Radioactive seed localization in breast cancer treatment

Non-Invasive 3D Breast Tumor Localization: A Viable Alternative to Invasive Tumor Marking

Background: We present a detailed description and the preliminary results of our original technique for non-invasive three-dimensional tumor localization in the breast, which was created as an alternative to standard invasive tumor marking before neoadjuvant systemic therapy (NAST), aiming to enable adequate surgery after complete tumor regression. Methods: A detailed description of the technique is provided in the main text. The technique's feasibility and precision were assessed in a single-arm, prospective study based on the histological parameters of the adequacy and rationality of the excision of completely regressed tumor beds. Results: Out of 94 recruited patients, 15 (16%) were deemed unsuitable, mainly due to the tumors' inadequate ultrasound visibility. Among the 79 processed patients, 31 (39%) had complete clinical regression after NAST and were operated on using our technique. The histological parameters of surgical precision (signs of tumor regression: 24/31; microscopic cancer residues: 7/31) were verified in all excised specimens (100% precision). There were no positive margins in seven cases with microscopic residues, indicating our technique's capacity to enable oncologically safe post-NAST surgery. Conclusions: The proposed technique is feasible and satisfactorily accurate in determining the location of regressed tumors, thus representing an alternative to invasive tumor marking, especially in surgical centers lacking trained staff and equipment for invasive marking. The technique's limitations are mainly related to the inadequate ultrasound visibility of the tumor.

Low-Cost Radio-Opaque Tumor Marking Techniques for Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy: a Systematic Review

Current standard of care localization techniques used in breast conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) are expensive and may not be available in LMICs (lower-middle income countries). This review evaluated the efficacy of radio-opaque low-cost tumor markers. A systematic search was conducted as per PRISMA guidelines through November 30, 2022, for all studies using non-commercial radio-opaque tumor markers for patients undergoing BCS post NACT. Rate of unsatisfactory margin on final histology was the primary outcome. Oxford Centre for Evidence Based Medicine (OCEBM) levels were used to assess internal validity. After screening, 07 studies were included for data synthesis. For marking, four studies used LIGA clips, two used 5-mm cut pieces of K-wire, and one used cut pieces of 25-G needle. Incidence of unsatisfactory margins (positive/close) ranged from 0 to 11%. All studies found these low-cost markers to be feasible, with 100% pre-surgery visibility and 100% retrieval rate. Low-cost radio-opaque tumor markers (LIGA clips, 5-mm cut pieces of K-wire and 25-G needle) are effective methods of tumor localization especially for LMICs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-023-01845-2.

Multidisciplinary radio-guided surgery team: Alternative to change the current paradigm

INTRODUCTION

Given the constant increase in the healthcare demand for examinations related to radio-guided surgery (RGS), our hospital adopted new professional profiles in the RGS team, in order to partially reduce the time spent by nuclear medicine physicians on this task.

AIM

To analyze the process of incorporating the profiles of Diagnostic Imaging Technician (DIT) and Sentinel Node Referent Nurse (SNRN), evaluating their deployment in the procedures linked to the technique.

MATERIAL AND METHODS

Analysis of RGS activity during the period 2018-2022, focusing on pre-surgical and surgical procedures related to breast cancer (BC) and malignant melanoma (MM), as they are those pathologies on which the transfer of care competencies was concentrated. Chronological evolution of the competencies assumed by the different profiles during their integration into the RGS team.

RESULTS

RGS's healthcare activity during the analyzed period experienced an increase of 109%. BC and MM were the pathologies that accounted for by far the greatest demand for care. The transfer of competencies in these two pathologies occurred in a progressive and staggered manner, with 74% (460/622) of the administration phase being carried out by the SNRN and 64% (333/519) of the surgeries by the DIT in 2022.

CONCLUSIONS

The creation of a multidisciplinary RGS team that includes different professional profiles (nuclear medicine physician [MN], ERGC and TSID) is an effective strategy to respond to the increase in the complexity and number of all procedures related to RGS.

Radioactive seed localization is a safe and effective tool for breast cancer surgery: an evaluation of over 25,000 cases

Radioactive seed localization (RSL) provides a precise and efficient method for removing non-palpable breast lesions. It has proven to be a valuable addition to breast surgery, improving perioperative logistics and patient satisfaction. This retrospective review examines the lessons learned from a high-volume cancer center's RSL program after 10 years of practice and over 25 000 cases. We provide an updated model for assessing the patient's radiation dose from RSL seed implantation and demonstrate the safety of RSL to staff members. Additionally, we emphasize the importance of various aspects of presurgical evaluation, surgical techniques, post-surgical management, and regulatory compliance for a successful RSL program. Notably, the program has reduced radiation exposure for patients and medical staff.

The Safe Use of 125I-Seeds as a Localization Technique in Breast Cancer during Pregnancy

INTRODUCTION

Some aspects of the treatment protocol for breast cancer during pregnancy (PrBC) have not been thoroughly studied. This study provides clarity regarding the safety of the use of ¹²⁵I-seeds as a localization technique for breast-conserving surgery in patients with PrBC.

METHODS

To calculate the exposure to the fetus of one ¹²⁵I-seed implanted in a breast tumor, we developed a model accounting for the decaying ¹²⁵I-source, time to surgery, and the declining distance between the ¹²⁵I-seed and the fetus. The primary outcome was the maximum cumulative fetal dose of radiation at consecutive gestational ages (GA).

RESULTS

The cumulative fetal dose remains below 1 mSv if a single ¹²⁵I-seed is implanted at a GA of 26 weeks. After a GA of 26 weeks, the fetal dose can be at a maximum of 11.6 mSv. If surgery takes place within two weeks of implantation from a GA of 26 weeks, and one week above a GA of 32 weeks, the dose remains below 1 mSv.

CONCLUSION

The use of ¹²⁵I-seeds is safe in PrBC. The maximum fetal exposure remains well below the threshold of 100 mSv, and therefore, does not lead to an increased risk of fetal tissue damage. Still, we propose keeping the fetal dose as low as possible, preferably below 1 mSv.

Image-Guided Localization Techniques for Metastatic Axillary Lymph Nodes in Breast Cancer; What Radiologists Should Know

Targeted axillary dissection (TAD) is an axillary staging technique after NACT that involves the removal of biopsy-proven metastatic lymph nodes in addition to sentinel lymph node biopsy (SLNB). This technique avoids the morbidity of traditional axillary lymph node dissection and has shown a lower false-negative rate than SLNB alone. Therefore, marking positive axillary lymph nodes before NACT is critical in order to locate and remove them in the subsequent surgery. Current localization methods include clip placement with intraoperative ultrasound, carbon-suspension liquids, localization wires, radioactive tracer-based localizers, magnetic seeds, radar reflectors, and radiofrequency identification devices. The aim of this paper is to illustrate the management of axillary lymph nodes based on current guidelines and explain the features of axillary lymph node markers, with relative advantages and disadvantages.

