, Köberle-Wührer R, Schuster A, Toeppker M, Haid B, Wenzl E, Offner F. Intra-operative sonography: a valuable aid during breast-conserving surgery for occult breast cancer. Ann Surg Oncol 2007; 14:3090-101. [PMID: 17593330 DOI: 10.1245/s10434-007-9490-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2007] [Accepted: 05/24/2007] [Indexed: 12/26/2022]
Abstract
BACKGROUND Breast cancer is increasingly detected during an early non-palpable stage. Together with pre-operative marking of the mass, intra-operative imaging provides invaluable clues. This study was designed to evaluate the usefulness of intra-operative sonography in the hands of the surgeon. METHODS Between July 2001 and October 2006, 567 patients underwent treatment for operable breast cancer at the landeskrankenhaus (LHK) Feldkirch. Three hundred and sixty lesions were not palpable. Two hundred and ninety-nine patients with poorly definable or non-definable lesions well seen by ultrasound imaging underwent intra-operative sonography (group 1), while 61 patients with non-palpable lesions only seen on mammography (group 2) were subjected to pre-operative needle localization. The study was non-randomized with prospective data acquisition RESULTS All lesions were identified by both sonography and pre-operative needle localization. In the ultrasound group (group 1) 81% of the lesions were successfully removed by primary intention without metachronous secondary surgery versus 62% in group 2 (p < 0.00228). Eighty-eight percent of the lesions in group 1 were eligible for breast-conserving surgery versus 75% in group 2. The mean clear margin in group 1 was substantially smaller (4.8 mm) than in group 2 (7.2 mm) (p < 0.0001). CONCLUSION Intra-operative sonography proved to be a reliable and helpful tool in the hands of the surgeon, not only for tumor localization, but also for orientation during tumor excision. It simplifies organizational work and spares the patient the discomfort of pre-operative needle localization.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/diagnostic imaging
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Lobular/diagnostic imaging
- Carcinoma, Lobular/surgery
- Cell Differentiation
- Female
- Humans
- Intraoperative Care
- Male
- Mammography
- Mastectomy, Segmental
- Medical Records
- Middle Aged
- Palpation
- Predictive Value of Tests
- Prospective Studies
- Risk Assessment
- Sensitivity and Specificity
- Ultrasonography
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Affiliation(s)
- Anton Haid
- Department of General and Thoracic Surgery, Landeskrankenhaus Feldkirch, Teaching Hospital of Innsbruck University, Carinagasse 47-49, 6800, Feldkirch, Austria.
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142
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Burkholder HC, Witherspoon LE, Burns RP, Horn JS, Biderman MD. Breast Surgery Techniques: Preoperative Bracketing Wire Localization by Surgeons. Am Surg 2007. [DOI: 10.1177/000313480707300608] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
With the development of expertise in image guidance for breast surgery, many surgeons now perform preoperative wire localization themselves. Use of a single wire versus multiple wires to bracket a radiographic breast abnormality has previously been described, although benefits of this technique based on clinical outcomes such as margin status, tissue volume removed, and re-excision rates have not been established. This study is a retrospective analysis of wire-localized breast biopsies performed by 14 surgeons over 29 months; stereotactic and ultrasound guidance were used. During this time, 489 wire localizations were done, of which 159 used multiple wires. Two hundred eleven of these biopsies were done for malignant disease, 86 using multiple wires. After controlling for tumor node metastases stage, single and multiple wire placements were compared using endpoints of margin status, need for re-excision, and total volume of tissue removed. Neither margin status nor re-excision was related to the number of wires placed. However, the number of wires placed was significantly related to the total volume of tissue removed. Use of more than one localizing wire was associated with greater volume of tissue removal (measured in centimeters cubed) in benign disease (46 vs 25, P < 0.001), equivalent volumes in stage 0 disease (73 vs 67), less volume in stage 1 disease (113 vs 164), and less volume in stages 2 through 4 (158 vs 207, P = 0.03). Outcomes based on surgeon case volume during the study period demonstrated that low- (1–40), medium- (41–80), and high-volume (>80) surgeons did not differ in the type or stage of breast pathology treated. Surgeons with high case volumes were more likely to place multiple localizing wires ( P < 0.001) and were more likely to do a breast-conserving procedure if re-excision was performed ( P < 0.018). Surgeons with low case volumes were more likely to perform a re-excision ( P < 0.025). Surgeon experience has a positive impact on quality outcome measures such as performance of a definitive procedure at the time of initial surgery and use of breast-conserving procedures at the time of re-excision. Multiple wire localization can be used to significantly reduce the volume of breast tissue removed in malignant disease without sacrificing margin status or increasing the need for future re-excision.
