ROLL versus RSL: toss of a coin?

Radioactive Seed Localization for Nonpalpable Breast Lesions: Systematic Review and Meta-Analysis

BACKGROUND

This study is a systematic review with meta-analysis comparing radioactive seed localization (RSL) versus radio-guided occult lesion localization (ROLL) and wire-guided localization (WGL) for patients with impalpable breast cancer undergoing breast-conserving surgery and evaluating efficacy, safety, and logistical outcomes. The protocol is registered in PROSPERO with the number CRD42022299726.

METHODS

A search was conducted in the Embase, Lilacs, Pubmed, Scielo, Web of Science, and clinicaltrials.gov databases, in addition to a manual search in the reference list of relevant articles, for randomized clinical trials and cohort studies. Studies selected were submitted to their own data extraction forms and risk of bias analysis according to the ROB 2 and ROBINS 1 tools. A meta-analysis was performed, considering the random effect model, calculating the relative risk or the mean difference for dichotomous or continuous data, respectively. The quality of the evidence generated was analyzed by outcome according to the GRADE tool. Overall, 46 articles met the inclusion criteria and were included in this systematic review; of these, 4 studies compared RSL and ROLL with a population of 1550 women, and 43 compared RSL and WGL with a population of 19,820 women.

RESULTS

The results showed that RSL is a superior method to WGL in terms of surgical efficiency in the impalpable breast lesions' intraoperative localization, and it is at least equivalent to ROLL. Regarding security, RSL obtained results equivalent to the already established technique, the WGL. In addition to presenting promising results, RSL has been proven to be superior to WGL and ROLL technologies.

Radioactive Seed Localization of Nonpalpable Breast Lesions in an Academic Comprehensive Cancer Program Community Hospital Setting

Wire localized excision (WLE) has been a long-standing method for localization of nonpalpable breast lesions. Disadvantages of this method include difficulty locating the wire tip in relation to borders of the lesion, imprecise placement of the wire, and the need to place the wire shortly before scheduled surgery. These shortcomings may lead to a high positive margin rate requiring re-excision to obtain clear margins for breast cancer. Radioactive seed localized excision (RSLE) of nonpalpable breast lesions has been advocated as a safe and effective alternative to WLE. The primary endpoints of the study were to compare re-excision rates between WLE and RSLE of nonpalpable breast lesions and to determine if there were any differences in volume of tissue removed. One hundred three patients were included in a retrospective review of localized breast excisions done by a single surgeon. Forty-four patients underwent WLE between April 2007 and February 2009. Fifty-nine patients underwent RSLE between September 2009 and January 2012. Margins were considered to be clear if at least 1 mm of normal tissue was obtained from the circumferential periphery of the lesion in question. RSLE resulted in a re-excision rate of 17 versus 55 per cent re-excision rate for wire localization ( P < 0.001). Excision volume was greater for patients having wire localization ( P = 0.074). RSLE is an effective technique for excision of non-palpable breast lesions in the community setting. This technique allows for accurate localization and appears to allow for smaller volume of tissue to be excised.

Wireless Breast Localization Using Radio-frequency Identification Tags: The First Reported European Experience in Breast Cancer

BACKGROUND/AIM

Wire-guided localisation (WGL) has been the mainstay for localisation of clinically occult breast lesions before excision. However, it has restrictive scheduling requirements, and causes patient discomfort. This has prompted the development of various wireless alternatives. In this prospective study we shall evaluate the role of radiation-free wireless localisation using a radiofrequency identification (RFID) tag and a hand-held reader (LOCalizer™) in the management of occult breast lesions.

PATIENTS AND METHODS

This technique was evaluated in a prospective cohort of 10 patients. The evaluation focused on: i) successful deployment, ii) identification and retrieval, iii) the status of surgical margins and need for re-operation, iv) resected specimen weight, v) marker migration rates (>5mm), and vi) acceptance by patients, radiologists and surgeons.

RESULTS

RFID tags (n=11) were deployed under ultrasound guidance pre-operatively to localise occult breast lesions in 10 patients. The mean time for deployment of the RFID tag was 5.4 min (range=2-20). The mean distance from the lesion was 0.45 mm (range=0-3). The mean duration for retrieval was 10.2 min (range=6-20). Mean specimen weight was 19.6 g for malignant lesions (range=4.5-42). All tags were identified, and none had migrated. There were no positive margins, re-operations, nor complications. Patient feedback was highly positive. Both radiologists and surgeons rated the LOCalizer™ technique as better than WGL.

