Ultrasound-guided lumpectomy of nonpalpable breast cancer versus wire-guided resection: a randomized clinical trial

Ultrasound-guided breast-conserving surgery compared to conventional breast-conserving surgery

PURPOSE

The goal of breast-conserving surgery is to achieve negative tumor margins, since insufficient marginal distance is associated with more local and distant recurrences. This study investigates whether IOUS (intraoperative ultrasound) can reduce the re-resection rate compared to standard breast surgery, regardless of tumor biology and focality.

MATERIALS AND METHODS

The present study is a monocentric, prospective, randomized, and non-blinded parallel group study conducted between 7/2015 and 2/2018. Patients with sonographically visible breast cancer were randomized into two study arms: 1) breast-conserving surgery with IOUS; 2) conventional arm.

RESULTS

364 patients were included in the study and underwent surgery. Tumor biology, size, and focality were equally distributed in both groups (p = 0.497). The study arms did not differ significantly in the proportion of preoperative wire markings (p= 0.084), specimen weight (p = 0.225), surgery duration (p = 0.849), and the proportion of shavings taken intraoperatively (p = 0.903). Positive margins were present in 16.6% of the cases in the IOUS arm and in 20.8% in the conventional arm (p = 0.347). Re-operation was necessary after intraoperative shavings in 14.4% of cases in the US arm and in 21.3% in the conventional arm (p = 0.100).

CONCLUSION

Although the present study showed a clear difference in the rate of positive tumor margins with IOUS compared to conventional breast surgery without IOUS, this was not statistically significant in contrast to the current literature. This could be due to the high expertise of the breast surgeons, the precise wire marking, or the fact that the IOUS technique was not standardized.

Blood flow on ultrasound imaging is a predictor of lump margin status in breast-conserving patients: a retrospective matching study

PURPOSE

This study investigated the relationship between breast ultrasound features and lump margin status in breast-conserving patients.

METHODS

A single-institution database and medical records system were searched to identify patients who had undergone breast-conserving surgery between 2015 and 2022. Patients were divided into case and control groups based on their postoperative margin status, and different matching methods [case-control matching (CCM) and propensity score matching (PSM)] were used to match the cases and controls at a ratio of 1:1.

RESULTS

Before matching, patients with positive margins were more likely to have a tumor with increased blood flow (OR = 2.90, 95% CI 1.83-4.61, p < 0.001) and microcalcifications (OR = 2.22, 95% CI 1.44-3.42, p < 0.001). Among the 83 pairs of CCM subjects, patients with positive margins were prone to increased blood flow (p = 0.007) and crab sign (p = 0.040). In addition, there was a significant difference in blood flow (p = 0.030) among PSM subjects. After adjusting for the unbalanced factors, the same results were obtained.

CONCLUSIONS

Ultrasound blood flow significantly predicts the status of breast-conserving margins, but further studies are required to verify our findings.

Toward Intraoperative Margin Assessment Using a Deep Learning-Based Approach for Automatic Tumor Segmentation in Breast Lumpectomy Ultrasound Images

There is an unmet clinical need for an accurate, rapid and reliable tool for margin assessment during breast-conserving surgeries. Ultrasound offers the potential for a rapid, reproducible, and non-invasive method to assess margins. However, it is challenged by certain drawbacks, including a low signal-to-noise ratio, artifacts, and the need for experience with the acquirement and interpretation of images. A possible solution might be computer-aided ultrasound evaluation. In this study, we have developed new ensemble approaches for automated breast tumor segmentation. The ensemble approaches to predict positive and close margins (distance from tumor to margin ≤ 2.0 mm) in the ultrasound images were based on 8 pre-trained deep neural networks. The best optimum ensemble approach for segmentation attained a median Dice score of 0.88 on our data set. Furthermore, utilizing the segmentation results we were able to achieve a sensitivity of 96% and a specificity of 76% for predicting a close margin when compared to histology results. The promising results demonstrate the capability of AI-based ultrasound imaging as an intraoperative surgical margin assessment tool during breast-conserving surgery.

Technique of intraoperative ultrasound-guided excision of impalpable breast lesions

The introduction of breast screening programs has led to the increased detection of occult breast lesions requiring diagnostic surgical biopsy or breast-conserving surgery for early-stage breast cancer. Excision of impalpable breast lesions can be challenging. Whilst a variety of techniques have now been described including the use of adjuncts such as hook wires, radioactive seeds, magnetic seeds or radiofrequency devices, many of these modalities are expensive and can be logistically problematic. The technique of surgeon-performed ultrasound-guided excision is a straightforward technique which is safe, cost-efficient and avoids a painful preoperative procedure for patients such as hook wire localisation. Whilst the use of intraoperative ultrasound-guided excision of breast lesions has been widely reported, the actual technique itself has been less well described.

The Use of Intraoperative Ultrasound During Breast Conserving Surgery

OBJECTIVES

The purpose of this study is to evaluate the utilization of intraoperative ultrasound (IOUS) for tumor localization in breast-conserving surgery and to examine its impact on margin positivity and re-excision rates. Additionally, the study seeks to identify factors contributing to surgeon utilization of IOUS.

METHODS

A retrospective chart review was conducted of patients with preoperative diagnosis of breast cancer undergoing breast-conserving surgery by breast surgeons at multiple centers within a single healthcare system. Characteristics such as lesion size, palpability, histology, receptor status, and use of neoadjuvant chemotherapy were recorded. Re-excision rates were determined based on localization technique and surgeons' status of breast ultrasound certification.

RESULTS

A total of 671 cases were performed, with 322 meeting study inclusion. 57 cases utilized IOUS, 250 utilized preoperative wire-guided localization (WGL), 10 used both methods and 5 cases used neither method. There was no significant difference in re-excision rates between IOUS and WGL or among the four surgeons. Ultrasound-certified surgeons were more likely to utilize IOUS, and re-excision rates trended higher for WGL, which may be clinically significant.

CONCLUSION

Increasing familiarity with and utilization of IOUS during breast-conserving surgery may be clinically advantageous over traditional localization techniques. Ultrasound certification may lead to increased use of IOUS among surgeons.

Comparison of Wire-Guided Lumpectomy (WGL) Versus Hematoma-Directed Ultrasound-Guided Lumpectomy (HDUGL) in Management of Nonpalpable Breast Lesions in Achieving a Negative Resection Margin: a Randomized Trial with Superiority Hypothesis and Cost-effectiveness Analysis

