Surgeon-controlled ultrasound-guided core biopsies in the breast--a prospective study and a new use for surgeons in the clinic

Intraoperative ultrasound-guided lumpectomy versus wire-guided excision for nonpalpable breast cancer

Objective

This study was designed to compare the margin clearance and re-excision rates of ultrasound (US)- and wire-guided excision in a large number of patients with nonpalpable breast cancer.

Methods

In total, 520 women who were histologically diagnosed with nonpalpable breast cancer were recruited in this study. All nonpalpable lesions were visible by US. The patients were randomly divided into two groups: those who underwent wire-guided breast-conserving surgery (BCS) and those who underwent US-guided BCS. Re-excision rates and positive surgical margins were recorded.

Results

A total of 262 patients underwent US-guided excision and 258 patients underwent wire-guided excision. No differences were found in tumor or patient characteristics. The positive margin rate was 4.6% in the US-guided group and 19.4% in the wire-guided group with a significant difference. Age, menopausal status, excision volume, histological grade, and tumor type significantly influenced the positive surgical margin rate. The intraoperative re-excision rate was significantly lower in the US-guided group than wire-guided group (11.1% vs. 24.0%, respectively).

Conclusions

US-guided BCS seems to be more effective than wire-guided BCS for treatment of nonpalpable breast cancers in terms of the margin clearance and re-excision rates. Patients can avoid the discomfort caused by preoperative wire placement.

Current status of ultrasound-guided surgery in the treatment of breast cancer

The primary goal of breast-conserving surgery (BCS) is to obtain tumour-free resection margins. Margins positive or focally positive for tumour cells are associated with a high risk of local recurrence, and in the case of tumour-positive margins, re-excision or even mastectomy are sometimes needed to achieve definite clear margins. Unfortunately, tumour-involved margins and re-excisions after lumpectomy are still reported in up to 40% of patients and additionally, unnecessary large excision volumes are described. A secondary goal of BCS is the cosmetic outcome and one of the main determinants of worse cosmetic outcome is a large excision volume. Up to 30% of unsatisfied cosmetic outcome is reported. Therefore, the search for better surgical techniques to improve margin status, excision volume and consequently, cosmetic outcome has continued. Nowadays, the most commonly used localization methods for BCS of non-palpable breast cancers are wire-guided localization (WGL) and radio-guided localization (RGL). WGL and RGL are invasive procedures that need to be performed pre-operatively with technical and scheduling difficulties. For palpable breast cancer, tumour excision is usually guided by tactile skills of the surgeon performing “blind” surgery. One of the surgical techniques pursuing the aims of radicality and small excision volumes includes intra-operative ultrasound (IOUS). The best evidence available demonstrates benefits of IOUS with a significantly high proportion of negative margins compared with other localization techniques in palpable and non-palpable breast cancer. Additionally, IOUS is non-invasive, easy to learn and can centralize the tumour in the excised specimen with low amount of healthy breast tissue being excised. This could lead to better cosmetic results of BCS. Despite the advantages of IOUS, only a small amount of surgeons are performing this technique. This review aims to highlight the position of ultrasound-guided surgery for malignant breast tumours in the search for better oncological and cosmetic outcomes.

Ultrasound-Guided Versus Wire-Guided Breast-Conserving Surgery for Nonpalpable Breast Cancer

PURPOSE

To determine the efficacy of ultrasound (US)-guided excision of nonpalpable breast cancer and compare it to standard wire-guided breast-conserving surgery (BCS).

METHODS

One hundred fifty-eight women with nonpalpable breast cancer who underwent BCS were retrospectively studied. Positive surgical margins and reexcision rates were investigated.

RESULTS

Of the total cohort, 68 patients were treated with wire-guided and 90 with US-guided tumor excision. The tumor and patient characteristics were similar in the 2 groups; 13.2% and 12.2% of patients in the wire-guided and US-guided groups, respectively, had positive margins. Patient age, menopausal status, tumor size, histologic type, and histologic grade were associated with increased risk of positive margins. The shave margins were reexcised at the time of original operation more often by wire-guided localization (26.5%) than in the US-guided group (10.0%) (P = .010). The surgeon was able to identify correctly the problematic margin in 100% via intraoperative US and in only 27.8% when the wire-guided surgery was used (P < .001). The reexcision rate by a second operation was similar in 2 groups (P = .798). Eight (11.8%) of 68 patients in the wire-guided group and 9 (10.0%) of 90 patients in the US-guided underwent a second operation.