Immediate or delayed oncoplastic surgery after breast conserving surgery at the Netherlands Cancer Institute: a cohort study of 251 cases

PURPOSE

Oncoplastic surgery (OPS) after breast conserving surgery is preferably performed during the same operation. Offering delayed OPS instead of mastectomy to patients with a high risk of tumor-positive margins allows breast conservation with the option of margin re-excision during OPS, without having to dismantle the reconstruction. We aimed to evaluate surgical outcomes after immediate and delayed OPS.

METHODS

We included early-stage breast cancer patients who underwent OPS at the Netherlands Cancer Institute between 2016 and 2019. Patients were selected for delayed OPS after multidisciplinary consultation if the risk of tumor-positive margins with immediate OPS was considered significant (> 30%). Groups were compared on baseline characteristics and short-term surgical outcomes.

RESULTS

Of 242 patients with 251 OPS, 130 (52%) OPS had neoadjuvant chemotherapy. Immediate OPS was performed in 176 (70%) cases and delayed OPS in 76 (30%). Selection for delayed OPS was associated with tumor size (OR 1.03, 95% CI 1.01-1.04), ILC (OR 2.61, 95% CI 1.10-6.20), DCIS (OR 3.45, 95% CI 1.42-8.34) and bra size (OR 0.76, 95% CI 0.62-0.94). Delayed and immediate OPS differed in tissue weight (54 vs. 67 g, p = 0.034), tissue replacement (51% vs. 26%, p < .001) and tumor-positive margins (66% vs. 18%, p < .001). Re-excision was performed in 48 (63%) delayed OPS and in 11 (6%) immediate OPS. Groups did not differ in complications (21% vs. 18%, p = 0.333). Breast conservation after immediate and delayed OPS was 98% and 93%, respectively.

CONCLUSION

Performing delayed OPS in selected cases facilitated simultaneous margin re-excision without increasing complications, and resulted in an excellent breast conservation rate.

Does Tumor Marking Before Neoadjuvant Chemotherapy Helps Achieve Better Outcomes in Patients Undergoing Breast Conservative Surgery? A Systematic Review

Patients with breast cancer are increasingly being offered breast conserving surgery (BCS) following neoadjuvant chemotherapy (NACT). We aimed to conduct a systematic review to assess the advantage of tumor marking in patients undergoing BCS after NACT. After registering the protocol for a systematic review with PROSPERO, a systematic search was conducted through September 30, 2020, for all studies involving patients undergoing BCS post NACT after tumor marking. Margin status on final histology was the primary outcome. Oxford Centre for Evidence Based Medicine (OCEBM) levels were used to assess internal validity. A total of 636 records from Medline/PubMed, 1381 from Embase, and 1422 from Cochrane library were extracted. After screening, 15 articles (1520 patients) were included for data synthesis. For marking, 6 studies used metallic markers and 5 used ¹²⁵I-radioactive seeds (RSL) followed by skin tattoo and radio-guided occult lesion localization using ^99mTc (ROLL) in one study each. Most studies used a single marker at the center except for two (143 patients), who practiced the bracketing technique. Incidence of unsatisfactory margins (positive/close) ranged from 5 to 23.5%. After excluding patients with complete pathological response, the "adjusted unsatisfactory margin" rate was found to be 19.3% (10.4-33%). Overall 20.6 recurrences (locoregional/distant) were reported per 1000 patient-years follow-up. Overall survival (OS) was only reported by one study as 96.6% and 84.7% in patients with and without marker placement (p = .01). Re-excision and secondary mastectomy rates (reported by nine studies) were 7.3% and 5.7% respectively. There is limited evidence that tumor marking before neoadjuvant chemotherapy improves the rate of unsatisfactory margins or survival outcomes in a patient undergoing BCS after NACT.

Nationwide registry study on trends in localization techniques and reoperation rates in non-palpable ductal carcinoma in situ and invasive breast cancer

BACKGROUND

There is a transition from wire-guided localization (WGL) of non-palpable breast cancer to other localization techniques. Multiple prospective studies have sought to establish superior clinical outcomes for radioactive-seed localization (RSL), but consistent and congruent evidence is missing.

METHODS

In this study, female patients with breast cancer operated with breast-conserving surgery after tumour localization of a non-palpable breast cancer or ductal carcinoma in situ (DCIS) were included. The cohort was identified from the nationwide Netherlands Breast Cancer Audit conducted between 2013 and 2018. Trends in localization techniques were analysed. Univariable and multivariable analyses were performed to assess the association between the localization technique and the probability of a reoperation.

RESULTS

A total of 28 370 patients were included in the study cohort. The use of RSL increased from 15.7 to 61.1 per cent during the study years, while WGL decreased from 75.4 to 31.6 per cent. The localization technique used (RSL versus WGL) was not significantly associated with the odds of a reoperation, regardless of whether the lesion was DCIS (odds ratio 0.96 (95 per cent c.i. 0.89 to 1.03; P = 0.281)) or invasive breast cancer (OR 1.02 (95 per cent c.i. 0.96 to 1.10; P = 0.518)).

CONCLUSION

RSL is rapidly replacing WGL as the preoperative localization technique in breast surgery. This large nationwide registry study found no association between the type of localization technique and the odds of having a reoperation, thus confirming the results of previous prospective cohort studies.

Toward omitting sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with clinically node-negative breast cancer

BACKGROUND

The nodal positivity rate after neoadjuvant chemotherapy (ypN+) in patients with clinically node-negative (cN0) breast cancer is low, especially in those with a pathological complete response of the breast. The aim of this study was to identify characteristics known before surgery that are associated with achieving ypN0 in patients with cN0 disease. These characteristics could be used to select patients in whom sentinel lymph node biopsy may be omitted after neoadjuvant chemotherapy.

METHODS

This cohort study included patients with cT1-3 cN0 breast cancer treated with neoadjuvant chemotherapy followed by breast surgery and sentinel node biopsy between 2013 and 2018. cN0 was defined by the absence of suspicious nodes on ultrasound imaging and PET/CT, or absence of tumour cells at fine-needle aspiration. Univariable and multivariable logistic regression analyses were performed to determine predictors of ypN0.