The advances in imaging techniques and growing awareness have increased the detection of nonpalpable breast lesions, which may be neoplastic or high-risk lesions. The standard technique of localizing these nonpalpable breast lesions is wire-guided biopsy/lumpectomy. However, wire-guided excision is fraught with the complications of migration, transection, patient discomfort, pneumothorax, vasovagal episodes, and injury to the radiologist, surgeon, and pathologist. We embarked upon a randomized controlled trial to compare the cost-effectiveness and patient-reported outcome (PRO) with hematoma-directed ultrasound-guided lumpectomy (HDUGL) versus conventional wire-guided lumpectomy (WGL) for nonpalpable breast lesions. This study was a parallel design, randomized controlled trial with a superiority hypothesis. Twenty-five patients could be randomized to wire-guided lumpectomy (WGL) group (n = 13) and hematoma-directed ultrasound-guided lumpectomy (HDUGL) group (n = 12). Post-excision specimen sonography and mammography for assessing adequacy of margin were done. A margin shave was performed in cases of close or suspicious margin on ultrasonography or mammogram. Both the groups were comparable in age, tumor size, histological subtypes, and location of lesions. The median resection volume in two groups was 34.5 (26.5) ml for HDUGL vs. 41 (15) ml for WGL. Intraoperative cavity shave was required only in the WGL group (n = 3.23%) and margin positivity was also more in the WGL group (n = 2,15.38%) as compared to the HDUGL group (n = 1,8.33%) but neither differences in cavity shave nor positive margins leading to re-operations were statistically significant. The difference in cost of surgery in two groups (INR 4680 ± 560.00 for HDUGL and INR 7486 ± 616.41 for WGL) was statistically significant (P = 0.00). Resultantly, HDUGL was more cost-effective (INR 5105.45) than WGL (INR 8847.09). Patients in the HDUGL group were more satisfied according to the Likert scale of 5 but this difference in two groups was not statistically significant (P = 0.07). The hematoma-directed ultrasound-guided lumpectomy (HDUGL) is better than wire-guided lumpectomy (WGL) for nonpalpable breast lesions in terms of cost-effectiveness. Trial details: CTRI No. CTRI/2019/05/019347. Registered on 24/05/2019, Registered prospectively.

An Audit on Oncological Safety with Magseed Localised Breast Conserving Surgery

Wire-localised wide local excision (W-WLE) has been standard of care for impalpable breast lesions. Logistics and risks of wire localisation can be challenging. Magseed-localised wide local excision (M-WLE) is an alternative to W-WLE. We compare safety parameters and length of hospital stay (LOS) in patients undergoing M-WLE to W-WLE. All M-WLEs performed at single institution over an 8-month period were included and compared to historic matched cohort of W-WLEs who would have been suitable for Magseed localisation. Data including patient demographics, successful placements, re-excision rates, tumour size, and length of stay (LOS) was analysed. Two hundred thirty-eight patients were included in the study. Cancers were safely excised in all cases. A significant difference in re-excisions rates favouring M-WLE group was seen (2.9% vs 10.4%). Median waiting time to surgery was significantly shorter in M-WLE group (4 h 15 min vs 7 h 3 min). No significant difference in median LOS between the two groups was seen. M-WLE has been shown to be oncologically safe and non-inferior to W-WLE with significantly lower re-excision rate. Reduced pre-operative waiting time in the M-WLE group will have a positive effect on patient journey. Further research should focus on potential impact on day-bed utilisation and theatre efficiency.

Intraoperative Ultrasound-Guided Excision of Non-Palpable and Palpable Breast Cancer: Systematic Review and Meta-Analysis

Wire-guided localization (WGL) is the most frequently used localization technique in non-palpable breast cancer (BC). However, low negative margin rates, patient discomfort, and the possibility of wire dislocation have been discussed as potential disadvantages, and re-operation due to positive margins may increase relapse risk. Intraoperative ultrasound (IOUS)-guided excision allows direct visualization of the lesion and the resection volume and reduces positive margins in palpable and non-palpable tumors. We performed a systematic review on IOUS in breast cancer and 2 meta-analyses of randomized clinical trials (RCTs). In non-palpable BC, 3 RCTs have shown higher negative margin rates in the IOUS arm compared to WGL. Meta-analysis confirmed a significant difference between IOUS and WGL in terms of positive margins favoring IOUS (risk ratio 4.34, p < 0.0001, I2 = 0%). 41 cohort studies including 3291 patients were identified, of which most reported higher negative margin and lower re-operation rates if IOUS was used. In palpable BC, IOUS was compared to palpation-guided excision in 3 RCTs. Meta-analysis showed significantly higher rates of positive margins in the palpation arm (risk ratio 2.84, p = 0.0047, I2 = 0%). In 13 cohort studies including 942 patients with palpable BC, negative margin rates were higher if IOUS was used, and tissue volumes were higher in palpation-guided cohorts in most studies. IOUS is a safe noninvasive technique for the localization of sonographically visible tumors that significantly improves margin rates in palpable and non-palpable BC. Surgeons should be encouraged to acquire ultrasound skills and participate in breast ultrasound training.

Preoperative localisation of nonpalpable breast lesions using magnetic markers in a tertiary cancer centre

Background

We retrospectively evaluated safety and performance of magnetic seed localisation of nonpalpable breast lesions.

Methods

We reviewed records of patients with nonpalpable breast lesions preoperative localised by placing magnetic Magseed® marker between February 2019 and December 2020. During surgery, Sentimag® magnetic probe was used to localise the marker and guide surgery. Safety, lesion identification and excision with tumour with free margins and re-excision rate were assessed.

Results

A total of 77 Magseed® devices were placed into the breasts of 73 patients, 44 under ultrasound and 33 under stereotactic guidance (4 bilateral). All devices were retrieved as were the target lesions. Magnetic marker placement was successful in all cases without any adverse event. Intraoperative identification and excision of the localised lesion were successful in 77 of 77 of cases (100%). In three cases (all of them calcifications with the seed placed under stereotactic guidance), the seed did not reach the exact target position of the biopsy clip; thus, larger excision was needed, with localisation failure attributed to incorrect clip insertion (n = 1) or to clip dislocation (n = 2). Migration of the marker was negligible in all patients. Complete excision after the initial procedure with at least 1-mm disease-free margins was obtained in 74 out of 77 (96.1%) lesions. The re-excision rate was 3 out of 77 (4%).

Conclusions

Magnetic marker localisation for nonpalpable breast lesions was safe, reliable, and effective in terms of lesion identification, excision with tumour-free margins and re-excision rate.

Optimal localization strategies for non-palpable breast cancers –A network meta-analysis of randomized controlled trials

Purpose

Mammographic screening programmes have increased detection rates of non-palpable breast cancers. In these cases, wire-guided localization (WGL) is the most common approach used to guide breast conserving surgery (BCS). Several RCTs have compared WGL to a range of novel localization techniques. We aimed to perform a network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing methods of non-palpable breast cancer localization.

Methods

A NMA was performed according to PRISMA-NMA guidelines. Analysis was performed using R packages and Shiny.

Results

24 RCTs assessing 9 tumour localization methods in 4236 breasts were included. Margin positivity and reoperation rates were 16.9% (714/4236) and 14.3% (409/2870) respectively. Cryo-assisted localization had the highest margin positivity (28.2%, 58/206) and reoperation (18.9%, 39/206) rates. Compared to WGL (n = 2045 from 24 RCTs) only ultrasound guided localization (USGL) (n = 316 from 3 RCTs) significantly lowered margin positivity (odds ratio (OR): 0.192, 95% confidence interval (CI): 0.079–0.450) and reoperation rates (OR: 0.182, 95%CI: 0.069–0.434). Anchor-guided localization (n = 52, 1 RCT) significantly lowered margin positivity (OR: 0.229, 95%CI: 0.050–0.938) and magnetic-marker localization improved patient satisfaction (OR: 0.021, 95%CI: 0.001–0.548). There was no difference in operation duration, overall complications, haematoma, seroma, surgical site infection rates, or specimen size/vol/wt between methods.

Conclusion

USGL and AGL are non-inferior to WGL for the localization of non-palpable breast cancers. The reported data suggests that these techniques confer reduced margin positivity rates and requirement for re-operation. However, caution when interpreting results relating to RCTs with small sample sizes and further validation is required in larger prospective, randomized studies.