CONCLUSION

US-guided BCS is as effective and safe as standard wire-guided excision of nonpalpable breast tumors.

Evaluation of office ultrasound usage among Australian and New Zealand breast surgeons

BACKGROUND

Surgeon performed ultrasound (US) is being increasingly embraced by breast surgeons worldwide as an integral part of patient assessment. The extent of its application within Australia and New Zealand is not well documented. The present study aimed to evaluate its current usage patterns and to determine suitable future training models.

METHODS

An online survey was sent to members of Breast Surgeons of Australia and New Zealand (BreastSurgANZ) between July and September 2010, with emphases on practice demographics, access to US equipment, usage, biopsy patterns, and training.

RESULTS

Of the 126 surveys sent, 59 were returned. The majority of respondents were metropolitan based (64 %), worked in both public and private sectors (71 %), and practiced endocrine or general surgery (85 %), as well as breast surgery. A preponderance of surgeons had access to equipment (63 %), performed at least 1 US monthly (63 %), but did not perform regular guided biopsies. Rural practice did not affect access or usage patterns. Most respondents underwent structured US training (73 %), which was associated with greater US and biopsy usage, biopsy complexity, intraoperative applications, and cross discipline applications (p < 0.03). Most surgeons favored a structured training program for future trainees (83 %).

CONCLUSIONS

The majority of breast surgeons from Australia and New Zealand have adopted office US to varying degrees. Geographic variation did not lead to access inequity and variation in scanning patterns. Formal US training may result in a wider scope of clinical applications by increasing operator confidence and is the preferred model within a specialist breast surgical curriculum.

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.

Cost minimization analysis of ultrasound-guided diagnostic evaluation of probably benign breast lesions

The objective of this study was to compare direct health care costs for two competing diagnostic strategies for probably benign breast lesions detected by ultrasound in young women. We developed a decision analytic model and performed a cost minimization analysis comparing ultrasound-guided vacuum-assisted core biopsy and conservative short-term diagnostic ultrasound follow-up. Relative probabilities for diagnostic outcomes were derived from pooled analysis of the medical literature. Direct health care costs were estimated using United States national average figures from calendar year 2010. Deterministic sensitivity analyses were conducted, as well as a first-order Monte Carlo simulation to confirm cost differences between the two strategies. The conservative short-term imaging follow-up strategy ($639.55 average cost per patient) was the most economical strategy compared to immediate vacuum-assisted core biopsy ($879.55 average cost per patient). Sensitivity analyses demonstrated that the preferred strategy is most dependent on the probabilities of detecting change in appearance on follow-up ultrasound, having a benign finding on immediate core biopsy, and finding cancer on a biopsy triggered by an interval change in ultrasound appearance. The model was also sensitive to the costs of vacuum-assisted core biopsy and diagnostic ultrasound. Conservative imaging follow-up of BIRADS 3 breast masses by ultrasound is cost saving compared to immediate vacuum-assisted core biopsy, with a potential of saving more than one-third of overall costs associated with the diagnostic work-up of such lesions. Watchful waiting with short-term interval follow-up ultrasounds will spare women from unnecessary procedures and spare the United States health care system from unnecessary direct health care costs.

Optimising surgical accuracy in palpable breast cancer with intra-operative breast ultrasound--feasibility and surgeons' learning curve

AIMS

To evaluate if intra-operative guidance with ultrasonography (US) could improve surgical accuracy of palpable breast cancer excision, and to evaluate the performance of surgeons during training for US-guided excision.

MATERIALS AND METHODS

Thirty female patients undergoing breast-conserving surgery for palpable T1-T2 invasive breast cancer were recruited. Three individual breast surgeons, assisted by US, targeted and excised the tumours. The main objective was to obtain adequate resection margins with optimal resection volumes. The specimen volume, tumour diameter and histological margin status were recorded. The specimen volume was divided by the optimal resection volume, defined as the spherical tumour volume plus a 1.0-cm margin. The resulting calculated resection ratio (CRR) indicated the amount of excess tissue resected.

