Comparison of radioguided excision with wire localization of occult breast lesions

Resection Ratios and Tumor Eccentricity in Breast-Conserving Surgery Specimens for Surgical Accuracy Assessment

This study aims to evaluate several defined specimen parameters that would allow to determine the surgical accuracy of breast-conserving surgeries (BCS) in a representative population of patients. These specimen parameters could be used to compare surgical accuracy when using novel technologies for intra-operative BCS guidance in the future. Different specimen parameters were determined among 100 BCS patients, including the ratio of specimen volume to tumor volume (resection ratio) with different optimal margin widths (0 mm, 1 mm, 2 mm, and 10 mm). Furthermore, the tumor eccentricity [maximum tumor-margin distance - minimum tumor-margin distance] and the relative tumor eccentricity [tumor eccentricity ÷ pathological tumor diameter] were determined. Different patient subgroups were compared using Wilcoxon rank sum tests. When using a surgical margin width of 0 mm, 1 mm, 2 mm, and 10 mm, on average, 19.16 (IQR 44.36), 9.94 (IQR 18.09), 6.06 (IQR 9.69) and 1.35 (IQR 1.78) times the ideal resection volume was excised, respectively. The median tumor eccentricity among the entire patient population was 11.29 mm (SD = 3.99) and the median relative tumor eccentricity was 0.66 (SD = 2.22). Resection ratios based on different optimal margin widths (0 mm, 1 mm, 2 mm, and 10 mm) and the (relative) tumor eccentricity could be valuable outcome measures to evaluate the surgical accuracy of novel technologies for intra-operative BCS guidance.

A single-institution retrospective evaluation of noninvasive localization for non-palpable breast microcalcification

TECHNIQUE

From January 1, 2018, to December 31, 2021, we localized the breast microcalcification of 40 patients before the surgical excision. We measured the distance between the nipple and the center of the calcification on the CC view and the ML view, respectively. The operation proceeded around the intersection between two lines, slightly larger than the diameter of the microcalcification. We also analyze the pathological findings.

RESULTS

All 40 patients successfully detected calcification by mammograms preoperatively using the method mentioned above. 38 patients have the microcalcification removal within the one-time operation, while the other two underwent an extended lumpectomy. 20 of 40 calcifications (50 %) were malignant and 12(30 %) were precancerous lesions. In the group of women older than 45 years old, the percentages of malignant and atypical hyperplasias are 56.25 % (18/32) and 31.25 % (10/32) respectively.

CONCLUSION

Our non-invasive method of preoperative localization is safe and cost-effective. Furthermore, initial observations suggest that there may be a link between age and malignant microcalcification.

Technetium-99-Guided Axillary Lymph Node Identification: A Case Report of a Novel Technique for Targeted Lymph Node Excision Biopsy for Node Positive Breast Cancer After Neoadjuvant Chemotherapy

Targeted axillary lymph node identification for breast cancer involves localization and removal of previously marked metastatic lymph nodes after the completion of neoadjuvant chemotherapy (NACT), when clinical and radiological complete responses of the axillary nodes are achieved. Traditionally, axillary lymph node dissection is performed for patients with node positive disease, but the high rates of pathological complete responses now seen after NACT have ushered in lower morbidity techniques such as sentinel lymph node excision biopsies, targeted axillary lymph node dissection and targeted axillary lymph node identification (clip node identification) in node positive disease which has converted to clinical/radiologically node negative. The latter two techniques often require the use of expensive seeds and advanced localization techniques. Here we describe the case of a 59-year-old woman who was diagnosed with node positive invasive breast cancer who was sequenced with NACT. We developed a novel technique, where technetium-99m was injected directly into a previously clipped metastatic axillary lymph node which was then localized with the Neoprobe gamma detection system intra-operatively and removed. This is a relatively low-cost technique that can be easily introduced in limited resourced health systems where radio-guided sentinel lymph node biopsies are already being performed.

The current role of nuclear medicine in breast cancer

Breast cancer is the most common cancer in females worldwide. Nuclear medicine plays an important role in patient management, not only in initial staging, but also during follow-up. Radiopharmaceuticals to study breast cancer have been used for over 50 years, and several of these are still used in clinical practice, according to the most recent guideline recommendations.In this critical review, an overview of nuclear medicine procedures used during the last decades is presented. Current clinical indications of each of the conventional nuclear medicine and PET/CT examinations are the focus of this review, and are objectively provided. Radionuclide therapies are also referred, mainly summarising the methods to palliate metastatic bone pain. Finally, recent developments and future perspectives in the field of nuclear medicine are discussed. In this context, the promising potential of new radiopharmaceuticals not only for diagnosis, but also for therapy, and the use of quantitative imaging features as potential biomarkers, are addressed.Despite the long way nuclear medicine has gone through, it looks like it will continue to benefit clinical practice, paving the way to improve healthcare provided to patients with breast cancer.

Comparison of Wire and Non-Wire Localisation Techniques in Breast Cancer Surgery: A Review of the Literature with Pooled Analysis