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Ultrasound-guided (USGL) and anchor-guided (AGL) localization had optimal outcomes.

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These methods significantly lowered margin positivity (odds ratio: 0.192 & 0.229).

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However, small sample sizes in trials evaluating USGL and AGL limit these results.

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Operation duration, complications, or specimen data were comparable for all methods.

Comparative effectiveness of different localization techniques for non-palpable breast cancer. A systematic review and network meta-analysis

BACKGROUND

Several localization techniques are in use for localization of non palpable breast cancer but data on comparative effectiveness of these techniques are sparse. Our aim was to provide the first comparative effectiveness data on the topic.

METHODS

PubMed, Ovid, Scopus and Cochrane library were searched for randomized controlled trials. Pairwise meta-analysis was performed when more than 2 studies reported on the same head-to-head comparison. Network meta-analysis was performed in Stata.

RESULTS

Eighteen studies with 3112 patients were identified. A star shaped network was formed for every outcome as all studies had as common comparator the wire localization technique (WGL). Ultrasound guided surgery (UGS) had decreased positive margin both in the pairwise [OR = 0.19(0.11, 0.35); P < 0.01] and network meta-analysis OR = 0.19 (0.11,0.60). There was also a statistically significant reduction in re-operation rate [OR = 0.19 (0.11, 0.36); P < 0.01] and operative time [MD = -4.24(-7.85,-0.63); P = 0.02] as compared to WGL in pairwise meta-analysis. Re-operation rate and operative time did not hold there statistical significance in network meta-analysis. On network meta-analysis UGS had a statistically significant reduction in positive margin as compared to radio-guided occult lesion localization (ROLL) OR = 0.19 (0.11,0.6) and radioactive seed localization (RSL) OR = 0.26(0.13, 0.52). UGS had a 54.6% of being the best technique for positive margin. All techniques were equivalent for successful excision, localization complications, operative time and overall complications.

CONCLUSIONS

UGS has potential benefits in reduction of positive surgical margin, the rest of the techniques seem to have equivalent efficacy. Further randomized trials are required to verify these results.

Image-Guided Breast Interventions: Biopsy and Beyond

Breast interventions primarily comprise of biopsy of the suspicious breast lesions to obtain accurate pathological diagnosis. Generally, image-guided breast biopsy is required for nonpalpable lesions, however, even in palpable lesions, image-guided biopsy should be performed as it improves the accuracy of diagnosis. Image-guided breast interventions have progressed well beyond biopsy, making the radiologist an important part of the multidisciplinary management of breast cancer. Preoperative localization of nonpalpable abnormalities guides optimal surgical excision to obtain negative margins without sacrificing the normal tissue. Ablative procedures for breast cancer treatment such as radiofrequency ablation (RFA) and high-intensity focused ultrasound ablation can sometimes replace surgery in older patients with comorbidities. This article enumerates and describes the expanding spectrum of image-guided interventions performed by breast radiologist.

Interim clinical trial analysis of intraoperative mass spectrometry for breast cancer surgery

Optimal resection of breast tumors requires removing cancer with a rim of normal tissue while preserving uninvolved regions of the breast. Surgical and pathological techniques that permit rapid molecular characterization of tissue could facilitate such resections. Mass spectrometry (MS) is increasingly used in the research setting to detect and classify tumors and has the potential to detect cancer at surgical margins. Here, we describe the ex vivo intraoperative clinical application of MS using a liquid micro-junction surface sample probe (LMJ-SSP) to assess breast cancer margins. In a midpoint analysis of a registered clinical trial, surgical specimens from 21 women with treatment naïve invasive breast cancer were prospectively collected and analyzed at the time of surgery with subsequent histopathological determination. Normal and tumor breast specimens from the lumpectomy resected by the surgeon were smeared onto glass slides for rapid analysis. Lipidomic profiles were acquired from these specimens using LMJ-SSP MS in negative ionization mode within the operating suite and post-surgery analysis of the data revealed five candidate ions separating tumor from healthy tissue in this limited dataset. More data is required before considering the ions as candidate markers. Here, we present an application of ambient MS within the operating room to analyze breast cancer tissue and surgical margins. Lessons learned from these initial promising studies are being used to further evaluate the five candidate biomarkers and to further refine and optimize intraoperative MS as a tool for surgical guidance in breast cancer.

Implementation of Intraoperative Ultrasound Localization for Breast-Conserving Surgery in a Large, Integrated Health Care System is Feasible and Effective

BACKGROUND

Intraoperative ultrasound (IUS) localization for breast cancer is a noninvasive localization technique. In 2015, an IUS program for breast-conserving surgery (BCS) was initiated in a large, integrated health care system. This study evaluated the clinical results of IUS implementation.

METHODS

The study identified breast cancer patients with BCS from 1 January to 31 October 2015 and from 1 January to 31 October 2019. Clinicopathologic characteristics were collected, and localization types were categorized. Clinical outcomes were analyzed, including localization use, surgeon adoption of IUS, day-of-surgery intervals, and re-excision rates. Multivariate logistic regression analysis was performed to evaluate predictors of re-excision.

RESULTS

The number of BCS procedures increased 23%, from 1815 procedures in 2015 to 2226 procedures in 2019. The IUS rate increased from 4% of lumpectomies (n = 79) in 2015 to 28% of lumpectomies (n = 632) in 2019 (p < 0.001). Surgeons using IUS increased from 6% (5 of 88 surgeons) in 2015 to 70% (42 of 60 surgeons) in 2019. In 2019, 76% of IUS surgeons performed at least 25% of lumpectomies with IUS. The mean time from admission to incision was shorter with IUS or seed localization than with wire localization (202 min with IUS, 201 with seed localization, 262 with wire localization in 2019; p < 0.001). The IUS re-excision rates were lower than for other localization techniques (13.6%, vs 19.6% for seed localization and 24.7% for wire localization in 2019; p = 0.006), and IUS predicted lower re-excision rates in a multivariable model (odds ratio [OR], 0.59).

CONCLUSIONS

In a high-volume integrated health system, IUS was adopted for BCS by a majority of surgeons. The use of IUS decreased the time from admission to incision compared with wire localization, and decreased re-excision rates compared with other localization techniques.

Surgical outcomes of localization using indocyanine green fluorescence in breast conserving surgery: a prospective study

We investigated localization and safe resection margins for breast cancer patients undergoing breast conserving surgery (BCS) using ultrasound-guided indocyanine green fluorescence (ICG-F) marking. From April 2016 to March 2019, we prospectively enrolled 114 patients who underwent BCS using US-guided ICG-F marking and we compared these results with 300 patients who underwent BCS using US-guided skin marking from January 2012 to December 2016. Clinical features, identification rates, status of resection margins, and re-operation rates were analyzed. The ICG-F identification rate was 100% (114/114). The mean approach time for resection of the lesion ICG-F using group was about 13 min. The positive rate of frozen resection margins was 10.5% using ICG-F and 25.0% using sono-guided skin marking (p < 0.01). The rate of additional intraoperative resection was significantly lower in the ICG-F marking group compared to that in the sono-guided skin marking group (8.8% vs. 23.3%, p < 0.01). The rate of final positive resection margins was 3.5% in the ICG-F using group and 14.7% in the sono-guided skin marking group (p < 0.01). The rate of re-operation was 4.4% in the ICG-F using group and 4% in the sono-guided group (p = 0.79). At follow-up after the operation using ICG-F, no complications occurred. Using ICG-F during BCS could be a safe, sophisticated method for localization.