RESULTS

All tumours were correctly identified during surgery, 29 of 30 tumours (96.7%) were removed with adequately negative margins, and one tumour was removed with focally positive margins. The median CRR was 1.0 (range, 0.4-2.8), implying optimal excision volume. For all breast surgeons, CRR improved during the training period. By the 8th procedure, all surgeons showed proficiency in performing intra-operative breast US.

CONCLUSION

Surgeons can easily learn the skills needed to perform intra-operative US for palpable breast tumour excision. The technique is non-invasive, simple, safe and effective for obtaining adequate resection margins. Within the first two cases, resections reached optimal volumes, thereby, presumably resulting in improved cosmetic outcomes. In a multicentre, randomised, clinical trial, intra-operative US guidance for palpable breast tumours will be evaluated for oncological and cosmetic outcomes.

Structured ultrasonography workshop for breast surgeons: is it an effective training tool?

BACKGROUND

Effective training is essential to ensure satisfactory performance in surgeon-performed ultrasonography (US) and guided breast needle biopsies (USGBB). This study aimed to determine the efficacy of conducting a structured workshop in the teaching of breast US application and in guided biopsy techniques.

METHODS

Consenting participants of the US for Surgeons Workshop at the General Surgeons Australia 2008 Annual Scientific Meeting were recruited. The workshop was divided into theoretical and practical components. For the theoretical component, brief pretests were administered, followed by lecture series, and then posttests. For the practical component, preinstructional USGBBs performed on breast phantoms and turkey breasts implanted with simulated lesions were assessed, followed by tutorials; it was concluded with postinstructional biopsy assessment. Points were deducted for simulated chest wall hits (complications). Previous experience and training in USBGG were recorded. Pre- and postlecture/instructional results were compared and the correlation tested using Student's t-test (p < 0.05).

RESULTS

In all, 14 participants were recruited: 71% had no to moderate experience with USGBB. For the theoretical component, 33% improvement over the pretest (p < 0.001) was seen across all levels of experience. For the practical component, there was 56% improvement after instruction (p = 0.001), which was most marked in the moderate experience group (83%, p = 0.03). Two complications were recorded for the least experienced group prior to instructions, but no complications were seen following instructions.

CONCLUSIONS

Structured workshops are effective for training surgeons in US application and USGBB and should be considered as part of standardized training guidelines and credentialing. Theory and practical components demonstrated similar efficacy and should be considered integral components in training programs. Formal training decreases complication rates, especially among the inexperienced.

Two-year follow-up of stereotactically guided 9-G breast biopsy: a multicenter evaluation of a self-contained vacuum-assisted device

PURPOSE

To evaluate the performance of a self-contained, battery-driven, vacuum-assisted breast biopsy (VABB) system for the sampling of clustered breast microcalcifications and masses under stereotactic guidance.

METHODS AND MATERIALS

A total of 144 patients (median age: 56 years; range: 21-87 years) in four European breast centers underwent percutaneous 9-gauge (G), stereotactic-guided VABB. The median lesion size was 11 mm (range 2-60 mm). Patients were biopsied in the prone (n=125) or upright position (n=19). All patients were followed up for at least 24 months.

RESULTS

The stereotactic procedure was successful in 142 (98.6%) of 144 cases, with two cases cancelled due to either severe patient motion (one case) or failure to detect faint calcifications (one case). A median of 12 specimens per procedure was obtained. In 39 cases (27.5%), the suspicious lesion could no longer be detected mammographically after the biopsy procedure. The histological diagnosis was malignancy in 45 (31.7%) cases. One case of atypical ductal hyperplasia diagnosed preoperatively was upgraded to ductal carcinoma in situ (DCIS) at operation, giving an overall sensitivity of 97.7% for the vacuum-assisted biopsy procedure. In two cases where DCIS was diagnosed at vacuum-assisted biopsy, the malignant tissue was apparently completely removed and could no longer be found at operation. No serious complications occurred. During the follow-up period, no breast cancers appeared at the location of biopsy. Six patients dropped out during the follow-up period.

CONCLUSION

The self-contained, vacuum-assisted biopsy device is well suited for stereotactically guided breast biopsies, having demonstrated excellent sensitivity and specificity in the preoperative workup of mammographically detected breast lesions after 2 years of follow-up.