RESULTS

Overall, 259 of 303 patients (85.5 per cent) achieved ypN0, with high rates among those with a radiological complete response (rCR) on breast MRI (95·5 per cent). Some 82 per cent of patients with hormone receptor-positive disease, 98 per cent of those with triple-negative breast cancer (TNBC) and all patients with human epidermal growth factor receptor 2 (HER2)-positive disease who had a rCR achieved ypN0. Multivariable regression analysis showed that HER2-positive (odds ratio (OR) 5·77, 95 per cent c.i. 1·91 to 23·13) and TNBC subtype (OR 11·65, 2·86 to 106·89) were associated with ypN0 status. In addition, there was a trend toward ypN0 in patients with a breast rCR (OR 2·39, 0·95 to 6·77).

CONCLUSION

The probability of nodal positivity after neoadjuvant chemotherapy was less than 3 per cent in patients with TNBC or HER2-positive disease who achieved a breast rCR on MRI. These patients could be included in trials investigating the omission of sentinel node biopsy after neoadjuvant chemotherapy.

Therapeutic applications of radioactive sources: from image-guided brachytherapy to radio-guided surgical resection

It is well known nowadays that radioactivity can destroy the living cells it interacts with. It is therefore unsurprising that radioactive sources, such as iodine-125, were historically developed for treatment purposes within radiation oncology with the goal of damaging malignant cells. However, since then, new techniques have been invented that make creative use of the same radioactivity properties of these sources for medical applications. Here, we review two distinct kinds of therapeutic uses of radioactive sources with applications to prostate, cervical, and breast cancer: brachytherapy and radioactive seed localization. In brachytherapy (BT), the radioactive sources are used for internal radiation treatment. Current approaches make use of real-time image guidance, for instance by means of magnetic resonance imaging, ultrasound, computed tomography, and sometimes positron emission tomography, depending on clinical availability and cancer type. Such image-guided BT for prostate and cervical cancer presents a promising alternative and/or addition to external beam radiation treatments or surgical resections. Radioactive sources can also be used for radio-guided tumor localization during surgery, for which the example of iodine-125 seed use in breast cancer is given. Radioactive seed localization (RSL) is increasingly popular as an alternative tumor localization technique during breast cancer surgery. Advantages of applying RSL include added flexibility in the clinical scheduling logistics, an increase in tumor localization accuracy, and higher patient satisfaction; safety measures do however have to be employed. We exemplify the implementation of RSL in a clinic through experiences at the Netherlands Cancer Institute.

Breast-Conserving Therapy in Patients with cT3 Breast Cancer with Good Response to Neoadjuvant Systemic Therapy Results in Excellent Local Control: A Comprehensive Cancer Center Experience

BACKGROUND

Many cT3 breast cancer patients are treated with mastectomy, regardless of response to neoadjuvant systemic therapy (NST). We evaluated local control of cT3 patients undergoing breast-conserving therapy (BCT) based on magnetic resonance imaging (MRI) evaluation post-NST. In addition, we analyzed predictive characteristics for positive margins after breast-conserving surgery (BCS).

METHODS

All cT3 breast cancer patients who underwent BCS after NST between 2002 and 2015 at the Netherlands Cancer Institute were included. Local recurrence-free interval (LRFI) was estimated using the Kaplan-Meier method, and predictors for positive margins were analyzed using univariable analysis and multivariable logistic regression.

RESULTS

Of 114 patients undergoing BCS post-NST, 75 had negative margins, 16 had focally positive margins, and 23 had positive margins. Of those with (focally) positive margins, 12 underwent radiotherapy, 6 underwent re-excision, and 21 underwent mastectomy. Finally, 93/114 patients were treated with BCT (82%), with an LRFI of 95.9% (95% confidence interval [CI] 91.5-100%) after a median follow-up of 7 years. Predictors for positive margins in univariable analysis were hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) subtype, lobular carcinoma, and non-mass enhancement (NME) on pre-NST MRI. MRI response was not correlated to positive margins. In multivariable regression, the odds of positive margins were decreased in patients with HER2-positive (HER2+; odds ratio [OR] 0.27, 95% CI 0.10-0.73; p = 0.01) and TN tumors (OR 0.17, 95% CI 0.03-0.82; p = 0.028). A trend toward positive margins was observed in patients with NME (OR 2.38, 95% CI 0.98-5.77; p = 0.055).

CONCLUSION

BCT could be performed in 82% of cT3 patients in whom BCT appeared feasible on post-NST MRI. Local control in these patients was excellent. In those patients with HR+/HER2- tumors, NME on MRI, or invasive lobular carcinoma, the risk of positive margins should be considered preoperatively.

Pathologic response of ductal carcinoma in situ to neoadjuvant systemic treatment in HER2-positive breast cancer

Purpose

The presence of extensive ductal carcinoma in situ (DCIS) adjacent to HER2-positive invasive breast cancer (IBC) is often a contra-indication for breast-conserving surgery, even in case of excellent treatment response of the invasive component. Data on the response of DCIS to neoadjuvant systemic treatment (NST) are limited. Therefore, we estimated the response of adjacent DCIS to NST-containing HER2-blockade in HER2-positive breast cancer patients and assessed the association of clinicopathological and radiological factors with response.

Methods

Pre-NST biopsies were examined to determine presence of DCIS in all women with HER2-positive IBC treated with trastuzumab-containing NST ± pertuzumab between 2004 and 2017 in a comprehensive cancer center. When present, multiple DCIS factors, including grade, calcifications, necrosis, hormone receptor, and Ki-67 expression, were scored. Associations of clinicopathological and radiological factors with complete response were assessed using logistic regression models.

Results

Adjacent DCIS, observed in 138/316 patients with HER2-positive IBC, was eradicated after NST in 46% of patients. Absence of calcifications suspicious for malignancy on pre-NST mammography (odds ratio (OR) 3.75; 95% confidence interval (95% CI) 1.72–8.17), treatment with dual HER2-blockade (OR 2.36; 95% CI 1.17–4.75), a (near) complete response on MRI (OR 3.55; 95% CI 1.31–9.64), and absence of calcifications (OR 3.19; 95% CI 1.34–7.60) and Ki-67 > 20% in DCIS (OR 2.74; 95% CI 1.09–6.89) on pre-NST biopsy were significantly associated with DCIS response.