CONCLUSION

Our study demonstrates that wireless localisation using RFID is an effective and time-efficient alternative to WGL, with low margin positivity and re-operation rates, and high patient, radiologist and surgeon acceptance.

A new microdispersed albumin derivative potentially useful for radio-guided surgery of occult breast cancer lesions

This paper describes a new nuclear imaging agent, 2-(4-isothiocyanatobenzyl)−1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid of human albumin (HAC), potentially suitable for application in the Radio-guided Occult Lesion Localization (ROLL) of non-palpable mammalian cancerous lesions, as a tool to overtake the short radio-signal half-life of the technetium-99m based radiopharmaceutical currently used. This conjugate is a microsized powder aggregate, water-insoluble between pH 3 and 8.5, obtained by conjugating the protein with the macrocyclic chelating agent DOTA through a one-pot reaction in aqueous medium. The product has been fully characterized and is stable to the thermal conditions adopted for labeling; after radiolabeling with longer half-life radionuclides such as ¹⁷⁷Lu or ¹¹¹In, it has shown radiochemical purity (RCP) >90% and resulted stable when stored in saline or plasma for 6 days at 37 °C. A μPET/CT study, performed in vivo on adult female rats, showed that the radioactivity of HAC labeled with ⁶⁴Cu remained located in the mammary glands for at least 40 h, without diffusion or drainage in healthy tissues or in the lymphatic circulation. This new imaging agent might make the ROLL procedure more accessible, safe and flexible, promoting a significant time and cost reduction of this intervention. Moreover, HAC might also be used in other radio-guided surgical procedures in oncology.

Hybrid radioguided occult lesion localization (hybrid ROLL) of (18)F-FDG-avid lesions using the hybrid tracer indocyanine green-(99m)Tc-nanocolloid

PURPOSE

To assess if combined fluorescence- and radio-guided occult lesion localization (hybrid ROLL) is feasible in patients scheduled for surgical resection of non-palpable (18)F-FDG-avid lesions on PET/CT.

METHODS

Four patients with (18)F-FDG-avid lesions on follow-up PET/CT that were not palpable during physical examination but were suspected to harbor metastasis were enrolled. Guided by ultrasound, the hybrid tracer indocyanine green (ICG)-(99m)Tc-nanocolloid was injected centrally in the target lesion. SPECT/CT imaging was used to confirm tracer deposition. Intraoperatively, lesions were localized using a hand-held gamma ray detection probe, a portable gamma camera, and a fluorescence camera. After excision, the gamma camera was used to check the wound bed for residual activity.

RESULTS

A total of six (18)F-FDG-avid lymph nodes were identified and scheduled for hybrid ROLL. Comparison of the PET/CT images with the acquired SPECT/CT after hybrid tracer injection confirmed accurate tracer deposition. No side effects were observed. Combined radio- and fluorescence-guidance enabled localization and excision of the target lesion in all patients. Five of the six excised lesions proved tumor-positive at histopathology.

CONCLUSION

The hybrid ROLL approach appears to be feasible and can facilitate the intraoperative localization and excision of non-palpable lesions suspected to harbor tumor metastases. In addition to the initial radioguided detection, the fluorescence component of the hybrid tracer enables high-resolution intraoperative visualization of the target lesion. The procedure needs further evaluation in a larger cohort and wider range of malignancies to substantiate these preliminary findings.

3D scintigraphic imaging and navigation in radioguided surgery: freehand SPECT technology and its clinical applications

Freehand SPECT (fhSPECT) is a technology platform for providing 3-dimensional (3D) navigation for radioguided surgical procedures, such as sentinel lymph node (SLN) biopsy (SLNB). In addition to the information provided by conventional handheld gamma detection probes, fhSPECT allows for direct visualization of the distribution of radioactivity in any given region of interest, allowing for improved navigation to radioactive target lesions and providing accurate lesion depth measurements. Herein, we will review the currently available clinical data on the use of fhSPECT: (i) for SLNB of various malignancies, including difficult-to-detect SLNs, and (ii) for radioguided localization of solid tumors. Moreover, the combination of fhSPECT with other technologies (e.g., small field-of-view gamma cameras, and diagnostic ultrasound) is discussed. These technical advances have the potential to greatly expand the clinical application of radioguided surgery in the future.