Background and Objectives: Wide local excision is a common procedure in the treatment of breast cancer. Wire-guided localisation (WGL) has been the gold standard for many years; however, several issues have been identified with this technique, and therefore, wire-free techniques have been developed. This scoping review synthesises the available literature comparing wire-guided localisation with the wire-free techniques used in breast-conserving cancer surgery. Materials and Methods: Multiple databases including Pubmed and MEDLINE were used to search articles between 1 January 2000 and 31 December 2022. Terms included "breast neoplasms", "margins of excision", and "reoperation". In total, 34/256 papers were selected for review. Comparisons were made between positive margins and re-excision rates of WGL with wire-free techniques including SAVI SCOUT, Magseed, ROLL, and RSL. Pooled p-values were calculated using chi-square testing to determine statistical significance. Results: Pooled analysis demonstrated statistically significant reductions in positive margins and re-excision rates when SAVI SCOUT, RSL, and ROLL were compared with WGL. When SAVI SCOUT was compared to WGL, there were fewer re-excisions {(8.6% vs. 18.8%; p = 0.0001) and positive margins (10.6% vs. 15.0%; p = 0.0105)}, respectively. This was also the case in the ROLL and RSL groups. When compared to WGL; lower re-excision rates and positive margins were noted {(12.6% vs. 20.8%; p = 0.0007), (17.0% vs. 22.9%; p = 0.0268)} for ROLL and for RSL, respectively {(6.8% vs. 14.9%),(12.36% vs. 21.4%) (p = 0.0001)}. Magseed localisation demonstrated lower rates of re-excision than WGL (13.44% vs. 15.42%; p = 0.0534), but the results were not statistically significant. Conclusions: SAVI SCOUT, Magseed, ROLL, and RSL techniques were reviewed. Pooled analysis indicates wire-free techniques, specifically SAVI SCOUT, ROLL, and RSL, provide statistically significant reductions in re-excision rates and positive margin rates compared to WGL. However, additional studies and systematic analysis are required to ascertain superiority between techniques.

Localization Techniques for Non-Palpable Breast Lesions: Current Status, Knowledge Gaps, and Rationale for the MELODY Study (EUBREAST-4/iBRA-NET, NCT 05559411)

BACKGROUND

Surgical excision of a non-palpable breast lesion requires a localization step. Among available techniques, wire-guided localization (WGL) is most commonly used. Other techniques (radioactive, magnetic, radar or radiofrequency-based, and intraoperative ultrasound) have been developed in the last two decades with the aim of improving outcomes and logistics.

METHODS

We performed a systematic review on localization techniques for non-palpable breast cancer.

RESULTS

For most techniques, oncological outcomes such as lesion identification and clear margin rate seem either comparable with or better than for WGL, but evidence is limited to small cohort studies for some of the devices. Intraoperative ultrasound is associated with significantly higher negative margin rates in meta-analyses of randomized clinical trials (RCTs). Radioactive techniques were studied in several RCTs and are non-inferior to WGL. Smaller studies show higher patient preference towards wire-free localization, but little is known about surgeons' and radiologists' attitudes towards these techniques.

CONCLUSIONS

Large studies with an additional focus on patient, surgeon, and radiologist preference are necessary. This review aims to present the rationale for the MELODY (NCT05559411) study and to enable standardization of outcome measures for future studies.

Role of a portable gamma-camera with optical view for margins assessment of pulmonary nodules resected by radioguided surgery

PURPOSE

Radioguided occult lesion localization (ROLL) of pulmonary nodules is an alternative to hook-wire. Both required of a histological margin assessment. The activity emerging from the radiotracer allows to obtain an intraoperative scintigraphic image of the surgical specimen by a portable gamma-camera (PGC) fitted with an optical view, which provides information about the localization of the nodule in relation to the margins. The aim of this study was to evaluate the intraoperative use of a PGC for margin assessment of pulmonary nodules.

METHODS

ROLL technique was used in 38 nodules (36 pulmonary, 1 chest wall, and 1 pleural nodules). A PGC intraoperative image of the surgical specimen was obtained in 32. Scintigraphic results were compared to the histological assessment. Other factors, such as nodule size, distance from the pleural surface, or distance covered by the needle, were considered as possible factors for non-centered lesions.

RESULTS

PGC images showed that the lesion was in contact with the margins in 8/32 cases and centered in 24. In all cases in which the lesion was considered as centered by the PGC, the margins were free of involvement (NPV 100%), although the PPV is low.

CONCLUSIONS

The use of a PGC for margin assessment after pulmonary nodule resection is feasible and provides a high NPV in our series. In addition, the short intraoperative time required for its use makes the PGC a useful tool for providing supplementary information to histopathologic results. Further studies from different surgical teams are required for an external validation.

Preoperative axillary nodal staging of invasive lobular breast cancer with ultrasound guided fine needle aspiration in patients with suspicious ultrasound findings versus aspiration in all patients - A retrospective single institutional analysis

INTRODUCTION

- At present, surgical strategies for breast cancer patients with >2 lymph nodes (LN) involved differ from those with no or lower degree of nodal involvement. Preoperative assessment of the axilla is less sensitive in patients with lobular carcinoma (ILC) than patients with other histological tumour types.

MATERIALS AND METHODS

- A retrospective analysis of axillary staging by palpation, axillary ultrasound (AXUS) and AXUS-guided fine-needle aspiration cytology (FNAC) of 153 patients with ILC diagnosed and operated on between January 2013 and December 2020 was performed. Patients had either sentinel node biopsy or axillary lymph node dissection according to current practice. In period 1, patients had FNAC only when AXUS suggested nodal involvement (n = 106), and in period 2, all ILC patients had axillary FNAC (n = 47).

RESULTS

- Of the factors associated with >2LNs involvement, logistic regression suggested only AXUS/FNAC based staging as independent variable for all patients. Patients with AXUS-guided FNAC had a significantly higher proportion of true negative and lower proportion of true positive cases in the P2 period (0 vs 55% and 72% vs 11% for >2 LNs involvement, respectively; both p < 0.0001).

CONCLUSIONS

- AXUS-guided FNAC of all ILC patients did not result in improved preoperative identification of patients with >2 metastatic LNs but increased the false-negative rate of the assessment by producing false-negative results in patients who would not have undergone a biopsy due to negative AXUS findings.

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.