Conclusions

As DCIS can respond to NST containing HER2-blockade, the presence of extensive DCIS in HER2-positive breast cancer before NST should not always indicate a mastectomy. The predictive factors we found could be helpful when considering breast-conserving surgery in these patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-021-06235-2.

Radioguided surgery with iodine-125 seeds in breast cancer patients treated with neoadjuvant chemotherapy

OBJECTIVE

To evaluate the use of radioactive iodine-125 seed (RIS) in breast and/or axillary surgery, in patients with breast cancer treated with neoadjuvant chemotherapy (NAC).

MATERIAL AND METHODS

Prospective study between January 2016 and June 2020. 80 women T1-3,N0-2,M0: 30 RIS marking the breast tumor, 36 both the tumor and the biopsied positive axillary node, and 14 only the axilla. Age: 54.7±11.4 years. Tumor size: 34.1±14.6mm. Histological type: invasive ductal carcinoma 90.0%. Molecular subtypes: luminal-A 23.8%, luminal-B/HER2- 33.7%, luminal-B/HER2+ 18.8%, HER2+ 7.5%, basal-like 16,2%.

RESULTS

Of the 66 patients with RIS marking of the tumor (51 pre-NAC, 15 post-NAC), 92.1% had tumor-free surgical margins, with a specimen volume of 126.7±111.2 cm3. Of the 5 second local excisions, in 3 the resection margin was involved (1 mastectomy). Of the 50 patients N1 with RIS marking (MLN), 44 pre-NAC and 6 post-NAC, MLN was identified in 97.2%: negative 23, positive 26. In 45/50 patients, sentinel node biopsy (SNB) was performed and it was identified in 93.3%: negative 26, positive 16. In 1 case RIS was not placed correctly and SNB was not identified due to non-migration. In 61.9% of the patients, MLN was among the SNB identified in the surgery. In 5 patients with mismatched SNB and MLN, the pathological result of the SNB was negative and the MLN was positive. Axillary lymph node dissection was performed in 53.8% of the patients.

CONCLUSION

RIS allow to perform breast-conserving surgery and improve detection of residual axillary disease in patients treated with NAC.

Locoregional therapy in breast cancer patients treated with neoadjuvant chemotherapy

Introduction: Neoadjuvant chemotherapy (NAC) is increasingly used preoperatively in breast cancer patients to achieve disease downstaging, reduce distant dissemination, and assess chemosensitivity. While NAC indications are expanding, knowledge of its impact on subsequent locoregional treatment with surgery and radiation therapy (RT) decisions is evolving. Radiation oncologists are often called upon to estimate locoregional recurrence (LRR) risks and provide recommendations for adjuvant RT to the breast/chest wall and regional lymph nodes postoperatively. In the non-NAC setting, adjuvant RT decisions are guided by the pathology findings after definitive surgery. In the NAC setting, decisions for or against adjuvant RT are complex, particularly in patients who achieve complete pathologic response (pCR).Areas covered: This review will examine contemporary data on NAC in patients with breast cancer and discuss its impact on surgical and RT decisions. We will also evaluate controversies in the role of LRRT for these patients, focussing on prognostic factors that include biological subtypes and pCR after NAC.Expert opinion: Advances in personalized medicine and diagnostic techniques have shifted paradigms and increased complexities in locoregional treatment decisions, particularly in the setting of NAC. Despite the challenges, our goals while we await prospective data remain focused on improving survival, minimizing toxicity, and optimizing function and cosmesis.

Selecting Image-Guided Surgical Technologies in Oncology: A Surgeon's Perspective

BACKGROUND

To improve surgical performance, image-guided (IG) technologies are increasingly introduced. Yet, it is unknown which oncological procedures yield most value from these technologies. This study aimed to select the most promising IG technology per oncologic indication.

METHODS

An Analytic Hierarchical Process was used to evaluate three IG technologies: navigation, optical imaging, and augmented reality, in five oncologic indications compared with usual care. Sixteen decision criteria were selected. The relative importance of the criteria and the expected performance of the technologies were evaluated among surgeons. The combination of these scores gives the expected value per technology.

RESULTS

On criteria level, sparing critical tissue (9%-18%) and reducing the risk of local recurrence (11%-27%) were most important. Navigation was preferred in three indications-removal of lymph nodes (42%), liver (47%), and rectal tumors (33%). In removing rectal tumors, optical imaging was equally preferred (34%). In removing breast and tongue tumors, no technology was clearly preferred.

CONCLUSIONS

In selecting IG technologies, especially optical and navigation technologies are expected to add value in addition to usual care. Further development of those technologies for the preferred indications seems valuable. Multi-attribute analysis showed to be useful in prioritization of conducting clinical studies and steer research and development initiatives.

Budget Impact Analysis of Preoperative Radioactive Seed Localization

BACKGROUND

This study models costs in implementing a radioactive seed localization (RSL) program for nonpalpable breast lesions at a large Canadian tertiary hospital to replace existing wire-guided localization (WGL).

METHODS

All direct and indirect operating costs of localization per lesion from the hospital's perspective were determined by retrospectively reviewing patient data and costs from January 2014 to December 2016. A budget impact analysis and sensitivity analysis were performed to calculate the mean cost per lesion, the minimum and maximum cost per lesion, operational costs, and initial costs.

RESULTS

There were 265 WGL lesions in 2014 and 170 RSL lesions in 2016 included in cost calculation. The mean cost per localization was $185 CAD for WGL ($148-$311) and $283 CAD ($245-$517) for RSL using preloaded seeds, adjusted to 2016 Canadian dollars. The annual operational expenditure including all localizations and overhead costs was $49,835 for WGL and $80,803 for RSL. Initial costs for RSL were $22,000, including external training and new equipment purchases.

CONCLUSIONS

Our budget impact analysis shows that RSL using preloaded radioactive seeds was more expensive than WGL when considering per-lesion localization costs and specific costs related to radiation safety. Manually loading radioactive seed could be a cost-saving alternative to purchasing preloaded seeds. Our breakdown of costs can provide a framework for other centres to determine which localization method best suit their departments.

Comparison of 3 γ-probes for simultaneous iodine-125-seed and technetium-99m breast cancer surgery: NEMA standard characterisation with extended processing

Purpose

Iodine-125 (¹²⁵I) seeds can be used as landmarks to locate non-palpable breast lesions instead of implanting metal wires. This relatively new technique requires a nuclear probe usually used for technetium-99m (^99mTc) sentinel node detection. This study aimed to compare the performances of different probes and valid the feasibility of this technique, especially in the case of simultaneous ¹²⁵I-seed and ^99mTc breast cancer surgery.