In vivo liver thermoacoustic imaging and demonstration based on localization wire

PURPOSE

Liver disease causes significant morbidity and mortality worldwide. Liver imaging plays an essential role in the noninvasive liver disease evaluation because of the limitation of liver biopsy. This paper aims to image in vivo liver with thermoacoustic imaging (TAI) and demonstrate this liver imaging technique with a cross-validation method.

METHODS

The imaging system composed of a large aperture antenna and a flexible transducer array was used, and we performed the position calibration using the delay and sum algorithm. The localization wire was utilized in the cross-validation of in vivo liver TAI.

RESULTS

We successfully validated in vivo liver TAI. In vivo images of different liver lobes without labels were observed. The imaging depth reached about 4 cm.

CONCLUSIONS

TAI has the potential to image the liver and provide useful dielectric properties of the liver tissue. This study realized the first in vivo liver TAI, suggesting its prospect in detecting liver disease noninvasively.

Breast-conserving surgery with 3D-printed surgical guide: a single-center, prospective clinical study

To facilitate precise tumor resection at the time of breast-conserving surgery (BCS), we developed and implemented a magnetic resonance imaging (MRI)-based three-dimensional-printed (3DP) breast surgical guide (BSG). This prospective cohort study was conducted at a single institution from July 2017 to February 2019 on women with breast cancer who underwent partial breast resection using patient-specific 3DP BSGs. Eighty-eight patients with invasive cancer were enrolled, of whom 1 patient had bilateral breast cancer. The mean size of the tumor long-axis on MRI before surgery was 2.8 ± 0.9 cm, and multiple tumors were observed in 34 patients. In 16 cases (18.0%), the resection margin was tumor-positive according to intraoperative frozen biopsy; all of these tumors were ductal carcinoma in situ and were re-excised intraoperatively. In 93.3% of the cases, the resection margin was tumor-free in the permanent pathology. The mean pathological tumor size was 1.7 ± 1.0 cm, and the mean distance from the tumor to the border was 1.5 ± 1.0 cm. This exploratory study showed that the tumor area on the MRI could be directly displayed on the breast when using a 3DP BSG for BCS, thereby allowing precise surgery and safe tumor removal.

Trial Registration Clinical Research Information Service (CRIS) Identifier (No. KCT0002375, KCT0003043).

Sentinel node occult lesion localization technique for impalpable breast cancer

BACKGROUND

Mammographic screening has enabled earlier detection of breast cancer, with 25-35% of malignancies being non-palpable at diagnosis. Accurate removal and sentinel node biopsy for staging these lesions are crucial to successful management. Both these aspects are achieved by peritumoural localization with radioisotope and lymphoscintigraphy for sentinel lymph node (SN) mapping using the sentinel node and occult lesion localization (SNOLL) technique. This study reports SNOLL outcomes in a large cohort of women with non-palpable breast cancers to assess its performance and promote its logistic advantages.

METHODS

This retrospective cohort study used data from BreastSurgANZ Quality Audit supplemented with private case notes. Inclusion criteria were females >18 years, with invasive breast cancer that was asymptomatic and non-palpable at presentation, who underwent SNOLL (n = 450). Primary outcomes were proportion of successful lesion localization, proportion of patients requiring re-excision and volume of tissue excised. Secondary outcomes focused on lymphoscintigraphy success rate in detecting sentinel nodes and SN positivity rates.

RESULTS

Tumours were successfully removed with the initial SNOLL procedure in 449 cases (99.8%). The re-excision rate was 15.1% (n = 68). The mean total excision volume was 54.69 cm3 (95% CI 51.49-57.88 cm3 ; range 2.75-195.33 cm3 ), with a mean closest circumferential margin of 7.05 mm (95% CI 6.60-7.49 mm; range 0 to ≥10 mm). Lymphoscintigraphy was successful in 96.9% (n = 436) of cases. Sentinel nodes were successfully identified and removed in 99.6% (n = 448) of cases. SN positivity rate was 18.4%.

CONCLUSION

SNOLL is an efficient and effective technique for localizing non-palpable invasive breast lesions while simultaneously identifying sentinel nodes.

An End-to-End Solution for Automatic Contouring of Tumor Region in Intraoperative Images of Breast Lumpectomy

Breast-conserving surgery, also known as lumpectomy, is an early stage breast cancer treatment that aims to spare as much healthy breast tissue as possible. A risk associated with lumpectomy is the presence of cancer positive margins post operation. Surgical navigation has been shown to reduce cancer positive margins but requires manual segmentation of the tumor intraoperatively. In this paper, we propose an end-to-end solution for automatic contouring of breast tumor from intraoperative ultrasound images using two convolutional neural network architectures, the U-Net and residual U-Net. The networks are trained on annotated intraoperative breast ultrasound images and evaluated on the quality of predicted segmentations. This work brings us one step closer to providing surgeons with an automated surgical navigation system that helps reduce cancer-positive margins during lumpectomy.

Impalpable breast lesion localisation, a logistical challenge: results of the UK iBRA-NET national practice questionnaire

INTRODUCTION

Breast conserving surgery of impalpable breast lesions requires safe and effective localisation techniques. Wire localisation has traditionally been used, but has limitations. Newer techniques are now being introduced to mitigate this. The iBRA-NET group aims to robustly evaluate these new techniques in well-designed prospective studies. We report the first phase of this evaluation, a survey to establish current practice and service provision of breast localisation techniques in the UK.

METHODS

A national practice questionnaire was designed using 'SurveyMonkey^®' and was circulated to UK breast surgeons via the Association of Breast Surgery and the Mammary Fold. The questionnaire was live from 6th October 2018 to 6th April 2019. Only one response per unit was requested to reflect the unit's practice.

RESULTS

Complete responses were received from 98 breast units across the UK. Wires were the mostly commonly used localisation technique (n = 82) with fewer units using Magseed^® (n = 9), Radioguided Occult Lesion Localisation (n = 5) and Radioiodine Seed Localisation (n = 2). There was significant variation in practice and logistics involved. Frequent delays and theatre overruns were reported in 39 and 16 units, respectively. The median satisfaction score of the current technique was 7 out of 10. The main perceived limitation of existing localisation methods was logistics affecting theatre scheduling and the main barrier to introducing a new technique was cost.

CONCLUSION

Wires are currently the most commonly used localisation technique but are associated with significant logistical issues. Newer techniques may offer a better solution but will need robust evaluation before they are adopted to ensure safety and efficacy.

A decade of intraoperative ultrasound guided breast conservation for margin negative resection - Radioactive, and magnetic, and Infrared Oh My…

BACKGROUND

The oncologic goal of margin-negative breast conservation requires adequate localization of tumor. Intraoperative ultrasound remains most feasible but under-utilized method to localize the tumor and assess margins.

METHODS

A prospectively maintained breast cancer database over a decade was queried for margin status in breast cancer patients undergoing breast conservation. Techniques of tumor localization, margin re-excision and closest margins were analyzed. Rate of conversion to mastectomy was determined.