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Affiliation(s)
- Hans C. Burkholder
- Department of Surgery, University of Tennessee, College of Medicine, Chattanooga Unit, Chattanooga, Tennessee
| | - Laura E. Witherspoon
- Department of Surgery, University of Tennessee, College of Medicine, Chattanooga Unit, Chattanooga, Tennessee
| | - R. Phillip Burns
- Department of Surgery, University of Tennessee, College of Medicine, Chattanooga Unit, Chattanooga, Tennessee
| | - Jeffrey S. Horn
- Department of Surgery, University of Tennessee, College of Medicine, Chattanooga Unit, Chattanooga, Tennessee
| | - Michael D. Biderman
- Department of Psychology, University of Tennessee at Chattanooga, Chattanooga, Tennessee
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143
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Ngô C, Pollet AG, Laperrelle J, Ackerman G, Gomme S, Thibault F, Fourchotte V, Salmon RJ. Intraoperative Ultrasound Localization of Nonpalpable Breast Cancers. Ann Surg Oncol 2007; 14:2485-9. [PMID: 17541694 DOI: 10.1245/s10434-007-9420-x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2007] [Accepted: 02/28/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND Preoperative localization of nonpalpable breast cancers requires good coordination between imaging and surgery departments, and insertion of a guide wire can be traumatic for the patient. This study was designed to evaluate the efficacy of intraoperative ultrasound localization of nonpalpable breast cancers directly by the surgeon. METHODS This prospective study was conducted from June 2006 to October 2006 in 70 patients who underwent surgery for nonpalpable invasive breast cancer. Ultrasound was performed in the operating room by the surgeon with the patient in the operative position. Tumor identification, the correlation with tumor diameter on preoperative ultrasound, analysis of resection margins, and the need to perform surgical re-excision were analyzed. RESULTS Intraoperative ultrasound identified the target in 67 (95.7%) of 70 patients. Two of the three lesions not detected by intraoperative ultrasound were < or =5 mm in diameter in patients with a body mass index of > or =25 (normal range, 19-24). The correlation with diagnostic ultrasound for tumor dimensions was satisfactory (correlation coefficient r = .80). Resection margins free of invasive lesions were obtained in 66 cases (94.3%). Three patients (4.3%) required surgical re-excision, one mastectomy due to multifocal cancer, and two lumpectomy due to positive resection margins. CONCLUSIONS Intraoperative ultrasound localization of nonpalpable breast cancers is feasible and effective, with a sensitivity of 98.3% for tumors >5 mm. It spares the patient the discomfort of a radiological and/or supplementary examination with insertion of a guide wire. It also saves time and money for hospital teams.
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Affiliation(s)
- Charlotte Ngô
- Department of General Surgery, Institut Curie, 26 Rue D'ulm, Paris, France
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144
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Layeequr Rahman R, Crawford S, Larkin A, Quinlan R. Superiority of Sonographic Hematoma Guided Resection of Mammogram Only Visible Breast Cancer: Wire Localization Should be an Exception—Not the Rule. Ann Surg Oncol 2007; 14:2228-32. [PMID: 17514405 DOI: 10.1245/s10434-007-9422-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Accepted: 03/16/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND The goal of breast conservation in cancer treatment is to obtain adequate margins with minimum tissue loss to achieve acceptable oncologic and cosmetic outcome. The standard for resection of breast cancers visible only on mammogram is wire localization (WL), which has a high rate of positive margins. We hypothesized that sonographic hematoma guided (SHG) resection achieves better margin clearance while minimizing volume of resection by more accurate lesion localization. METHODS This retrospective study was conducted at the University Comprehensive Breast Center. Consecutive patients over the span of one year, undergoing breast conservation for stereotactic biopsy proven cancers that were not visualized on ultrasound were studied. SHG and WL technique were compared for age, mammographic abnormality, and tumor characteristics. Outcome variables included closest margin of resection, volume of resection, resection index (resection volume/tumor volume), and rate of margin revision. RESULTS Forty-five patients had SHG, while 51 had WL lumpectomy. The SHG and WL groups were similar in age, mammographic abnormality, tumor type, and stage. Median (25th-75th centile) tumor size was larger in SHG group vs WL group [1.2 (1.1-1.3) vs 0.8 (0.4-1.4) cm; P = .009]. Median (25th-75th centile) closest margin in SHG vs WL group was 5.0 (5.0-8.0) vs 4.0 (1.0-10) mm [P = .0041]. Median (25th-75th centile) resection volume in SHG vs WL group was 85.0 (60.0-128.0) vs 142.2 (54.4-229.0) cm(3) [P = .0127]. Median (25th-75th centile) resection index in SHG vs WL group was 77.3 (59.3-285.7) vs 337.1 (88.9-3982.2) [P = .0004]. Margin was revised in 2 (4.4%) SHG vs 8 (15.7%) WL patients [P = .0978]. CONCLUSION Sonographic hematoma guided lumpectomy is superior to wire localization in obtaining adequate margins with minimal volume of resection.