Methods

Three probes with different features (SOE-3211, SOE-3214 and GammaSUP-II) were characterised according to the NEMA NU3-2004 standards for a ^99mTc source and a ¹²⁵I-seed. Several tests such as sensitivity, linearity or spatial resolution allowed an objective comparison of their performances. NEMA testing was extended to work on signals discrimination in case of simultaneous detection of two different sources (innovative figure of merit “Shift Index”) and to assess the ^99mTc scatter fraction, a useful parameter for the improvement of the probes in terms of detector materials and electronic system.

Results

Although the GammaSUP-II probe saturated at a lower activity (1.6 MBq at 10 mm depth), it allowed better sensitivity and spatial resolution at the different NEMA tests performed with the ^99mTc source (7865 cps/MBq and 15 mm FWHM at 10 mm depth). With the ¹²⁵I-seed, the GammaSUP-II was the most sensitive probe (3106 cps/MBq at 10 mm depth) and the SOE-3211 probe had the best spatial resolution (FWHM 20 mm at 10 mm depth). The SOE-3214 probe was more efficient on discriminating ¹²⁵I from ^99mTc in case of simultaneous detection. The SOE probes were more efficient concerning ^99mTc scatter fraction assessments. The SOE-3211 probe, with overall polyvalent performances, seemed to be an interesting trade-off for detection of both ¹²⁵I and ^99mTc.

Conclusion

The three probes showed heterogeneous performances but were all suitable for simultaneous ^99mTc sentinel node and ¹²⁵I-seed detection. This study provides an objective and innovative methodology to compare probes performances and then choose the best trade-off regarding their expected use.

Use of Reduced Activity Seeds in Breast Radioactive Seed Localization

Radioactive seed localization procedures, using I seeds of typical activity 3.7 MBq and higher, are performed to localize nonpalpable lesions in the breast for surgical excision and pathology analysis. This study evaluated the use and dosimetry of I seeds of activity <3.7 MBq in radioactive seed localization procedures through retrospective health record review, Monte Carlo simulation, and experimental detection. An average seed strength at the time of specimen excision of 2.48 ± 0.629 MBq was used in 295 radioactive seed localization procedures at Gundersen Health System in La Crosse, Wisconsin, US. The average explanted seed activity served as a basis for Monte Carlo simulation of an I IsoAid Advantage seed embedded in soft tissue, which scored the dose deposited to soft tissue. Tabulated values of the dose to postsurgical residual tissue as a function of explanted tumor radius were shown and compared with previously published results. Use of seeds of activity from 1.44 to 3.7 MBq at the time of excision did not adversely affect seed detection and excision. The absorbed dose to residual tissue calculated using Monte Carlo was an average of 1.4 times larger than previously published results when scaled to identical seed strengths. This study demonstrates that seeds of activity <3.7 MBq can be used for radioactive seed localization procedures with no loss in efficacy and a benefit of reduced radiation dose to patients. This is important because the estimated radiation dose to residual tissue is approximately 1.4 times higher than previously indicated.

A Single-Institute Experience With Radioactive Seed Localization of Breast Lesions-A Retrospective Study

OBJECTIVES

To assess the benefits associated with radioactive seed localization (RSL) in comparison to conventional wire localization (WL) for nonpalpable breast lesions.

METHODS

Radioactive seed localization was initiated at our institution in July 2013. Retrospective review of all WL performed between June 2012 and July 2013 (2013) and all RSL performed during June 2015 and July 2016 (2016). Patients who received neoadjuvant therapy or did not undergo their planned surgeries and WL performed in 2016 were excluded. The following data were collected: final pathology, resection margins for malignant lesions, time to surgery, seed migration, and number of localized lumpectomies performed by each surgeon.

RESULTS

A total of 292 WL procedures (288 women) in 2013 and 194 RSL procedures (186 women) in 2016 were eligible for the study. All WLs were inserted the day of surgery. Mean time from RSL insertion to surgery was 4.0 ± 2.8 days (range: 1-17 days). There was no difference in specimen size for malignant lesions (6.8 ± 2.8 cm for WL and 6.9 ± 2.9 cm for RSL; P = .5). Specimen radiographs were obtained in 233 (80%) of 292 WL compared to 194 (100%) of 194 RSL (P < .001). For malignant lesions, positive margins were present in 34 (17.2%) of 198 with WL compared to 15 (10.3%) of 146 with RSL (P < .001). Close margins (≤1 mm) were present in 31 (15.6%) of 198 with WL compared to 1 (0.6%) of 146 with RSL (P < .001). The seed fell out of the specimen during surgery in 6 (3.1%) of 194. No seed loss was recorded. The surgeons (n = 4) who transitioned to RSL increased the number of surgeries per month from a mean of 4.4 ± 2.6 in 2013 to 6.9 ± 3.5 in 2016, equivalent to a 41% increase (P = .003).

CONCLUSIONS

The use of RSL, as compared to conventional WL, resulted in a reduction in the number of pathologically involved surgical margins and was associated with an increased number of surgeries. Furthermore, RSL can be performed up to 14 days prior to surgery, which may improve scheduling flexibility in the radiology department.

Combined procedure of marking axillary positive node with iodine-125 seed and sentinel lymph node biopsy in breast cancer patients treated with neoadjuvant chemotherapy

OBJECTIVE

To present our initial experience in the combined procedure of intraoperative detection of axillary positive node marked with ¹²⁵I seed (ML) and sentinel node biopsy (SLN) after neoadjuvant chemotherapy (NACT), in breast cancer patients.

MATERIAL AND METHODS

Prospective study, January 2017 - March 2019, 16 breast cancer patients T1-3N1. TNM stage: IIA: 3, IIB: 10, IIIA: 3. Histological type ductal invasive: 14. Molecular subtype: luminal A: 3, luminal B: 9, HER2: 3, basal like: 1. The ML was marked 227±36 days before neoadjuvant chemotherapy (n: 10), or 1-6 days before surgery, on previously identified node by ultrasound visibility marker, hydrogel (n: 3) or three dimensional-3D (n: 3). Axillary lymphadenectomy was undertaken in 10 patients.

RESULTS

ML and SLN were identified in the surgery in 93.7% (15/16) of the cases, in 33.3% (5/15) ML was not among SLN, and in only one patient (1/5) was there a discrepancy between the result of ML and SLN (macrometastases vs. negative 0/2). Median number of lymph nodes SLN: 2.2±0.9 (range 1-3) and AD: 13.5±5.2 (range 7-23). In all cases, histopathological analysis of ML, ¹²⁵I seed and/or marker within, correctly predicted axillary status after neoadjuvant chemotherapy. In all patients the ¹²⁵I radioactive seed was recovered.