RESULTS

Of the 945 breast cancer patients treated at a university-based Breast Center of Excellence between January 1, 2009 and December 31, 2018, 149(15.8%) had ductal carcinoma in situ; 712(75.3%) had invasive ductal carcinoma, and 63(6.7%) had invasive lobular carcinoma. Clinical stage distribution was: T1 = 372(39.4%); T2 = 257(27.2%); T3 = 87(9.2%). Five hundred and eighty three (61.7%) patients underwent breast conservation. The median (25th -75th centile) closest margin was 6(2.5, 10.0) mm. Thirty five (6.0%) patients underwent margin re-excision, of which 9(25%) were converted to mastectomy. Tumor localization was achieved with ultrasound in 521(89.4%) patients and with wire localization in 62(10.6%) patients. The median (25th-75th centile) closest margin with wire localization was 5.0(2.0, 8.5) mm versus 5.0 (2.0, 8.0) mm with ultrasound guidance [p = 0.6635]. The re-excision rate with wire localization was 14.5% versus 4.9% with ultrasound guidance [p = 0.0073]. The unadjusted Odds Ratio (95% CI) for margin revision in wire localized group compared with ultrasound was 3.2 (7.14, 1.42) [p = 0.0045]; multivariate adjusted OR (95%) was 4(9.09, 1.7) [p = 0.0013].

CONCLUSIONS

Ultrasound guidance for localization of breast cancer remains the most effective option for margin negative breast conservation.

Optimization of Wire-guided Technique With Bracketing Reduces Resection Volumes in Breast-conserving Surgery for Early Breast Cancer

BACKGROUND

Wire-guided localization (WGL) of early breast cancer can be facilitated using multiple wires, which is called bracketing wire-guided localization (BWL). The primary aim of this study is to compare BWL and conventional WGL regarding minimization of resection volumes without compromising margin status. Secondly, BWL is evaluated as an alternative method for intraoperative ultrasound (US) guidance in poorly definable breast tumors on US.

PATIENTS AND METHODS

In this retrospective cohort study, patients with preoperatively diagnosed breast cancer undergoing wide local excision between January 2016 and December 2018 were analyzed. Patients with multifocal disease or neoadjuvant treatment were excluded from this study. Optimal resection with minimal healthy breast tissue removal was assessed using the calculated resection ratio (CRR).

RESULTS

BWL was performed in 17 (9%) patients, WGL in 44 (22%), and US in 139 (70%). The rate of negative margins was comparable in all 3 groups. The CRR was significantly smaller for BWL (0.6) than WGL (1.3) in tumors larger than 1.5 cm. Additionally, BWL (0.8) led to smaller CRRs than US (1.7). This could be explained by the high number of small tumors (≤ 1.5 cm) in the US group for which greater CRRs are obtained than for large tumors (> 1.5 cm) (1.9 vs. 1.4; P = .005).

CONCLUSION

For breast tumors larger than 1.5 cm, BWL achieves more optimal resection volumes without compromising margin status compared with WGL. Moreover, BWL seems a suitable alternative to US in patients with poorly ultrasound-visible breast tumors and patients with a small tumor in a (large) breast.

Accuracy and feasibility of SentiMag technique for localization of non-palpable breast lesions

BACKGROUND

Non-palpable breast lesions are more frequent now than in the past due to the attention toward the mammary pathology and the screening diffusion; the marking of such lesions is very important for a successful surgery. The SentiMag System uses a magnetic marker that is inoculated transdermal in the breast through an 18-gauge needle.

METHODS

Between April 1^st and June 30^th, 2018, 16 patients with non-palpable breast lesions were selected and subjected to surgery using the SentiMag System in our Unit. They were women with a mean age of 52 years (range 30-84 years). Seven of 16 (43.7%) had a borderline preoperative histological or cytological diagnosis (C3/B3), and nine (56.3%) a diagnosis of carcinoma (C5/B5). Six (37.5%) were marked on ultrasound guidance and 10 (62.5%) on a mammography stereotaxic guide.

RESULTS

The time for the marker positioning ranged from 2 to 10 minutes. The radiological control of the surgical specimen always showed the presence of both the lesion and the marker, both centered within the specimen and intact. The pathology revealed seven benign lesions, one in-situ, and eight infiltrating carcinomas.

CONCLUSIONS

The SentiMag represents a fast and safe preoperative marking system of non-palpable breast lesions, cutting the radio exposure for personnel and patients. The marker is not displaced over time and it is rapid to place and easy to locate intraoperatively, allowing a clear dissection plane around the lesion. Thus, this reduces the amount of gland removed, improving the aesthetic result mostly in small breasts.

Intraoperative Ultrasound and Oncoplastic Combined Approach: An Additional Tool for the Oncoplastic Surgeon to Obtain Tumor-Free Margins in Breast Conservative Surgery-A 2-Year Single-Center Prospective Study

BACKGROUND

The main goal of oncoplastic breast-conserving surgery (OBCS) is to obtain tumor-free resection margins after cancer excision with satisfactory cosmetic results. Positive tumor margins are associated with high rates of tumor recurrence requiring reoperation. The aim of this prospective clinical trial was to demonstrate the reliability of intraoperative ultrasound (IOUS) to obtain tumor-free resection margins in OBCS.

PATIENTS AND METHODS

Between December 2016 and March 2018, data from 130 patients with by T1-2 breast cancer, either invasive or in situ, who underwent OBCS were prospectively collected. The oncoplastic surgeon performed IOUS in the operating theater to localize the lesion and mark its skin projection. Then specimens were examined to assess the presence of the lesion and margin adequacy. Definitive histologic reports were reviewed, with a focus on margin status.

RESULTS

All patients experienced oncoplastic approaches, and lesions were always found on the specimen at the histologic report. In 126 cases (97%), margins were considered adequate. In 17 cases (13%), IOUS showed positive margins, and resection was contextually enlarged. In 12 of these (9%), the pathologic report confirmed the need for enlarged resection. This study shows that IOUS-guided surgery can obtain a high percentage of tumor-free resection margins in OBCS without scheduling conflicts between radiology, nuclear, and surgery departments. Full cooperation between radiologists and oncoplastic surgeons is required to achieve high-standard oncologic and reconstructive outcomes.

CONCLUSION

IOUS represent an additional tool for the breast surgeon to improve margin-free management of neoplastic lesions, preventing reoperations in patients undergoing oncoplastic surgery.

Re-Excision Rates in Breast-Conserving Surgery for Invasive Breast Cancer after Neoadjuvant Chemotherapy with and without the Use of a Radiopaque Tissue Transfer and X-ray System

Background

Significant re-excision rates in breast-conserving surgery (BCS) after neoadjuvant systemic chemotherapy may result from difficulties in defining the surgical target particularly in cases with excellent treatment response. Devices allowing an exact topographic localisation of the lesion in the resected tissue could reduce re-excision rates by optimising the intraoperative detection of involved margins.

Methods

80 patients with invasive breast cancer receiving BCS after neoadjuvant chemotherapy were included in this non-randomized case-control study. 40 patients with specimen radiography performed in a standard approach (control group) were compared to 40 patients with use of a radiopaque tissue transfer system (study group).

Results

19/80 (23.75%) patients required re-excision because of involved margins; among those, 14/40 (35%) were in the control group and 5/40 (12.5%) in the study group. The association between the use of the radiopaque tissue transfer system and the lower re-excision rate was statistically significant (p = 0.023).