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145
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van der Ploeg IMC, Hobbelink M, van den Bosch MAAJ, Mali WPTM, Borel Rinkes IHM, van Hillegersberg R. 'Radioguided occult lesion localisation' (ROLL) for non-palpable breast lesions: a review of the relevant literature. Eur J Surg Oncol 2007; 34:1-5. [PMID: 17442531 DOI: 10.1016/j.ejso.2007.03.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Accepted: 03/02/2007] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND 'Radioguided occult lesion localisation' (ROLL) is a possible alternative to the commonly used 'wire-guided localisation' (WGL) of non-palpable breast lesions. Intratumoural injection of a radiotracer identifies both the primary tumour and the sentinel lymph nodes for intraoperative gamma probe guided dissection. METHOD A broad literature search was conducted, using the Pubmed, Embase and The Cochrane Library databases. Five clinically controlled trials and one randomised controlled trial, all of modest size, were selected which describe both ROLL and WGL. Four articles were found that describe the combined use of the ROLL technique with the sentinel node procedure. RESULTS In the ROLL group between 69% and 84% of the lesions were radically excised, compared with 44-60% of the lesions in the WGL group. The studies that combined ROLL and the sentinel node procedure mentioned even higher percentages of radically excised specimens ranging from 90% to 95% and an identification rate of sentinel nodes up to 100%. One randomised controlled trial mentioned that the ROLL procedure had a faster localisation time, was easier to perform, was less painful and gave a better cosmetic result than WGL. CONCLUSION ROLL seems a promising technique, which appears to be more radical than WGL. Localisation tends to be more accurate and faster, the excision procedure is more elegant and simple to perform, and the cosmetic result seems to be better. Further research is necessary to establish the exact role of ROLL in the management of non-palpable breast lesions.
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Affiliation(s)
- I M C van der Ploeg
- Department of Surgery, University Medical Centre Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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146
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Abstract
The use of ultrasound has grown tremendously since it was introduced in 1951. This article describes use of this modality in patients who have breast disease.
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Affiliation(s)
- Margaret Thompson
- Division of Breast Surgical Oncology, Department of Surgery, University of Arkansas for Medical Sciences, 4301 West Markham, Slot 725, Little Rock, AR 72205-7199, USA
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147
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Tafra L, Fine R, Whitworth P, Berry M, Woods J, Ekbom G, Gass J, Beitsch P, Dodge D, Han L, Potruch T, Francescatti D, Oetting L, Smith JS, Snider H, Kleban D, Chagpar A, Akbari S. Prospective randomized study comparing cryo-assisted and needle-wire localization of ultrasound-visible breast tumors. Am J Surg 2006; 192:462-70. [PMID: 16978950 DOI: 10.1016/j.amjsurg.2006.06.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2006] [Revised: 06/15/2006] [Accepted: 06/15/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND This study compared the surgical results of 2 localization methods-cryo-assisted localization (CAL) and needle-wire localization (NWL)-in patients undergoing breast lumpectomy for breast cancer. METHODS A total of 310 patients were treated in an institutional review board-approved study with 18 surgeons at 17 sites. Patients were randomized 2:1 to undergo either intraoperative CAL or NWL. A cryoprobe was inserted under ultrasound guidance in the operating room and an ice ball created an 8- to 10-mm margin around the lesion. The palpable ice ball then was dissected. NWL was placed according to institutional practice and resection was performed in a standard fashion. Surgical margins, complications, re-excisions, tissue volume, procedure times, ease of localization, specimen quality, and patient satisfaction were evaluated. Positive margins were defined as any type of disease present 1 mm or less from any specimen edge. RESULTS Positive margin status did not differ between the 2 groups (28% vs. 31%). The volume of tissue removed was significantly less in the CAL group (49 vs. 66 mL, P = .002). Re-excisions were similar in both groups. CAL was superior in ease of lumpectomy, quality of specimen, acute surgical cosmesis, short-term cosmesis, patient satisfaction, and overall procedure time for the patient. CAL had a lower invasive positive margin rate (11% vs. 20%, P = .039) but a higher observed ductal carcinoma in situ-positive margin rate (30% vs. 18%, approaching statistical significance, P = .052). CONCLUSIONS CAL is a preferred alternative to standard wire localization because it provides a palpable template, removes less tissue and improves cosmesis, decreases overall procedure time, and is more convenient for the patient and surgeon.