CONCLUSIONS

Placing of ¹²⁵I seeds is a feasible technique for intraoperative location of axillary positive node combined with SLN. The histopathological result of ML allows the axillary status to be determined after neoadjuvant chemotherapy.

Feasibility of radioguided occult lesion localization of clip-marked lymph nodes for tailored axillary treatment in breast cancer patients treated with neoadjuvant systemic therapy

Background

Selective removal of initially tumor-positive axillary lymph nodes in breast cancer patients who underwent neoadjuvant systemic treatment (NST) improves the accuracy of nodal staging and provides the opportunity for more tailored axillary treatment. This study evaluated whether radioguided occult lesion localization (ROLL) of clip-marked lymph nodes is feasible in clinical practice.

Methods

Prior to NST, a clip marker was placed inside a proven tumor-positive lymph node in all breast cancer patients (cTis-4N1-3 M0). After NST, technetium-99m-labeled macroaggregated albumin was injected in the clip-marked lymph nodes. The next day, these ROLL-marked nodes were selectively removed at surgery to evaluate the pathological response of the axilla.

Results

Thirty-seven patients (38 axillae) underwent clip insertion. After NST, the clip was visible by ultrasound in 36 procedures (95%). In the other two patients, the ROLL-node injection was performed in a sonographically suspicious unclipped node (1), and near the clip under computed tomography guidance (1). Initial surgery successfully identified the ROLL-marked node with clip in 33 procedures (87%). Removed specimens in the other five procedures contained only the sonographically suspicious tumor-positive unclipped node (1), a node with signs of complete response but no clip (2), a clip without node (1), and tissue without node nor clip, and a second successful ROLL-node procedure was performed (1). Overall, 10 ROLL-marked nodes had no residual disease.

Conclusions

This study demonstrates that the ROLL procedure to identify clip-marked lymph nodes is feasible. This facilitates selective removal at surgery and may tailor axillary treatment in patients treated with NST.

Surgical clips vs. iodine-125 (125I) seeds for marking the location of nonpalpable malignant breast lesions: preliminary results

OBJECTIVES

To assess the usefulness of iodine-125 (125I) seeds as an alternative to surgical clips for marking the location of nonpalpable malignant breast lesions for surgery.

MATERIAL AND METHODS

We included patients with histologically confirmed nonpalpable malignant lesions treated by surgery in 2015 or 2016. Patients were randomly assigned to presurgical marking with metallic clips (Group A) or with 125I seeds (Group B). In both groups, marking was guided by ultrasound and/or mammography depending on the radiologic characteristics of the lesion. During surgery, a gamma probe was used and afterward the presence of seeds in the surgical specimen was checked radiologically. In the histological analysis, the absence of tumor in the stain was considered free margins. We analyzed the following variables: age, lesion characteristics (laterality, mean size on MRI and in the surgical specimen, radiological type), and presence/absence of free margins.

RESULTS

In Group A (n=53), the most common histologic subtypes were infiltrating ductal carcinoma (IDC, 84.9%) and luminal A (LA, 49.1%); the mean size of the lesions was 1.8cm. In Group B (n=45), the most common histologic subtypes were IDC (82.2%) and LA (46.5%); the mean size of the lesions was 1.5cm. In Group A, 13.2% had involved margins and 13.2% underwent a second surgical intervention. In Group, B 11.4% had involved margins and 7.5% underwent a second surgical intervention. The differences between groups were not significant (p=0.7 for involved margins and p=0.5 for reintervention). The volume of the surgical specimens was significantly lower in Group B than in Group A (128.68cm3 vs. 189.37cm3; p<0.05).

CONCLUSIONS

Using 125I seeds was feasible and enabled significantly smaller surgical specimens than using metallic clips.

125I radioactive seed localization for non-palpable lesions in breast cancer

AIM

Marking of non-palpable breast lesions with ¹²⁵I radioactive seeds is an alternative to the use of the surgical wire. The objective of this work is to present the results that we have obtained using radioactive seed localization compared to the reference technique in our center, the wire localization of non-palpable breast lesions.

MATERIAL AND METHOD

Longitudinal prospective study that includes patients with histological diagnostic of breast cancer, with non-palpable lesions that are candidates to primary surgical treatment by radioactive seed localization (2016-2018) and by wire localization (2015-2016). Histological analysis of the surgical specimen was performed determining the status of surgical margins. The volume of the surgical specimen was calculated.

RESULTS

A total of 146 patients were included, 95 who underwent surgery by radioactive seed localization and 51 by wire localization. The mean cube volume of the specimens were 135.67cm3 vs. 190.77cm3 (p=0.017), respectively. Eleven patients who underwent surgery by radioactive seed localization showed affected margins of the specimen (11.6%), versus 7 (13.2%) of wire localization group (p=0.084). Reintervention was performed in 9 of the patients marked with seeds and in 7 marked with wires (p=0.49).

CONCLUSION

The use of ¹²⁵I radioactive seeds is feasible in non-palpable breast lesions, with a low rate of reintervention and volumes of surgical specimens significantly lower than those obtained by wire localization.

Radio-guided and clip-guided preoperative localization for malignant microcalcifications offer similar performances in breast-conserving surgery

Obtaining a tailored breast resection is challenging in microcalcifications detected on screening mammography, and an accurate localization is required. The aim of this study was to compare the efficacy of radio-guided localization (ROLL) versus ultrasound localization of a titanium clip with collagen (TCC) in terms of clear margins, re-intervention rates, excess of resected breast tissue, and operative times in pure malignant microcalcifications detected on screening mammography. Two hundred and twenty-one consecutive patients with malignant microcalcifications detected on screening mammography from a tertiary breast unit were reviewed: 177 patients were localized by TCC and 44 patients by stereotactic ROLL. A propensity score-matched analysis was performed, followed by a logistic regression model, to avoid selection bias. Adequacy of resection was expressed as the calculated resection ratio considering lesion size. No differences were found in clear margins with ROLL versus TCC (77.3% vs 81.8%, adjusted OR 2, P = 0.27). Re-operation rates were similar, being 11.3% with ROLL and 7.4% with TCC (P = 0.627). Mean resection volume was 46.2 cm³ with ROLL versus 54.2 cm³ with TCC (P = 0.222). Adjusted mean calculated resection ratio was 1.8 with ROLL and 2.1 with TCC (P = 0.38). Surgery time was longer with TCC compared to ROLL (69.6 vs 52.7 minutes, P < 0.0001). ROLL and TCC are equally effective to excise malignant microcalcifications with clear margins, providing similar re-intervention rates and resection volumes.