Image-Guided Localization Techniques for Surgical Excision of Non-Palpable Breast Lesions: An Overview of Current Literature and Our Experience with Preoperative Skin Tattoo

Breast conserving surgery has become the standard of care and is more commonly performed than mastectomy for early stage breast cancer, with recent studies showing equivalent survival and lower morbidity. Accurate preoperative lesion localization is mandatory to obtain adequate oncological and cosmetic results. Image guidance assures the precision requested for this purpose. This review provides a summary of all techniques currently available, ranging from the classic wire positioning to the newer magnetic seed localization. We describe the procedures and equipment necessary for each method, outlining the advantages and disadvantages, with a focus on the cost-effective preoperative skin tattoo technique performed at our centre. Breast surgeons and radiologists have to consider ongoing technological developments in order to assess the best localization method for each individual patient and clinical setting.

Magnetic resonance imaging based 3-dimensional printed breast surgical guide for breast-conserving surgery in ductal carcinoma in situ: a clinical trial

Breast-conserving surgery (BCS) is performed in patients with ductal carcinoma in situ (DCIS) because of the small size of the tumor. It is essential to know the quantitative extent of the tumor before performing this precise partial resection surgery. A three-dimensional printed (3DP) breast surgical guide (BSG) was developed using information obtained from supine magnetic resonance imaging (MRI) and 3D printing technology and it was used for treating patients with breast cancer. Here, we report our experience with the application of the BSG for patients with DCIS. Patients with breast cancer who underwent BCS from July 2017 to February 2019 were included in this study. The patients underwent partial resection with a supine-MRI based 3DP-BSG. A total of 102 BCS using 3DP-BSG were conducted, and 11 cases were DCIS. The patients’ median age was 56 years (range, 38–69 years). The mean tumor diameter was 1.3 ± 0.9 cm. The median surgical time was 70 min (range, 40–88 min). All patients had tumor-free resection margins. The median distance from the tumor to the margin was 11 mm (range, 2–35 mm). Direct demarcation of the tumor extent in the breast and a pain-free procedure are the advantages of using 3DP-BSG in patients with DCIS.

Trial registration: Clinical Research Information Service (CRIS) Identifier Number: KCT0002375, KCT0003043.

Is SNOLL a good localization technique in early breast cancer treatment? A single center's experience

Aim

The aim of this study was to evaluate the method and present one center's experience in applying the SNOLL technique to patients with non-palpable suspicious breast lesions.

Materials and methods

371 patients with suspected malignant lesions or diagnosed non-palpable breast cancer were subjected to a preoperative SNOLL procedure. The day before the surgery, they were administered two radiotracers to localize the tumor in the breast and the sentinel node. The following day, with the help of a handheld gamma probe the breast conserving surgery was performed.

Results

All 371 patients (100%) had their suspected occult breast lesions resected. Histo-pathological examination revealed cancer in 339 patients all these patients had their sentinel nodes examined. The intraoperative tests showed the sentinel node to be metastatic in 35 patients, who were then given a simultaneous axillary lymphadenectomy. Another 7 patients were diagnosed with positive lymph nodes in the final pathology and had to undergo a second operation. Reoperations compelled by positive surgical margins were performed in 26 cases.

Conclusions

SNOLL as a good technique of intraoperative localization, enables to remove a nonpalpable breast cancer together with sentinel lymph node in a single surgical procedure. It seems to be a optional method to be used in patients treated with breast conserving therapy.

Comparison of Radioactive Seed Localized Excision and Wire Localized Excision of Breast Lesions: A Community Hospital's Experience

BACKGROUND

Most data comparing wire localized excision (WLE) and radioactive seed localized excision (RSLE) derive from academic institutions with limited data from community hospitals. This study aimed to compare positive margin rates between WLE and RSLE and to determine if there were any differences in specimen volume and operation time.

PATIENTS AND METHODS

A retrospective cohort study was conducted on patients who underwent WLE or RSLE at a Canadian community hospital. Group characteristics were compared as appropriate. Multivariable logistic regression was used determine if the localization techniques were independently associated with having a positive margin. Statistical significance was set as P < .05.

RESULTS

The cohort consisted of 747 (WLE) and 577 (RSLE) patients. Both groups had similar mean age, mean tumor (invasive and ductal carcinoma-in-situ) size, histologic grade distribution, presence of lymphovascular invasion, and extensive intraductal component, nodal status, and hormone receptor and HER2 status. Compared to WLE, patients who underwent RSLE had significantly lower invasive positive margin rates (8.1% vs. 12.3%, P = .03), shorter operation time (39.5 minutes vs. 68.7 minutes, P = .0001), and smaller surgical specimens (21.4 cm³ vs. 30.2 cm³, P = .008). Ductal carcinoma-in-situ positive margin rates were not different between the groups. However, the localization technique was not independently associated with having a positive margin (odds ratio = 1.55; 95% confidence interval, 0.99-2.44).

CONCLUSION

RSLE led to a shorter operation time and smaller surgical specimens compared to WLE, but there was no difference in positive margin rates. RSLE is an effective technique to excise nonpalpable breast lesions in the community setting.

Real-time oncological guidance using diffuse reflectance spectroscopy in electrosurgery: the effect of coagulation on tissue discrimination

In breast surgery, a lack of knowledge about what is below the tissue surface may lead to positive tumor margins and iatrogenic damage. Diffuse reflectance spectroscopy (DRS) is a spectroscopic technique that can distinguish between healthy and tumor tissue making it a suitable technology for intraoperative guidance. However, because tumor surgeries are often performed with an electrosurgical knife, the effect of a coagulated tissue layer on DRS measurements must be taken into account. It is evaluated whether real-time DRS measurements obtained with a photonic electrosurgical knife could provide useful information of tissue properties also when tissue is coagulated and cut. The size of the coagulated area is determined and the effect of its presence on DR spectra is studied using ex vivo porcine adipose and muscle tissue. A coagulated tissue layer with a depth of 0.1 to 0.4 mm is observed after coagulating muscle with an electrosurgical knife. The results show that the effect of coagulating adipose tissue is negligible. Using the fat/water ratio's calculated from the measured spectra of the photonic electrosurgical knife, it was possible to determine the distance from the instrument tip to a tissue transition during cutting. In conclusion, the photonic electrosurgical knife can determine tissue properties of coagulated and cut tissue and has, therefore, the potential to provide real-time feedback about the presence of breast tumor margins during cutting, helping surgeons to establish negative margins and improve patient outcome.