The results of a structured diagnostic pathway designed to minimise the chance of breast cancer misdiagnosis

AIM

To describe results from a structured clinic pathway designed to minimise inaccuracies and diagnostic delays in the diagnosis of breast cancer.

METHODS

Patients referred to our breast clinic undergo clinical, imaging and biopsy assessment according to a standard protocol. Over 4 years, patients who were discharged with a benign diagnosis and later found to have breast cancer were reviewed.

RESULTS

A total of 4366 new referrals were seen in the symptomatic breast clinic and 571 (13%) new cancers were diagnosed. Fourteen of the new cancer patients had been seen in the clinic previously (range 7-48 months) and discharged with a benign diagnosis. None of these tumours appeared to result from misdiagnosis of a lesion previously assessed to be benign. The rate of development of cancer in the cohort discharged with a benign diagnosis was closely similar to that in the normal United Kingdom population.

CONCLUSIONS

A structured breast clinic pathway can produce a rate of diagnostic accuracy closely approaching 100%.

Ultrasound for accurate measurement of invasive breast cancer tumor size

Accurate presurgical assessment of tumor size is important for choosing appropriate treatment, especially with the increasing use of neoadjuvant and minimally invasive therapy. Breast sonography is increasingly used by breast surgeons as a part of their basic clinical evaluation. We undertook this study to compare clinical evaluation, mammography, and breast sonography for evaluating breast tumor size. A prospective analysis of 124 consecutive patients with palpable breast cancer was performed. Tumor masses belonging to T1 and small T2 were selectively selected. All women had clinical, mammographic, and sonographic assessment of tumor size. Measurements were compared to the pathologic tumor size of the surgical specimen. Both mammographic and sonographic measurements tend to underestimate tumor size, while clinical assessment tends to overestimate it. Ultrasound was significantly more accurate in determining tumor size. The maximal tumor diameter measured was within 2 mm of the pathologic tumor size in 45.2% of cases measured by breast ultrasound, 28.2% of cases measured by mammography, and 14.5% of cases measured clinically. These data suggest that ultrasound is more accurate than clinical breast examination and mammography in assessing breast cancer size. Ultrasound assessment should be used by surgeons as an accurate adjunct to clinical examination in outpatient breast clinics.

Magnetic Resonance-Guided Large-Core Breast Biopsy Inside a 1.5-T Magnetic Resonance Scanner Using an Automatic System

RATIONALE AND OBJECTIVE

The aim of this study was to investigate the feasibility and the precision of magnetic resonance (MR)-guided large-core breast biopsies (LCBB) by using the second prototype of an automatic system (ROBITOM II), which is used to localize lesions while operating at the isocenter of a 1.5-T whole-body scanner.

METHODS AND MATERIALS

In comparison to the first prototype, ROBITOM II is equipped with a dedicated double breast coil and a high-speed trocar setting unit. In vitro experiments (n = 25) with grapefruit phantoms, which contained multiple vitamin E capsules (12 x 7 mm in size) as artificial lesions, were performed. Four patients with MR-detectable breast lesions underwent biopsy. A trocar was positioned in front of the lesion and inserted into the breast. Specimens were harvested with a coaxial technique by using a 14-G core needle biopsy gun.

RESULTS

In all 25 in vitro experiments, capsule material was detected in the specimen cylinder. In 4 patients, the coaxial needle was detected exactly at the expected position. Between 8 and 16 tissue cylinders were harvested. Histologic evaluation resulted in 1 invasive ductal carcinoma and 1 papilloma, which were confirmed after open surgery. One patient who had a proven breast cancer was biopsied for exclusion of multifocal disease. She showed fibrocystic changes, whereas open surgery revealed 3 small areas of ductal carcinoma in situ (DCIS). Another patient showed fibroadenoma after biopsy. This patient is in the follow-up period, which has lasted between 3 and 4 months up until now.

CONCLUSIONS

In this pilot patient study, the feasibility of manipulator-assisted large-core breast biopsy inside a 1.5-T whole-body scanner was demonstrated by using ROBITOM II. The precision of the device was confirmed with in vitro experiments. Although these findings are preliminary and the follow-up period is rather short, they nevertheless represent a successful proof-of-principle of LCBB with ROBITOM II.