Injectable iodine-125 labeled tissue marker for radioactive localization of non-palpable breast lesions

We have developed a ¹²⁵I-radiolabeled injectable fiducial tissue marker with the potential to replace current methods used for surgical guidance of non-palpable breast tumors. Methods in routine clinical use today such as radioactive seed localization, radio-guided occult lesion localization and wire-guided localization suffers from limitations that this injectable fiducial tissue marker offers solutions to. The developed ¹²⁵I-radiolabeled injectable fiducial tissue marker is based on highly viscous sucrose acetate isobutyrate. The marker was readily inserted in NMRI mice and proved to be spatially well-defined and stable over a seven day period with excellent CT contrast (>1500 HU), enabling fluoroscopic visualization of the marker during placement. The radioactivity remains strongly associated with the marker during the implantation period, which limits exposure to healthy tissue. Biodistribution studies show that there is negligible radioactivity in all non-tumor tissues sampled, with the exception of the thyroid gland, where limited accumulation was observed (0.06% of injected dose after 7 days). Based on the excellent performance of the marker and the fact that it can be delivered through thin hypodermic needles (≥27G), the marker holds great promise for clinical application, since patient discomfort is reduced significantly compared to current methods.

STATEMENT OF SIGNIFICANCE

A new type of tissue marker for local administration to non-palpable breast tumors has been developed. The surgical guidance marker is based on derivatives of the biomaterial sucrose acetate isobutyrate and unlike currently used markers it is injectable in the tissue using thin needles, reducing the discomfort to the patients significantly. The marker confers CT contrast and has radioactive properties, meaning it also could find use in brachytherapy. The design of the iodine-125 labeled fiducial tissue marker enables control of dosimetry as well as a choice of iodine isotope used. The marker is anticipated to be clinical applicable due to its contrast performance in mice and its potential for enhanced flexibility in surgical procedures, compared to current methods.

Breast-conserving surgery following neoadjuvant therapy-a systematic review on surgical outcomes

Purpose

Neoadjuvant chemotherapy (NACT) is increasingly used in breast cancer treatment. One of the main goals of NACT is to reduce the extent of local surgery of the breast and axilla. The aim of this study was to determine surgical outcomes for patients receiving breast-conserving therapy (BCT) after NACT, including margin status plus secondary surgeries, excision volumes, and cosmetic outcomes.

Methods

A systematic review was performed in accordance with PRISMA principles. Pubmed, MEDLINE, Embase, and the Cochrane Library were searched for studies investigating the results of BCT following NACT. The main study outcomes were margin status, additional local therapies, excision volumes, and cosmetic outcomes. Non-comparative studies on NACT were also included. Exclusion criteria were studies with less than 25 patients, and studies excluding secondary mastectomy patients.

Findings

Of the 1219 studies screened, 26 studies were deemed eligible for analysis, including data from 5379 patients treated with NACT and 10,110 patients treated without NACT. Included studies showed wide ranges of tumor-involved margins (2–39.8%), secondary surgeries (0–45.4%), and excision volumes (43.2–268 cm³) or specimen weight (26.4–233 g) after NACT. Most studies were retrospective, with a high heterogeneity and a high risk of bias. Cosmetic outcomes after NACT were reported in two single-center cohort studies. Both studies showed acceptable cosmetic outcomes.

Interpretation

There is currently insufficient evidence to suggest that NACT improves surgical outcomes of BCT. It is imperative that clinical trials include patient outcome measures in order to allow monitoring and meaningful comparison of treatment outcomes in breast cancer.

Breast conserving surgery for extensive DCIS using multiple radioactive seeds

BACKGROUND AND OBJECTIVES

Breast conserving surgery (BCS) can be challenging for large regions of ductal carcinoma in situ (DCIS), resulting in high rates of positive resection margins. Radioactive seed localization (RSL) using multiple radioactive iodine (¹²⁵I) seeds can be used to bracket extensive DCIS (eDCIS). The goal of this study was to retrospectively compare the use of a single or multiple ¹²⁵I seeds in RSL to enable BCS in patients with eDCIS.

METHODS

All patients with eDCIS (area of ≥3.0 cm) who underwent either single or multiple-seed RSL between January 2008 and December 2016 were included. Patient, tumor and surgery characteristics were compared between both groups. Primary outcome measures were positive resection margin and re-operation rates.

RESULTS

Respectively 48 and 58 patients with eDCIS underwent single- and multiple-seed RSL and subsequent BCS. The rate of positive resection margin (focal and more than focal) with single-seed RSL was 47.9%, compared to 29.3% with multiple-seed RSL (p = 0.06). The re-operation rate was 39.6% with single-seed RSL and 20.7% in the multiple-seed RSL group (p = 0.05).

CONCLUSION

Multiple-seed RSL enables bracketing of large areas of DCIS, with the potential to decrease the high rate of positive resection margins in this patient group.

Real-time wireless tumor tracking during breast conserving surgery

PURPOSE

To evaluate a novel surgical navigation system for breast conserving surgery (BCS), based on real-time tumor tracking using the Calypso[Formula: see text] 4D Localization System (Varian Medical Systems Inc., USA). Navigation-guided breast conserving surgery (Nav-BCS) was compared to conventional iodine seed-guided BCS ([Formula: see text]I-BCS).

METHODS

Two breast phantom types were produced, containing spherical and complex tumors in which wireless transponders (Nav-BCS) or a iodine seed ([Formula: see text]I-BCS) were implanted. For navigation, orthogonal views and 3D volume renders of a CT of the phantom were shown, including a tumor segmentation and a predetermined resection margin. In the same views, a surgical pointer was tracked and visualized. [Formula: see text]I-BCS was performed according to standard protocol. Five surgical breast oncologists first performed a practice session with Nav-BCS, followed by two Nav-BCS and [Formula: see text]I-BCS sessions on spherical and complex tumors. Postoperative CT images of all resection specimens were registered to the preoperative CT. Main outcome measures were the minimum resection margin (in mm) and the excision times.