Radioguided Occult Lesion Localization: Technical Procedures and Clinical Applications

PURPOSE

Regarding radioguided surgery, the concept of "radioguided occult lesion localization" (ROLL) is based on both preoperative interventional imaging and intraoperative radioguided detection of a clinically occult neoplastic lesion.

METHODS

This methodology consists in the direct administration into the lesion of Tc-macroaggregated human albumin formed by relatively large particles retained at the injection site, which direct radioguided excisional biopsy.

RESULTS

This modality has expanded from the classic application of ROLL for nonpalpable breast lesions to other tumors, such as solitary pulmonary nodules or recurrences from differentiated thyroid carcinoma. In 2011, in order to improve the classification of different radioguided surgical procedures, ROLL applications were included in the more complete concept of GOSTT (Guided intraOperative Scintigraphic Tumor Targeting). This concept was introduced to include the entire range of basic and advanced radioguided procedures necessary to supply a "road map" for the surgeon.

CONCLUSIONS

The terms ROLL and GOSTT have further developed by incorporating novel modalities such as hybrid tracers for simultaneous fluorescence and radioactive signal detection and innovative navigation systems based on mixed-reality protocols.

Assessment of Ultrasound / Radio-guided Occult Lesion Localization in Non-palpable Breast Lesions

OBJECTIVES

Controversy exists about the localization of non-palpable breast lesions. In many countries, the gold standard for the diagnosis of these lesions is needle localization due to its accuracy. This study sought to compare the ultrasound- and radio-guided occult lesion localization (ROLL) as a simple method with the conventional procedures in terms of their diagnostic power.

METHODS

This study was conducted on 94 patients with non-palpable breast lesions detected by ultrasonography and localized by the combination of ultrasonography and using radiopharmaceuticals. One to ten hours prior to surgery, 0.1-0.2 ml (equivalent to 0.5-1 mCi) of Tc-99m-phytate was injected to the lesion under the guidance of ultrasonography. Then, the lesion was localized using a hand-held gamma probe, and excision of the lesion was performed according to its radioactivity signal. Data analysis was performed using SPSS, version 16.

RESULTS

Benign and malignant pathologic results were observed in 77 (81.9%) and 17(18.1%) of the patients, respectively, and the mean volume of the excised tissue was 26.29±27 mm³. 79 patients had a solitary lesion (84%), 55 in the left breast (58.5%) and 39 in superolateral quadrant (41.5%). The mean size of the lesions was 15.7 mm in diameter (ranging from 4 to 34 mm). Additionally, there was a need to secondary surgery in 3 (3.2%) patients and inappropriate localization in 6 (6.4%) patients (subcutaneous or intra-ductal spread of radiodrug).

CONCLUSION

Combination of ultrasound- and radio-guided localization methods for localizing non-palpable breast lesions is a simple and acceptable method for localization with no significant complications. For radio-drug spread and subsequent excessive excised tissue volume, subcutaneous and intra-ductal lesions are not suitable indication for ROLL.

Translating the 2-dimensional mammogram into a 3-dimensional breast: Identifying factors that influence the movement of pre-operatively placed wire

BACKGROUND

Pre-operative measurements from the skin to a wire-localized breast lesion can differ from operating room measurements. This study was designed to measure the discrepancies and study factors that may contribute to wire movement.

METHODS

Prospective data were collected on patients who underwent wire localization lumpectomy. Clip and hook location, breast size, density, and direction of wire placement were the main focus of the analysis.

RESULTS

Wire movement was more likely with longer distance from skin to hook or clip, larger breast size (especially if "fatty"), longer time between wire placement and surgery start time, and medial wire placement in larger breast. Age, body mass index, presence of mass, malignant diagnosis, tumor grade, and clip distance to the chest wall were not associated with wire movement. A longer distance from skin to hook correlated with larger specimen volume.

CONCLUSIONS

Translation of the lesion location from a 2-dimensional mammogram into 3-dimensional breasts is sometimes discrepant because of movement of the localizing wire. Breast size, distance of skin to clip or hook, and wire exit site in larger breasts have a significant impact on wire movement. This information may guide the surgeon's skin incision and extent of excision.

Use of the ROLL technique for lumpectomy in non-palpable breast lesions

OBJECTIVE

To evaluate the efficiency of radioguided occult lesion localising in non-palpable breast lesions (NPBL) compared to the surgical wire technique.

METHOD

A prospective study was conducted on 161 women with NPBL, of whom 80 marked with the wire (group 1), whereas 81 women were marked with an intratumour injection of ^99mTc-nanocoloid (group 2). The NPBL were located by ultrasound or stereotactic guidance. The lumpectomies were performed following the wire direction in group 1, and with the aid of a gamma-probe in group 2. Surgical margins were then checked, determining the need of extension if the margin was less than 5mm in the intra-surgical study, and less than 2mm in the deferred study. Data were collected on the mean number detected by surgery, surgical margins, number of extensions, presence of residual tumour in the extension, second surgeries, lumpectomy volume, as well as total resected volume, volume/tumour ratio, and complications.

RESULTS

No significant differences were observed between the two groups in the mean number detected, surgical margins, number of extensions, presence of residual tumour in the extension, second surgeries, lumpectomy volume, total resected volume, volume/tumour ratio or complications. The multivariate analysis showed the determining factors of the resected volume were the radiological guidance technique, as well as the surgeon.