Conclusion

Our analysis provides a rationale for the routine use of a radiopaque tissue transfer system for specimen radiography in BCS after neoadjuvant chemotherapy for invasive breast cancer in order to reduce re-excision rates.

Real-time electromagnetic navigation for breast-conserving surgery using NaviKnife technology: A matched case-control study

Breast-conserving surgery (BCS) is a mainstay in breast cancer treatment. For nonpalpable breast cancers, current strategies have limited accuracy, contributing to high positive margin rates. We developed NaviKnife, a surgical navigation system based on real-time electromagnetic (EM) tracking. The goal of this study was to confirm the feasibility of intraoperative EM navigation in patients with nonpalpable breast cancer and to assess the potential value of surgical navigation. We recruited 40 patients with ultrasound visible, single, nonpalpable lesions, undergoing BCS. Feasibility was assessed by equipment functionality and sterility, acceptable duration of the operation, and surgeon feedback. Secondary outcomes included specimen volume, positive margin rate, and reoperation outcomes. Study patients were compared to a control group by a matched case-control analysis. There was no equipment failure or breach of sterility. The median operative time was 66 (44-119) minutes with NaviKnife vs 65 (34-158) minutes for the control (P = .64). NaviKnife contouring time was 3.2 (1.6-9) minutes. Surgeons rated navigation as easy to setup, easy to use, and useful in guiding nonpalpable tumor excision. The mean specimen volume was 95.4 ± 73.5 cm³ with NaviKnife and 140.7 ± 100.3 cm³ for the control (P = .01). The positive margin rate was 22.5% with NaviKnife and 28.7% for the control (P = .52). The re-excision specimen contained residual disease in 14.3% for NaviKnife and 50% for the control (P = .28). Our results demonstrate that real-time EM navigation is feasible in the operating room for BCS. Excisions performed with navigation result in the removal of less breast tissue without compromising postive margin rates.

Intraoperative sonography for nonpalpable breast lesions: Additional indications for a consolidate technique

This prospective study evaluated the intraoperative ultrasound scan (IUSS) for nonpalpable breast lesions' detection. A total of 108 consecutive female patients underwent surgery using IUSS: Frozen sections demonstrated clear margins in 95.5% of neoplastic patients. Only four (4.5%) patients underwent local re-excision in the same operation. IUSS demonstrated to be quick, accurate, useful, effective, and safe for the intraoperative management of neoplastic nonpalpable breast lesions when performed by a surgeon who has undergone US training, particularly for people in whom alternative approaches can show some limitations due to contraindications or because of scheduling constraints, costs, and patient discomfort.

The Impact of Margin Status on Breast Conservation Rates

BACKGROUND

Contemporary data indicate that breast conservation treatment (BCT) results in superior survival outcomes compared with mastectomy. However, positive margins after lumpectomy have implications for local control, and re-excisions are recommended to achieve negative margins. The need for reoperations after an initial attempt at BCT is associated with higher chance of conversion to mastectomy. Achieving negative margins at the first therapeutic surgical procedure is therefore critical to optimise BCT rates and survival outcomes.

METHODS

A compilation of scientific reports on BCT, margin status, rates of reoperation, and the impact on BCT rates was reviewed. Re-excision rates after initial lumpectomy is variable to a staggering degree and reported to be between 0 and 100%. High reoperation rates (ROR) are associated with higher likelihood of conversion to mastectomy, which may not confer favourable treatment outcomes. Although widely agreed that decreasing ROR is a desirable objective, there is controversy regarding the need for its urgent implementation as a quality metric. Critics of this cite challenges related to how this can be achieved and its attendant ramifications. On the other hand, without the appropriate incentive for quality improvement of surgical treatment of breast cancer, patients may be subject to poorer overall outcomes.

DISCUSSION

Techniques and approaches are discussed in this article to enable a reduction in positive margin status, and therefore ROR. The rationale for achieving ROR of 10-20% are explicated, as well as the impact this would have on BCT rates, which translates to better survival outcomes for women with breast cancer.

A Randomized Prospective Trial of Supine MRI-Guided Versus Wire-Localized Lumpectomy for Breast Cancer

BACKGROUND

Wire-localized excision of non-palpable breast cancer is imprecise, resulting in positive margins 15-35% of the time.

METHODS

Women with a confirmed diagnosis of non-palpable invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS) were randomized to a new technique using preoperative supine magnetic resonance imaging (MRI) with intraoperative optical scanning and tracking (MRI group) or wire-localized (WL group) partial mastectomy. The main outcome measure was the positive margin rate.

RESULTS

In this study, 138 patients were randomly assigned. Sixty-six percent had IBC and DCIS, 22% had IBC, and 12% had DCIS. There were no differences in patient or tumor characteristics between the groups. The proportion of patients with positive margins in the MRI-guided surgery group was half that observed in the WL group (12 vs. 23%; p = 0.08). The specimen volumes in the MRI and WL groups did not differ significantly (74 ± 33.9 mL vs. 69.8 ± 25.1 mL; p = 0.45). The pathologic tumor diameters were underestimated by 2 cm or more in 4% of the cases by MRI and in 9% of the cases by mammography. Positive margins were observed in 68% and 58% of the cases underestimated by 2 cm or more using MRI and mammography, respectively, and in 15% and 14% of the cases not underestimated using MRI and mammography, respectively.

CONCLUSIONS

A novel system using supine MRI images co-registered with intraoperative optical scanning and tracking enabled tumors to be resected with a trend toward a lower positive margin rate compared with wire-localized partial mastectomy. Margin positivity was more likely when imaging underestimated pathologic tumor size.

Rapid Implementation of Intraoperative Ultrasonography to Reduce Wire Localization in The Permanente Medical Group

CONTEXT

Preoperative wire localization (WL), the most common localization technique for nonpalpable breast lesions, has drawbacks including scheduling constraints, cost, and patient discomfort.

OBJECTIVE

To reduce WL use in our health care system, we investigated using hydrogel clips to facilitate intraoperative ultrasonography-guided lumpectomies.

DESIGN

We retrospectively reviewed electronic medical records of patients with nonpalpable, ultrasound-visible breast lesions who underwent lumpectomy by 7 surgeons at 4 pilot sites in Kaiser Permanente Northern California between January 2015 and October 2015. Hydrogel clips, used for several years before the study period, were placed routinely during core-needle biopsy in all patients with nonpalpable, ultrasound-visible breast lesions.

MAIN OUTCOME MEASURES

Localization method, lesion size, margin positivity, and receipt of neoadjuvant therapy.

RESULTS

One hundred forty-three patients underwent hydrogel clip placement and lumpectomy by pilot-site surgeons. Localization consisted of intraoperative ultrasonography alone, preoperative skin marking, or WL. Of the 143 patients, 71.3% did not need WL (60.8% ultrasonography alone and 10.5% skin marking). The non-WL and WL groups had similarly sized lesions, and the positive margin rate was 7.2% overall, with no significant difference between the non-WL and WL groups (5.9% vs 11.5%, p = 0.33). Of the 12 patients who underwent neoadjuvant chemotherapy, 8 (67%) did not require WL.

CONCLUSION

A multifacility protocol using intraoperative ultrasonography to visualize hydrogel clips was implemented, which decreased WL procedures and produced no significant difference in margin positivity between the WL and non-WL groups. This technique can be a cost-effective alternative to WL in patients who are candidates for hydrogel clip placement.