RESULTS

The rate of incomplete tumor resections was 6.7% for Nav-BCS and 20% for [Formula: see text]I-BCS. The minimum resection margins on the spherical tumors were 3.0 ± 1.4 mm for Nav-BCS and 2.5 ± 1.6 mm for [Formula: see text]I-BCS (p = 0.63). For the complex tumors, these were 2.2 ± 1.1 mm (Nav-BCS) and 0.9 ± 2.4 mm ([Formula: see text]I-BCS) (p = 0.32). Mean excision times on spherical and complex tumors were 9.5 ±  2.7 min and 9.4 ± 2.6 min (Nav-BCS), compared to 5.8 ± 2.2  min and 4.7 ± 3.4 min ([Formula: see text]I-BCS, both (p < 0.05).

CONCLUSIONS

The presented surgical navigation system improved the intra-operative awareness about tumor position and orientation, with the potential to improve surgical outcomes for non-palpable breast tumors. Results are positive, and participating surgeons were enthusiastic, but extended surgical experience on real breast tissue is required.

Radioactive seed localization for breast conservation surgery: Low positive margin rate with no learning curve

BACKGROUND

Radioactive seed localization (RSL) is an alternative to wire localization. We compared the rate of positive margins for evidence of a learning curve in implementing RSL.

METHODS

A retrospective review of RSL by three surgeons at a single institution from 2002 to 2016. Positive margins were defined as ink on tumor.

RESULTS

Surgeon experience with RSL for ranged from 142 to >500 cases. The positive margin rate among the first 100 of each surgeons' experience (n = 300) was 2.3% and the rate during the most recent up to 100 cases after experience with at least 100 RSL procedures (n = 242) was 4.1% (p = 0.32). Individual surgeon's positive margin rates ranged from 2 to 5% in the early experience and 2-7% in the later experience (p = NS).

CONCLUSIONS

RSL for breast conservation surgery has a low rate of positive margins even early in a surgeon's experience. Implementation of RSL can be done with no evidence of a learning curve.

Supine Breast MRI Using Respiratory Triggering

RATIONALE AND OBJECTIVES

This study aims to evaluate if navigator-echo respiratory-triggered magnetic resonance acquisition can acquire supine high-quality breast magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Supine respiratory-triggered magnetic resonance imaging (Trig-MRI) was compared to supine non-Trig-MRI to evaluate breathing-induced motion artifacts (group 1), and to conventional prone non-Trig-MRI (group 2, 16-channel breast coil), all at 3T. A 32-channel thorax coil was placed on top of a cover to prevent breast deformation. Ten volunteers were scanned in each group, including one patient. The acquisition time was recorded. Image quality was compared by visual examination and by calculation of signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and image sharpness (IS).

RESULTS

Scan time increased from 56.5 seconds (non-Trig-MRI) to an average of 306 seconds with supine Trig-MRI (range: 120-540 seconds). In group 1, the median values (interquartile range) of SNR, CNR, and IS improved from 11.5 (6.0), 7.3 (3.1), and 0.23 (0.2) cm on supine non-Trig-MRI to 38.1 (29.1), 32.8 (29.7), and 0.12 (0) cm (all P < 0.01) on supine Trig-MRI. All qualitative image parameters in group 1 improved on supine Trig-MRI (all P < 0.01). In group 2, SNR and CNR improved from 14.7 (6.8) and 12.6 (5.6) on prone non-Trig-MRI to 36.2 (12.2) and 32.7 (12.1) (both P < 0.01) on supine Trig-MRI. IS was similar: 0.10 (0) cm vs 0.11 (0) cm (P = 0.88).

CONCLUSIONS

Acquisition of high-quality supine breast MRI is possible when respiratory triggering is applied, in a similar setup as during subsequent treatment. Image quality improved when compared to supine non-triggered breast MRI and prone breast MRI, but at the cost of increased acquisition time.

Feasibility of magnetic marker localisation for non-palpable breast cancer

OBJECTIVES

Accurate tumour localisation is essential for breast-conserving surgery of non-palpable tumours. Current localisation technologies are associated with disadvantages such as logistical challenges and migration issues (wire guided localisation) or legislative complexities and high administrative burden (radioactive localisation). We present MAgnetic MArker LOCalisation (MaMaLoc), a novel technology that aims to overcome these disadvantages using a magnetic marker and a magnetic detection probe. This feasibility study reports on the first experience with this new technology for breast cancer localisation.

MATERIALS AND METHODS

Fifteen patients with unifocal, non-palpable breast cancer were recruited. They received concurrent placement of the magnetic marker in addition to a radioactive iodine seed, which is standard of care in our clinic. In a subset of five patients, migration of the magnetic marker was studied. During surgery, a magnetic probe and gammaprobe were alternately used to localise the markers and guide surgery. The primary outcome parameter was successful transcutaneous identification of the magnetic marker. Additionally, data on radiologist and surgeon satisfaction were collected.

RESULTS

Magnetic marker placement was successful in all cases. Radiologists could easily adapt to the technology in the clinical workflow. Migration of the magnetic marker was negligible. The primary endpoint of the study was met with an identification rate of 100%. Both radiologists and surgeons reflected that the technology was intuitive to use and that it was comparable to radioactive iodine seed localisation.

CONCLUSION

Magnetic marker localisation for non-palpable breast cancer is feasible and safe, and may be a viable non-radioactive alternative to current localisation technologies.

Intraoperative Margin Management in Breast-Conserving Surgery: A Systematic Review of the Literature

BACKGROUND

Breast surgeons have a wide variety of intraoperative techniques available to help achieve low rates for positive margins of excision, with variable levels of evidence.

METHODS

A systematic review of the medical literature from 1995 to July 2016 was conducted, with 434 abstracts identified and evaluated. The analysis included 106 papers focused on intraoperative management of breast cancer margins and contained actionable data.

RESULTS

Ultrasound-guided lumpectomy for palpable tumors, as an alternative to palpation guidance, can lower positive margin rates, but the effect when used as an alternative to wire localization (WL) for nonpalpable tumors is less certain. Localization techniques such as radioactive seed localization and radioguided occult lesion localization were found potentially to lower positive margin rates as alternatives to WL depending on baseline positive margin rates. Intraoperative pathologic methods including gross histology, frozen section analysis, and imprint cytology all have the potential to lower the rates of positive margins. Cavity-shave margins and the Marginprobe device both lower rates of positive margins, with some potential for negative cosmetic effects. Specimen radiography and multiple miscellaneous techniques did not affect positive margin rates or provided too little evidence for formation of a conclusion.

CONCLUSIONS

A systematic review of the literature showed evidence that several intraoperative techniques and actions can lower the rates of positive margins. These results are presented together with graded recommendations.