CONCLUSIONS

The radioguided occult lesion localising technique helps in the detection and resection of NPBL with the same efficiency as the surgical wire, and adds the possibility of sentinel node detection in the same surgery. The determining factors of the resected volume were the radiological guidance technique and the surgeon.

First Case of ROLL Technique for Mesorectal Recurrence Excision

The radio-guided occult lesion localization (ROLL) technique has been in use since the mid-1990s, mainly in breast surgery. Today, ROLL is used for numerous oncologic pathologies, including parathyroid lesions, melanomas, and colorectal tumors. We report a patient with an 11-mm left mesorectal solitary recurrence of a primary ovarian cancer in whom the ROLL technique was used to identify the implant. A radioisotope was introduced through a 22-gauge needle with endoscopic ultrasound technique using an linear echo endoscope. On the day of surgery, the patient's perianal region was scanned with a gamma probe to identify the area of maximal radioactivity, to determine the optimal placement of the incision over the lesion. After macroscopic excision of the lesion, radioactivity was measured in the lesion bed to ensure complete removal of affected tissues. In our case, the ROLL technique was performed safely for the detection and excision of a recurrent lesion of difficult identification. To our knowledge, this is the first reported case involving use of the ROLL technique to aid the excision of a mesorectal lesion.

Comparison of wire-guided localization and radio-guided occult lesionlocalization in preoperative localization of nonpalpable breast lesions

BACKGROUND/AIM

Breast lesions that are not palpable on physical examination but considered suspicious for malignancy on mammography or ultrasonography should be marked before surgery. Wire-guided localization (WGL) is the most frequently used method for preoperative marking of nonpalpable breast lesions (NPBLs). An alternative is marking by a radioactive agent (radio-guided occult lesion localization; ROLL). The present study aimed to compare WGL and ROLL for preoperative marking.

MATERIALS AND METHODS

The study included 25 patients marked by ROLL and 11 patients marked by WGL. The groups were compared in terms of patient and lesion characteristics, method-related characteristics, hospital stay duration, complications, cosmetic outcomes, and rate of correct marking.

RESULTS

Suspicious lesions were marked with a success rate of 95.6% by ROLL and 100% by WGL. Complications and pain sensation rates were found significantly lower in the ROLL group compared to WGL. Although ROLL was considered more advantageous in terms of hospital stay duration, positive surgical margins, cosmetic outcomes, and excision duration, the differences between the groups were not statistically significant.

CONCLUSION

ROLL, which is a simple, comfortable, and reliable method, could be used as an alternative to the WGL in preoperative marking of NPBLs.

Intraoperative indocyanine green fluorescence guidance for excision of nonpalpable breast cancer

Background

Different techniques have been used for the guidance of nonpalpable breast cancer (NBC), but none of them has yet achieved perfect results. The aim of this study was to evaluate the feasibility of indocyanine green (ICG) fluorescence-guided nonpalpable breast cancer lesion excision (IFNLE), to introduce an alternative technique.

Methods

The data about 56 patients with preoperatively diagnosed NBCs operated with the help of intraoperative IFNLE between November of 2010 and September of 2014 were retrospectively analyzed.

Results

ICG fluorescence localized all lesions at surgery. Re-excision due to positive resection margins was necessary in two patients (3.6 %; 2/56) with ductal carcinoma in situ (DCIS) at the surgical margins. Mastectomy was necessary in one patient (1.8 %; 1/56) due to multifocal invasive carcinoma. The mean volume of the excised tissue was 38.2 ± 16.5 cm³.

Conclusions

IFNLE is a technically applicable and clinically acceptable procedure whenever a breast cancer needs image-guided excision.

Surgical Resection Margins after Breast-Conserving Surgery: Senonetwork Recommendations

This paper reports findings of the “Focus on Controversial Areas” Working Party of the Italian Senonetwork, which was set up to improve the care of breast cancer patients. After reviewing articles in English on the MEDLINE system on breast conserving surgery for invasive carcinoma, the Working Party presents their recommendations for identifying risk factors for positive margins, suggests how to manage them so as to achieve the highest possible percentage of negative margins, and proposes standards for investigating resection margins and therapeutic approaches according to margin status. When margins are positive, approaches include re-excision, mastectomy, or, as second-line treatment, radiotherapy with a high boost dose. When margins are negative, boost administration and its dose depend on the risk of local recurrence, which is linked to biopathological tumor features and surgical margin width. Although margin status does not affect the choice of systemic therapy, it may delay the start of chemotherapy when further surgery is required.

Randomized controlled clinical trial comparing radioguided occult lesion localization with wire-guided lesion localization to evaluate their efficacy and accuracy in the localization of nonpalpable breast lesions

PURPOSE

The aim of this study was to compare the radioguided occult lesion localization (ROLL) technique with the wire-guided lesion localization (WGLL) technique to assess their efficacy and accuracy in the localization of nonpalpable breast lesions in patients at a unique reference medical center. These patients' reports were negative for malignancy but included highly suspicious imaging findings.

METHODS

A controlled clinical trial was designed to compare the WGLL and ROLL techniques in women presenting with breast lesions diagnosed by mammography or ultrasonography at the Instituto Nacional de Cancerología in Bogotá, Colombia, from March 2006 to June 2011.

RESULTS

This study examined 129 patients; 64 (49.6%) patients were treated with ROLL, and 65 (51.4%) were treated with WGLL. The ROLL technique achieved better median lesion centricity (ROLL = 11.7 and WGLL = 15.4; P = .038). No significant differences were found regarding demographic variables, operative specimen characteristics, the need to extend margins, operative complications, the degree of difficulty, or patient or surgeon satisfaction.

