Breast cancer recurrence following radioguided seed localization and standard wire localization of nonpalpable invasive and in situ breast cancers: 5-Year follow-up from a randomized controlled trial

ACR Appropriateness Criteria® Imaging of Invasive Breast Cancer

As the proportion of women diagnosed with invasive breast cancer increases, the role of imaging for staging and surveillance purposes should be determined based on evidence-based guidelines. It is important to understand the indications for extent of disease evaluation and staging, as unnecessary imaging can delay care and even result in adverse outcomes. In asymptomatic patients that received treatment for curative intent, there is no role for imaging to screen for distant recurrence. Routine surveillance with an annual 2-D mammogram and/or tomosynthesis is recommended to detect an in-breast recurrence or a new primary breast cancer in women with a history of breast cancer, and MRI is increasingly used as an additional screening tool in this population, especially in women with dense breasts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

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.

ACR Appropriateness Criteria® Imaging After Breast Surgery

Given that 20% to 40% of women who have percutaneous breast biopsy subsequently undergo breast surgery, knowledge of imaging women with a history of benign (including high-risk) disease or breast cancer is important. For women who had surgery for nonmalignant pathology, the surveillance recommendations are determined by their overall risk. Higher-than-average risk women with a history of benign surgery may require screening mammography starting at an earlier age before 40 and may benefit from screening MRI. For women with breast cancer who have undergone initial excision and have positive margins, imaging with diagnostic mammography or MRI can sometimes guide additional surgical planning. Women who have completed breast conservation therapy for cancer should get annual mammography and may benefit from the addition of MRI or ultrasound to their surveillance regimen. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Use of Needle Localization in the Surgical Management of Non-seroma, Mass-forming BIA-ALCL

Outcomes related to the treatment of breast implant-associated anaplastic large cell lymphoma, a rare extranodal T-cell lymphoma associated with textured breast implants, are largely dependent on the successful resection to negative margins via en bloc capsulectomy and resection of any associated masses. To date, the use of needle localization, a common technique used in breast surgery, to assist in the complete removal of breast implant-associated anaplastic large cell lymphoma has not been described. We present the case report of a 66-year-old woman, with a previous medical history of left-sided invasive ductal carcinoma, who presented 7 years after textured breast implant placement with a left-sided mass without peri-implant seroma. Biopsy demonstrated breast implant-associated anaplastic large cell lymphoma and the associated breast mass extended beyond the capsule borders. The present report describes the novel use of needle localization in this patient to facilitate the complete removal of the malignancy-associated mass with maximal preservation of the overlying soft tissue envelope.

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.

Does Localization Technique Matter for Non-palpable Breast Cancers?

BACKGROUND

There are several techniques for localization of non-palpable breast tumors, but comparisons of these techniques in terms of margin positivity and volume of tissue resected are lacking.

METHODS

Between 2011-2013 and 2016-2018, 2 randomized controlled trials involving 10 centers across the United States accrued 631 patients with stage 0-3 breast cancer, all of whom underwent breast conserving surgery. Of these, 522 had residual non-palpable tumors for which localization was required. The localization technique was left to the discretion of the individual surgeon. We compared margin positivity and volume of tissue resected between various localization techniques.

RESULTS

The majority of the patients (n = 465; 89.1%) had wire localization (WL), 50 (9.6%) had radioactive seed (RS) localization, and 7 (1.3%) had Savi Scout (SS) localization. On bivariate analysis, there was no difference in terms of margin positivity (37.8% vs. 28.0% vs. 28.6%, P = .339) nor re-excision rates (13.3% vs. 12.0% vs. 14.3%, P = .961) for the WL, RS, and SS groups, respectively. Further, the volume of tissue removed was not significantly different between the 3 groups (71.9 cm³ vs. 55.8 cm³ vs. 86.6 cm³ for the WL, RS, and SS groups, respectively, P = .340). On multivariate analysis, margin status was affected by tumor size (OR = 1.336; 95% CI: 1.148-1.554, P<.001) but not by type of localization (P = .670).

CONCLUSIONS

While there are a number of methods for tumor localization, choice of technique does not seem to influence volume of tissue resected nor margin status.