Is the future magnetic? Magseed localisation for non palpable breast cancer. A multi-centre non randomised control study

INTRODUCTION

Magseed is an alternative method of localising non-palpable breast lesions that has addressed many of the limitations of wire guided localisation (WGL). It consists of a paramagnetic seed that can be visualised on mammography and ultrasound. Intraoperative localisation of the seed is achieved with the use of the Sentimag probe. The aim of this study was to prospectively compare localisation in patients undergoing wide local excision (WLE) for non-palpable lesions between Magseed and WGL.

METHODS

We prospectively collected data on all patients undergoing image-guided WLE between October 2017 and September 2018 in two academic breast units with a planned accrual of 100 consecutive patients undergoing Magseed localisation. Data was also collected on a cohort of 100 consecutive patients undergoing WGL in the same time period.

RESULTS

Demographic and disease characteristics were well balanced between the two groups. 4/104 patients were converted preoperatively from Magseed to WGL (2 misplaced Magseeds; 2 undetected Magseeds). Intraoperative identification and excision of the localised lesion was successful in all patients as confirmed with specimen radiography. Overall no significant differences were observed in the proportion of patients requiring re-excision between the two groups (Magseed 16% vs. WGL 14% p = 0.692). Specimens size by weight and volume was similar for both groups (Magseed 39.6 g vs. WGL 44.5 g p = 0.206 and 90.1 cm³ for Magseed vs. 95.6 cm³ for WGL p = 0.579).

CONCLUSIONS

In our series Magseed localisation proved to be as reliable and effective as WGL in terms of lesion identification, excision with tumour free margins and specimen weight.

Ultrasound-guided preoperative localization of breast lesions: a good choice

PURPOSE

The aim of the study was to verify whether ultrasound (US)-guided preoperative localization of breast lesions is an adequate technique for correct and safe surgical resection and to contribute positively and effectively to this topic in the literature with our results.

METHODS

From June 2016 to November 2016, 155 patients with both benign and malignant breast lesions were selected from our institute to undergo US localization before surgery. The lesions included were: sonographically visible and nonpalpable lesions; palpable lesions for which a surgeon had requested US localization to better evaluate the site and extension; sonographically visible, multifocal breast lesions, both palpable and nonpalpable. US localization was performed using standard linear transducers (Siemens 18 L6, 5.5-8 MHz, 5.6 cm, ACUSON S2000 System, Siemens Medical Solutions). The radiologist used a skin pen to mark the site of the lesion, and the reported lesion's depth and distance from the nipple and pectoral muscle were recorded. The lesions were completely excised by a team of breast surgeons, and the surgical specimens were sent to the Radiology Department for radiological evaluation and to the Pathology Department for histological assessment.

RESULTS

In 155 patients who underwent to preoperative US localization, 188 lesions were found, and the location of each lesion was marked with a skin pen. A total of 181 lesions were confirmed by the final histopathologic exam (96.28%); 132 of them (72.92%) were malignant, and 124 of these (93.93%) showed free margins.

CONCLUSIONS

US-guided preoperative localization of sonographically visible breast lesions is a simple and nontraumatic procedure with high specificity and is a useful tool for obtaining accurate surgical margins.

Review of methods for intraoperative margin detection for breast conserving surgery

Breast conserving surgery (BCS) is an effective treatment for early-stage cancers as long as the margins of the resected tissue are free of disease according to consensus guidelines for patient management. However, 15% to 35% of patients undergo a second surgery since malignant cells are found close to or at the margins of the original resection specimen. This review highlights imaging approaches being investigated to reduce the rate of positive margins, and they are reviewed with the assumption that a new system would need high sensitivity near 95% and specificity near 85%. The problem appears to be twofold. The first is for complete, fast surface scanning for cellular, structural, and/or molecular features of cancer, in a lumpectomy volume, which is variable in size, but can be large, irregular, and amorphous. A second is for full, volumetric imaging of the specimen at high spatial resolution, to better guide internal radiologic decision-making about the spiculations and duct tracks, which may inform that surfaces are involved. These two demands are not easily solved by a single tool. Optical methods that scan large surfaces quickly are needed with cellular/molecular sensitivity to solve the first problem, but volumetric imaging with high spatial resolution for soft tissues is largely outside of the optical realm and requires x-ray, micro-CT, or magnetic resonance imaging if they can be achieved efficiently. In summary, it appears that a combination of systems into hybrid platforms may be the optimal solution for these two very different problems. This concept must be cost-effective, image specimens within minutes and be coupled to decision-making tools that help a surgeon without adding to the procedure. The potential for optical systems to be involved in this problem is emerging and clinical trials are underway in several of these technologies to see if they could reduce positive margin rates in BCS.

Intraoperative ultrasound in breast cancer surgery-from localization of non-palpable tumors to objectively measurable excision

Background

The utilization of intraoperative ultrasound (IOUS) in breast cancer surgery is a relatively new concept in surgical oncology. Over the last few decades, the field of breast cancer surgery has been striving for a more rational approach, directing its efforts towards removing the tumor entirely yet sparing tissue and structures not infiltrated by tumor cells. Further progress in objectivity and optimization of breast cancer excision is possible if we make the tumor and surrounding tissue visible and measurable in real time, during the course of the operation; IOUS seems to be the optimal solution to this complex requirement. IOUS was introduced into clinical practice as a device for visualization of non-palpable tumors, and compared to wire-guided localization (WGL), IOUS was always at least a viable, or much better alternative, in terms of both precision in identification and resection and for patients’ and surgeons’ comfort. In recent years, intraoperative ultrasound has been used in the surgery of palpable tumors to optimize resection procedures and overcome the disadvantages of classic palpation guided surgery.

Objective

The aim of this review is to show the role of IOUS in contemporary breast cancer surgery and its changes over time.

Methods

A PubMed database comprehensive search was conducted to identify all relevant articles according to assigned key words.

Conclusion

Over time, the use of IOUS has been transformed from being the means of localizing non-palpable lesions to an instrument yielding a reduced number of positive resection margins, with a smaller volume of healthy breast tissue excided around tumor, by making the excision of the tumor optimal and objectively measurable.

Doppler Ultrasound-Visible SignalMark Microspheres are Better Identified than HydroMARK® Clips in a Simulated Intraoperative Setting in Breast and Lung Tissue

BACKGROUND

Preoperative breast and lung markers have significant drawbacks, including migration, patient discomfort, and scheduling difficulties. SignalMark is a novel localizer device with a unique signal on Doppler ultrasound.

OBJECTIVE

We aimed to evaluate intraoperative identification of SignalMark microspheres compared with HydroMARK^® clips. We also assessed the safety and efficacy of SignalMark in the lung.

METHODS

Twelve breasts of lactating pigs were injected with SignalMark or HydroMARK^® by a breast radiologist, and subsequently identified using a standard ultrasound machine by three surgeons blinded to marker location. Time to identification of each marker was recorded, with a maximum allotted time of 300 s. To further demonstrate efficacy in lung parenchyma, a second cohort of pigs underwent lung injections.