CONCLUSION

The ROLL technique is as effective as WGLL for the localization of nonpalpable breast lesions. In our study, ROLL achieved better lesion centricity. Therefore, we propose that this technique could be used as a standard procedure in the detection of nonpalpable breast lesions at experienced centers.

Dual-head gamma camera system for intraoperative localization of radioactive seeds

Breast-conserving surgery is a standard option for the treatment of patients with early-stage breast cancer. This form of surgery may result in incomplete excision of the tumor. Iodine-125 labeled titanium seeds are currently used in clinical practice to reduce the number of incomplete excisions. It seems likely that the number of incomplete excisions can be reduced even further if intraoperative information about the location of the radioactive seed is combined with preoperative information about the extent of the tumor. This can be combined if the location of the radioactive seed is established in a world coordinate system that can be linked to the (preoperative) image coordinate system. With this in mind, we propose a radioactive seed localization system which is composed of two static ceiling-suspended gamma camera heads and two parallel-hole collimators. Physical experiments and computer simulations which mimic realistic clinical situations were performed to estimate the localization accuracy (defined as trueness and precision) of the proposed system with respect to collimator-source distance (ranging between 50 cm and 100 cm) and imaging time (ranging between 1 s and 10 s). The goal of the study was to determine whether or not a trueness of 5 mm can be achieved if a collimator-source distance of 50 cm and imaging time of 5 s are used (these specifications were defined by a group of dedicated breast cancer surgeons). The results from the experiments indicate that the location of the radioactive seed can be established with an accuracy of 1.6 mm  ±  0.6 mm if a collimator-source distance of 50 cm and imaging time of 5 s are used (these experiments were performed with a 4.5 cm thick block phantom). Furthermore, the results from the simulations indicate that a trueness of 3.2 mm or less can be achieved if a collimator-source distance of 50 cm and imaging time of 5 s are used (this trueness was achieved for all 14 breast phantoms which were used in this study). Based on these results we conclude that the proposed system can be a valuable tool for (real-time) intraoperative breast cancer localization.

Surgical treatment of nonpalpable primary invasive and in situ breast cancer

Breast cancer is the most-common cancer among women worldwide, and over one-third of all cases diagnosed annually are nonpalpable at diagnosis. The increasingly widespread implementation of breast-screening programmes, combined with the use of advanced imaging modalities, such as magnetic resonance imaging (MRI), will further increase the numbers of patients diagnosed with this disease. The current standard management for nonpalpable breast cancer is localized surgical excision combined with axillary staging, using sentinel-lymph-node biopsy in the clinically and radiologically normal axilla. Wire-guided localization (WGL) during mammography is a method that was developed over 40 years ago to enable lesion localization preoperatively; this technique became the standard of care in the absence of a better alternative. Over the past 20 years, however, other technologies have been developed as alternatives to WGL in order to overcome the technical and outcome-related limitations of this technique. This Review discusses the techniques available for the surgical management of nonpalpable breast cancer; we describe their advantages and disadvantages, and highlight future directions for the development of new technologies.

A Retrospective Comparative Study of Image-Guided Excisional Biopsy in High-Risk Non-Palpable Breast Lesions: Predictive Factors for Malignancy

OBJECTIVE

The use of mammography (MM) in breast cancer screening programs has been increasing in recent years. Thus, increasing the number of detected nonpalpable breast cancer patients, through early diagnosis and treatment also increased survival rates. In our study, we wanted to share the factors about imaging-guided exicional biopsies for non-palpable breast lesions in postoperative proven breast carcinoma patients.

MATERIALS AND METHODS

The surgical data were reviewed for 83 patients with non-palpabl high-risk breast lesions undergoing imaging-guided surgery in our department between January, 2006 and May, 2011. Histopathologic results and age, ultrasound(US) results, MM image results, BI-RADS categorization, localization of lesion(quadrant) were assessed and factors for predicting malignity were detected.

RESULTS

Median age was 52 (age range 32-80 years). 29 (34,9%) of patients were malign in histopathologic results. In four patient, re-excision performed because of positive surgical margins. Axillary examination results were normal in 24 (82,7%) of malignant patients. In MM examination; microcalcifications and nodular opasity were diagnosed in 74,6% of patients before surgery. There were no differance about malignity in these groups after surgery (p:0,428). 59% and 32,7% of patients were BI-RADS 4 and 3, respectively. Postoperative diagnosed malignancies in BI-RADS 4 group were significantly higher than BI-RADS 3 group (p:<0,001).

CONCLUSION

In our study; we concluded that, preoperative BI-RADS categorization (US and MM) is correlated with histopathologic findings after surgery and imaging-guided breast surgery is effective for diagnosis of early-stage breast carcinoma.

Breast cancer: Actual methods of treatment and future trends

The recent ten to twenty years have seen a substantial progress in the diagnosis and treatment of breast cancer. A rapid development of various curative options has led to the improvement of treatment outcomes, while paying more and more attention to the aspects of quality of life and cosmetic effect. In our publication, we wish to outline certain trends in the development of modern treatment of breast cancer. Among topics discussed are new forms of molecular diagnostics, new approach to the idea of sentinel node biopsy, as well as new techniques for delivery of medical procedures, the increasing use of nomograms, progress in the techniques of breast conservative treatment, modern approach to occult breast lesions, the increasing use of neoadjuvant treatment and intraoperative radiotherapy.

Ultrasonography-guided breast-conserving surgery is superior to palpation-guided surgery for palpable breast cancer

INTRODUCTION

The aim of this study was to determine the efficacy of ultrasonography (US)-guided excision of palpable breast cancer and to compare it with the standard palpation-guided breast-conserving surgery (BCS).