Is specimen radiography still necessary in patients with non-palpable breast cancer undergoing breast-conserving surgery using radioactive I-125 seed localization?

AIM

To evaluate the diagnostic performance for margin assessment of specimen radiography (SR) in breast conserving surgery (BCS) using radioactive I¹²⁵-seed localization (RSL).

METHODS

The clinical, radiographic and histopathological data of women who underwent BCS after pre-operative RSL with intraoperative SR during nine consecutive years were analyzed. The histological margin and radiographic margin outcomes on SR were compared and results of intraoperative re-excisions were investigated.

RESULTS

A consecutive series of 448 women with invasive carcinoma (n = 211), ductal carcinoma in situ (DCIS) (n = 79) and a combination of DCIS and invasive carcinoma (n = 158) were included. The median minimal margins for the radiological masses and microcalcifications measured on SR were 14 mm and 11 mm, respectively. Based on a radiological cut-off SR margin value of 1 mm, the overall sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were 21.0%, 95.0%, 26.0%, and 94.0%, respectively. The area under the receiver-operating curve was 0.73. Intraoperative re-excisions based on SR were performed in 31 (6.9%) patients; histopathological examination of the additional excised tissue revealed DCIS or invasive carcinoma in 6 (19.4%) patients. Hence, SR was beneficial for 6/448 patients (1.3%), and unnecessary intraoperative re-excisions were performed in 20/448 patients (4.5%). The number need to treat is 75; this implies that per 75-SR one resection with involved margins is prevented.

CONCLUSION

SR has a moderate diagnostic performance for margin involvement using RSL. A more accurate intraoperative margin assessment tool is warranted.

Reflector Localization of Breast Lesions and Parameters Associated with Positive Surgical Margins in Women Undergoing Breast Conservation Surgery

OBJECTIVE

To evaluate our experience with reflector localization of breast lesions and parameters influencing surgical margins in patients with a malignant diagnosis.

METHODS

A retrospective institution review board-approved review of our institutional database was performed for breast lesions preoperatively localized from September 1, 2016, through December 31, 2017. Wire localizations were excluded. From electronic medical records and imaging, the following data was recorded: breast density, lesion type and size, reflector placement modality and number placed, reflector distance from lesion and skin, excision of lesion and reflector, tissue volume, margin status, and final pathology. Statistical analysis was performed with a Fisher's exact test, Mann-Whitney test, and logistic regression. P < 0.05 was significant.

RESULTS

A total of 111 reflectors were deployed in the breasts of 103 women with 109 breast lesions. Ninety (81.1%) reflectors were placed under mammographic guidance and 21 (18.9%) under US. The lesions consisted of 68 (62.4%) masses, 17 (15.6%) calcifications, 2 (1.8%) architectural distortions, and 22 (20.2%) biopsy markers. Fourteen (21.2%) of 66 cases with a preoperative malignant diagnosis had a positive surgical margin. Final pathology, including 6 lesions upgraded to malignancy on excision, demonstrated 72 (66.0%) malignant, 22 (20.2%) high-risk, and 15 (13.8%) benign lesions. Univariate and multivariate analysis revealed no statistically significant parameters (lesion type or size, placement modality, reflector distance to skin or lesion, specimen radiography or pathology) were associated with a positive surgical margin.

CONCLUSION

Reflector localization is an alternative to wire localization of breast lesions. There were no lesion-specific or technical parameters affecting positive surgical margins.

Innovations in image-guided preoperative breast lesion localization

Screening mammography increases detection of non-palpable breast lesions requiring image-guided localization prior to surgery. Accurate preoperative localization is crucial for successful surgical outcomes. Wire-guided localization is currently the most widely used localization method for non-palpable breast lesions; however, this technique has multiple disadvantages including patient discomfort, possible wire transection and migration, suboptimal surgical incision placement due to wire location and limited scheduling flexibility decreasing operating room efficiency. As a result, promising new techniques including radioactive seed localization, non-radioactive radar localization and magnetic seed localization have been developed as alternatives. In this article, we provide an overview of these techniques and discuss their advantages, drawbacks and currently available outcome data.