RESULTS

A total of eight SignalMark markers and four HydroMARK^® clips were placed in pig breasts. Overall, the surgeons correctly identified SignalMark 95.8% of the time (n = 23/24) and HydroMARK^® clips 41.7% of the time (n = 5/12) within 300 s (p < 0.001). The mean time to identification was significantly faster for SignalMark, at 80.8 ± 20.1 s, than for HydroMARK^®, at 209.4 ± 35.2 s (p < 0.002). For the lung injections, all 10 SignalMark markers were visible on Doppler ultrasound at the time of placement, and at the 7- and 21-day time points.

CONCLUSIONS

Surgeons identified SignalMark in significantly less time than HydroMARK^® clips in a simulated intraoperative setting, and SignalMark was easily viewed in the lung. These results suggest that SignalMark is a feasible option for efficient intraoperative localization of non-palpable breast and lung tumors using ultrasound guidance.

Precision biopsy of breast microcalcifications: An improvement in surgical excision

The aim of the present study was to improve the conventional wire-guided localization biopsy (WGLB) of breast microcalcifications to overcome disadvantages associated with the procedure, including inaccurate localization and large specimen volume. The novel approach described in the present study was termed double wire-guided localization and rotary cutting biopsy (DWGLB). Prior to surgery, the precise localization of the lesions was assessed using two wires under the assistance of mammography X-ray and ultrasound, followed by complete excision of the lesions using a novel rotary cutting tool. The cylindrical specimen was placed on a scaled specimen holder for pathological examination. DWGLB was performed in 108 patients with the classification of as Breast Imaging Reporting and Data System score 4A. Percutaneous localization of the lesions guided by a mammography X-ray and ultrasound were successful in all 108 lesions (100%) with one puncture attempt. The lesions were precisely excised in all of 108 patients, and included 13 malignant lesions (DCIS of breast in 7 cases, DCIS with focal invasive carcinoma in 3 cases and invasive ductal carcinoma in 3 cases). The average distance of the BARD Dualok to the lesion was 4.1 mm; the average weight of specimens was 8.5 g. Compared with WGLB, DWGLB offers several advantages, including more accurate localization of lesions, a more standardized biopsy method and a smaller specimen volume. DWGLB can also provide the precise position of lesions in the specimen for further pathological examination.

Ultrasound-Guided Breast-Conservative Surgery Decreases the Rate of Reoperations for Palpable Breast Cancer

The purpose of this study is to verify whether the performance of ultrasound-guided quadrantectomy (USGQ) versus palpation-guided quadrantectomy (PGQ) can reduce the incidence of positive margins and if it can change the attitude of the surgeon. A retrospective study was conducted on 842 patients underwent quadrantectomy for breast cancer, 332 of them underwent USGQ, whereas 550 underwent PGQ. The histological type of the tumors and the margin status obtained with the histological examination were compared. The histological examination of the surgical specimen showed involvement of the margins in 24/842 patients (2.85%), 22 (2.61%) of them belonged to the PGQ group, and two to the USGQ group (P = 0.0011). The highest rate of microscopically positive margins was, statistically significant, for carcinoma in situ, when compared with patients with invasive carcinoma (0.0001). USGQ technique showed several advantages compared with PGQ. In fact, the former notes a lower positive margin rate and, consequently, a lower rate of reintervention. In addition, it may change the surgeon's attitude by causing him to remove another slice of margin to ensure more histological negativity. It should be the gold standard technique for breast-conservative surgery of palpable tumors.

Obtaining adequate surgical margin status in breast-conservation therapy: intraoperative ultrasound-guided resection versus specimen mammography

Background and aim

The purpose of breast-conserving surgery (BCS) for women with cancer is to perform an oncological radical procedure with disease-free margins at the final histological assessment and with the best aesthetic result possible. Intraoperative resected specimen ultrasound and intraoperative resected specimen mammography may reduce the rates of positive margins and reexcision among patients undergoing conserving therapy. Our objective is to compare the two methods with the histopathological results for a preset cut off and asses which parameters can influence the positive margin status.

Method

A prospective study was performed on 83 patients who underwent breast conservation surgery for early breast cancer (pT1-3a pN0-1 M0) between 2014 and 2016. After excision the specimen was oriented in the operating room by the surgeon. Metallic clips and threads were placed on margins: one clip and the long thread at 12 o’clock, two clips and the short threads at 9 o’clock. The next step was intraoperative ultrasound assessment of the specimen. For the margins under 2 mm we performed selective margin shaving, followed by mammography to identify and document the lesion and finally histopathological examination of the specimen with reporting the gross and microscopic margins. The positive margins required re-excision or boost of radiation at the posterior or anterior margins, depending on the case.

Results

We set a cut-off at 2 mm. The sensitivity and specificity of the intraoperative margin assessment via the ultrasound method were 90.91% (95% CI 70.84–98.88%) and 67.21% (95% CI 54–78.69%) respectively. The sensitivity and specificity of the intraoperative margin assessment via the mammographic procedure were 45.45% (95% CI 24.39–67.79%) and 85.25% (95% CI 73.83–93.02%) respectively. There was positive correlation between the histopathological and intraoperative ultrasound exam (p=0.018) and negative correlation between the histopathological exam and the post-operative mammographic exam (p=0.68). We found a positive correlation between the positive margin status and age (<40), preoperative chemotherapy, intraductal carcinoma, inflammatory process around the tumor, and the immunohistochemical triple negative profile.

Conclusions

According to our results, the intraoperative ultrasound of the breast specimen for a cutt-off at 2 mm can decrease the rates of margin positivity compared to the mammographic procedure and has the potential to diminish the number of subsequent undesired re-excisions.

Definition and Management of Positive Margins for Invasive Breast Cancer

Breast-conserving surgery (BCS) followed by radiation therapy is the current standard of care for early stage breast cancer. Successful BCS necessitates complete tumor resection with clear margins at the pathologic assessment of the specimen ("no ink on tumor"). The presence of positive margins warrants additional surgery to obtain negative final margins, which has significant physical, psychological, and financial implications for the patient. The challenge lies in developing accurate real-time intraoperative margin assessment techniques to minimize the presence of "ink on tumor" and the subsequent need for additional surgery.

Breast-specific factors determine cosmetic outcome and patient satisfaction after breast-conserving therapy: Results from the randomized COBALT study

BACKGROUND AND OBJECTIVES

To identify breast-specific factors and the role of tumor, treatment, and patient-related items in influencing patient opinion on cosmesis and satisfaction after breast-conserving therapy (BCT).

METHODS

Data from the randomized COBALT study was used. At 3, 12, and 36 months, 128 patients with T1-T2 breast cancer completed a questionnaire on breast-specific factors and overall cosmetic outcome and patient satisfaction, using a 4-point Likert scale.

RESULTS

There was a strong positive correlation between breast-specific factors, overall cosmetic outcome,and satisfaction at all time-points. Excellent/good cosmetic outcomes and satisfaction decreased during follow-up. A shift was noted in the degree of influence of the various breast-specific factors. At 3 years, symmetry factors such as size, shape, and nipple position largely determined a patient's opinion on the final cosmesis, followed by firmness. The risk of an unacceptable outcome was associated with young age and large excision volumes.

CONCLUSION

A questionnaire including breast-specific questions provides important information on final cosmetic results and satisfaction after BCT. These outcomes can also be of great value as quality indicators and pre-operative counseling. The major influence of breast-specific factors on asymmetry underlines the importance of achieving an optimal excision volume at the initial procedure.