METHODS

For this purpose, 335 women with palpable breast cancer who underwent BCS were retrospectively studied. The positive surgical margins and re-excision rates were investigated.

RESULTS

Of the total cohort, 137 patients were treated with palpation-guided BCS and 198 underwent US-guided tumor excision. The tumor and patient characteristics were similar in both groups. Patient age, postmenopausal status, tumor size, histological grade, intraductal tumor component, lobular histology, and palpation-guided tumor excision were associated with increased risk of positive margins. The shave margins were re-excised at the time of original operation more often by palpation-guided localization (28.5%) than by the US-guided procedure (11.1%) (P < .0001). A surgeon was able to correctly identify the "problematic" margin in 81.1% of cases via intraoperative US and in only 17.9% via palpation (P < .0001). The re-excision rate during a second operation was significantly reduced by US-guided tumorectomy (P = .004). Of 198 patients in the US-guided group, 23 (11.6%) underwent a second operation, as did 33 of 137 patients in the palpation group (24.1%). The sensitivity and specificity of US-guided excisions were 52.7% and 97.5%, respectively, whereas the sensitivity and the specificity of palpation-guided tumor excisions were 15.5% and 65.9%, respectively.

CONCLUSION

US-guided BCS is superior to palpation-guided excision in predicting the closest margins, obtaining clear surgical margins, and reducing re-operations.

Magnetic resonance imaging-radioguided occult lesion localization (ROLL) in breast cancer using Tc-99m macro-aggregated albumin and distilled water control

Background

Magnetic resonance imaging (MRI) guided wire localization presents several challenges apart from the technical difficulties. An alternative to this conventional localization method using a wire is the radio-guided occult lesion localization (ROLL), more related to safe surgical margins and reductions in excision volume. The purpose of this study was to establish a safe and reliable magnetic resonance imaging-radioguided occult lesion localization (MRI-ROLL) technique and to report our initial experience with the localization of nonpalpable breast lesions only observed on MRI.

Methods

Sixteen women (mean age 53.2 years) with 17 occult breast lesions underwent radio-guided localization in a 1.5-T MR system using a grid-localizing system. All patients had a diagnostic MRI performed prior to the procedure. An intralesional injection of Technetium-99m macro-aggregated albumin followed by distilled water was performed. After the procedure, scintigraphy was obtained. Surgical resection was performed with the help of a gamma detector probe. The lesion histopathology and imaging concordance; the procedure’s positive predictive value (PPV), duration time, complications, and accuracy; and the rate of exactly excised lesions evaluated with MRI six months after the surgery were assessed.

Results

One lesion in one patient had to be excluded because the radioactive substance came back after the injection, requiring a wire placement. Of the remaining cases, there were four malignant lesions, nine benign lesions, and three high-risk lesions. Surgical histopathology and imaging findings were considered concordant in all benign and high-risk cases. The PPV of MRI-ROLL was greater if the indication for the initial MR examination was active breast cancer. The median procedure duration time was 26 minutes, and all included procedures were defined as accurate. The exact and complete lesion removal was confirmed in all (100%) patients who underwent six-month postoperative MRI (50%).

Conclusions

MRI-ROLL offers a precise, technically feasible, safe, and rapid means for performing preoperative MRI localizations in the breast.

Procedures for location of non-palpable breast lesions: a systematic review for the radiologist

Accurate location of small breast lesions is mandatory for proper surgical management. The purpose of this article is systematically review procedures used to locate non-palpable breast lesions, including a description of the current status, advantages, and disadvantages for each technique. A total of 47 articles were finally included: 7 articles for the wire location technique, 5 articles for the radioguided location technique, 13 articles that compare wire location with radioguided location, 3 articles for the carbon location technique, 2 articles that compare wire location with carbon location, and 17 articles for the clip location technique. The success of location and the clear margin are reported for each location technique and for the separate articles included; clip migration shift, also, is reported for the clip location technique. Odds ratio with related 95 % confidence intervals were also calculated for successful location. Comparative analysis or meta-analysis for all the different breast lesion location techniques is missing. Prospective investigations and randomized investigations for homogeneous populations are still needed to determine which is the most cost-effective modality among those used to date.

Excessive resections in breast-conserving surgery: a retrospective multicentre study

The main determinant of cosmetic outcomes following breast-conserving surgery (BCS) for breast cancer is the volume of resection. The importance of achieving optimal oncological control may lead to an unnecessarily large resection of breast tissue. The aim of this study is to evaluate excess resection volume in BCS for cancer by determining a calculated resection ratio (CRR). This retrospective study was conducted in four affiliated institutions and involved 726 consecutive patients with T1-T2 invasive breast cancer treated by BCS between January 2006 and 2009. The pathology reports were reviewed for tumor palpability, tumor size, surgical specimen size, and oncological margin status. The optimal resection volume (ORV) was defined as the spherical tumor volume with an added 1.0 cm margin of healthy breast tissue. The total resection volume (TRV) was defined as the ellipsoid volume of the surgical specimen. CRR was determined by dividing the TRV by the ORV. Of all tumors, 72% (525/726) were palpable, and 28% (201/726) were nonpalpable. The tumor stage was T1 in 492 patients (67.8%) and T2 in 234 patients (32.2%). The median CRR was 2.5 (0.01-42.93). Margin status was positive or focally positive in 153 patients (21.1%). Lower tumor stage was associated with a higher CRR (factor 0.61 [p < 0.0001] and a lower positive margin rate [p = 0.064]). Accordingly, the median CRR of the nonpalpable lesions was higher than that of the palpable lesions (3.1 and 2.2, respectively; p < 0.01), and the involved margin rate was lower (17.4% and 22.5%, respectively; p = 0.13). Of patients with a CRR >4.0, 10.7% still had tumor involved margins. This study clearly shows that BCS is associated with excessive resection of healthy breast tissue while clear margins are not assured. Surgical factors should be modified to improve surgical accuracy.