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Affiliation(s)
- Lorraine Tafra
- Anne Arundel Medical Center, 2002 Medical Pkwy., Suite 120, Annapolis, MD 21401, USA.
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148
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Abstract
In the last few decades, conservative surgery has become an option in the surgical treatment of breast cancer. The success of conservative surgery depends not only on appropriate patient selection but also on the combination of adequate surgical margins and an acceptable cosmetic result. Obtaining negative surgical margins in conservative breast surgery influences the incidence of local disease recurrence and probably overall survival. Therefore, it is essential to optimize intraoperative examination of margins as well as to explore new techniques that would achieve the greatest possible percentage of negative margins.
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Affiliation(s)
- Isabel T Rubio
- Cirugía General, Instituto Oncológico, Centro Médico Teknon, Barcelona, Spain.
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149
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Nadeem R, Chagla LS, Harris O, Desmond S, Thind R, Titterrell C, Audisio RA. Occult breast lesions: A comparison between radioguided occult lesion localisation (ROLL) vs. wire-guided lumpectomy (WGL). Breast 2005; 14:283-9. [PMID: 15985370 DOI: 10.1016/j.breast.2005.04.002] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2004] [Revised: 03/19/2005] [Accepted: 04/07/2005] [Indexed: 12/22/2022] Open
Abstract
Mammographic screening increases the number of impalpable breast cancers requiring surgical excision. It is important to optimise the localisation technique to remove the smallest amount of tissue, still adequately excising the lesion. The last 65 wire-guided lumpectomies (WGLs) were compared vs. the first 65 radioguided occult lesion localisations (ROLLs) performed for impalpable breast cancers. Data collection included patient's age, radiological abnormality, pre-operative core biopsy, type of primary surgery, length of localisation and excision, hospital stay, cancer size, weight and volume of the excised specimen, clearance margins. All patients were successfully localised with ROLL and WGL. Localisation time was reduced with ROLL (P<0.001). Clear margins were achieved in 83% ROLLs and 57% WGLs (P=0.001). Pathological cancer size and specimen weight were similar in both groups, although the specimen volume was slightly smaller for ROLL. A total of 74% ROLLs had excellent cosmetic outcomes and 26% good, vs. 55% excellent and 45% good in WGLs. A larger amount of normal breast tissue was excised with WGL, without achieving any better cancer clearance. ROLL provides a feasible alternative to WGL. This quick and simple technique achieves an improved rate of clear margins.
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Affiliation(s)
- R Nadeem
- Department of Surgery, Whiston Hospital, Merseyside, UK
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150
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Rutgers EJT. Guidelines to assure quality in breast cancer surgery. Eur J Surg Oncol 2005; 31:568-76. [PMID: 16023942 DOI: 10.1016/j.ejso.2005.02.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2004] [Revised: 09/20/2004] [Accepted: 02/11/2005] [Indexed: 12/22/2022] Open
Abstract
The outcome of breast cancer surgery, with respect to cosmetic results, loco regional control and prognostic information from nodal staging, may vary substantially. Optimal breast cancer care starts with a proper surgical act, which can only be performed when optimal imaging and preoperative diagnosis are available. Next, on the basis of all peroperative findings, the right surgical procedure should be indicated after multidisciplinary consultation and discussion, keeping the objective of the final outcome in mind. The surgical act itself is best performed by an experienced surgeon who has maintained their experience after sufficient training. The outcome of the different procedures can be measured according to simple criteria and prospective registration. All possible surgical procedures, the indication-objectives, the training-objectives and outcome measures are described.
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Affiliation(s)
- E J Th Rutgers
- Department of Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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