Excision of Nonpalpable Breast Cancer with Indocyanine Green Fluorescence-Guided Occult Lesion Localization (IFOLL)

BACKGROUND: Currently employed techniques for the localization of nonpalpable breast lesions suffer from various limitations. In this paper, we report on 2 patients in order to introduce an alternative technique, indocyanine green fluorescence-guided occult lesion localization (IFOLL), and determine its applicability for the surgical removal of this type of breast lesions. CASE REPORTS: Preoperatively, one of the patients had a needle biopsy-proven diagnosis of breast cancer, and the other one had suspicious findings for malignancy. Lesion localization was performed within 1 h before surgery under ultrasonography control by injecting 2 ml and 0.2 ml of indocyanine green into the lesion and its subcutaneous tissue projection, respectively. During surgery, the site of skin incision and the resection margins were identified by observing the area of indocyanine-derived fluorescence under the guidance of a near-infrared-sensitive camera. In both cases, the breast lesion was correctly localized, and the area of fluorescence corresponded well to the site of the lesions. Subsequent surgical excision was successful with no complications. On histopathologic examination, the surgical margins were found to be clear. CONCLUSION: IFOLL seems to be a technically applicable and clinically acceptable procedure for the removal of nonpalpable breast cancer.

Comparison of radioguided occult lesion localization (ROLL) and wire localization for non-palpable breast cancers: a meta-analysis

Four randomized trials encompassing 449 patients of non-palpable breast cancer undergoing with radio-guided occult lesion localization (ROLL) or wire guided localization (WGL). In the fixed effects model, accurate localization, peri-procedural complications, and reoperation rate were comparable between two techniques. Risk of having positive resection margins following WGL was higher. Duration of localization and surgical excision was shorter for ROLL. Volume and weight of the excised occult breast lesion was similar in WGL and ROLL groups.

Preliminary experience in sentinel node and occult lesion localization (SNOLL) technique-One center study

AIM

The aim of this study was to present one center experience in applying the SNOLL technique to patients with suspected occult breast lesions.

BACKGROUND

In the last years, the widespread use of mammographic screening programs resulted in an increasing number of women with nonpalpable suspicious breast lesions requiring further examination. The new method called sentinel node and occult lesion localization (SNOLL) enables the intraoperative detection of nonpalpable breast tumors and sentinel node biopsy in one surgical procedure.

MATERIALS AND METHODS

46 patients with suspected malignant lesions or diagnosed non-palpable breast cancer were subjected to a pre-operative SNOLL procedure. The day before the surgery, they were administered two radiotracers: one to localize the tumor and the other to localize the sentinel node. During the surgery, the breast tumor and the sentinel node, which in most cases had been examined intraoperatively, were detected with a handheld gamma probe and resected under its control.

RESULTS

All 46 (100%) patients had their occult breast lesions resected. Histopathologic examination revealed cancer in 40 patients: in situ in 2 cases, invasive in 38 cases. All these patients had their sentinel nodes examined. In one case only, the sentinel node could not be located with a gamma probe. Intraoperative tests showed the sentinel node to be metastatic in 5 patients, who were then given a simultaneous axillary lymphadenectomy. In addition, the final histopathologic examination revealed metastasis to the sentinel node in one patient, who had to be reoperated.

CONCLUSION

SNOLL is a modern technique that enables a precise intraoperative localization of non-palpable suspected malignant breast lesions in combination with a sentinel node biopsy. Extended application of intraoperative management leads to significant decrease in the number of reoperations performed in patients with early bread cancer.

Ultrasound-guided breast-sparing surgery to improve cosmetic outcomes and quality of life. A prospective multicentre randomised controlled clinical trial comparing ultrasound-guided surgery to traditional palpation-guided surgery (COBALT trial)

Background

Breast-conserving surgery for breast cancer was developed as a method to preserve healthy breast tissue, thereby improving cosmetic outcomes. Thus far, the primary aim of breast-conserving surgery has been the achievement of tumour-free resection margins and prevention of local recurrence, whereas the cosmetic outcome has been considered less important. Large studies have reported poor cosmetic outcomes in 20-40% of patients after breast-conserving surgery, with the volume of the resected breast tissue being the major determinant. There is clear evidence for the efficacy of ultrasonography in the resection of nonpalpable tumours. Surgical resection of palpable breast cancer is performed with guidance by intra-operative palpation. These palpation-guided excisions often result in an unnecessarily wide resection of adjacent healthy breast tissue, while the rate of tumour-involved resection margins is still high. It is hypothesised that the use of intra-operative ultrasonography in the excision of palpable breast cancer will improve the ability to spare healthy breast tissue while maintaining or even improving the oncological margin status. The aim of this study is to compare ultrasound-guided surgery for palpable tumours with the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumour-free margins, cosmetic outcomes and quality of life.

Methods/design

In this prospective multicentre randomised controlled clinical trial, 120 women who have been diagnosed with palpable early-stage (T1-2N0-1) primary invasive breast cancer and deemed suitable for breast-conserving surgery will be randomised between ultrasound-guided surgery and palpation-guided surgery. With this sample size, an expected 20% reduction of resected breast tissue and an 18% difference in tumour-free margins can be detected with a power of 80%. Secondary endpoints include cosmetic outcomes and quality of life. The rationale, study design and planned analyses are described.

Conclusion

The COBALT trial is a prospective, multicentre, randomised controlled study to assess the efficacy of ultrasound-guided breast-conserving surgery in patients with palpable early-stage primary invasive breast cancer in terms of the sparing of breast tissue, oncological margin status, cosmetic outcomes and quality of life.

Trial Registration Number

Netherlands Trial Register (NTR): NTR2579