Evaluation of a Marker Clip System in Sonographically Guided Core Needle Biopsy for Breast Cancer Localization Before and After Neoadjuvant Chemotherapy

The Evaluation of a Cost-Effective Method for Tumour Marking Prior to Neo-Adjuvant Chemotherapy Using Silver Rods

Objective

The lack of objective documentation of pre-neoadjuvant chemotherapy (NAC) tumour margins is a major constraint in performing safe breast conserving surgery (BCS) in patients with breast cancer. Using a novel method of marking pre-NACT tumour margins with indigenous silver wire markers, this retrospective observational study attempted to assess the feasibility of safe BCS in breast cancer patients by performing excision wide of the marked pre-NACT margins.

Materials and Methods

This retrospective observational study was conducted on breast cancer patients who were attending our oncology centre between May, 2015 and April, 2022. All patients had received NAC followed by surgery as recommended by our multidisciplinary team. All the patients had a primary operable solitary breast cancer. We used radiopaque metallic rods made from silver to localize tumour margins prior to NAC.

Results

Sixty-four breast cancer patients were included; none had marker-related complications. Following NAC, BCS could be easily performed in 60 patients guided by the silver markers, which were used as temporary implants and removed during surgery. Only 2 patients were seen with positive margins and were converted to mastectomy.

Conclusion

Breast cancer localization using sterile silver markers before the initiation of NAC is safe, easy, inexpensive, and effective, causing no morbidity or significant pain to the patients.

Comparing Apparent Diffusion Coefficient and FNCLCC Grading to Improve Pretreatment Grading of Soft Tissue Sarcoma-A Translational Feasibility Study on Fusion Imaging

Simple Summary

Histological subtype and grading are essential for the planning of soft tissue sarcoma. Pretherapeutic grading based on core needle biopsies is frequently not reliable due to intratumoral heterogeneity. This pilot study assessed the ability of functional radiological imaging to improve histopathological grading. Multiple biopsies were taken from the sarcoma specimens during tumor resection and radiopaque markers were placed. Subsequently, fusion of preoperative magnetic resonance imaging and postoperative computed tomography of the specimen allowed for comparison of histopathological grading and diffusion-weighted imaging. The apparent diffusion coefficient appears to correlate with FNCLCC criteria and may supplement pretreatment assessment and multimodal treatment allocation in soft tissue sarcoma.

Abstract

Histological subtype and grading are cornerstones of treatment decisions in soft tissue sarcoma (STS). Due to intratumoral heterogeneity, pretreatment grading assessment is frequently unreliable and may be improved through functional imaging. In this pilot study, 12 patients with histologically confirmed STS were included. Preoperative functional magnetic resonance imaging was fused with a computed tomography scan of the resected specimen after collecting core needle biopsies and placing radiopaque markers at distinct tumor sites. The Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) grading criteria of the biopsies and apparent diffusion coefficients (ADCs) of the biopsy sites were correlated. Concordance in grading between the specimen and at least one biopsy was achieved in 9 of 11 cases (81.8%). In 7 of 12 cases, fusion imaging was feasible without relevant contour deviation. Functional analysis revealed a tendency for high-grade regions (Grade 2/3 (G2/G3)) (median (range) ± standard deviation: 1.13 (0.78–1.70) ± 0.23 × 10⁻³ mm²/s) to have lower ADC values than low-grade regions (G1; 1.43 (0.64–2.03) ± 0.46 × 10⁻³ mm²/s). In addition, FNCLCC scoring of multiple tumor biopsies proved intratumoral heterogeneity as expected. The ADC appears to correlate with the FNCLCC grading criteria. Further studies are needed to determine whether functional imaging may supplement histopathological grading.

Surgery after Neoadjuvant Chemotherapy: A Clip-Based Technique to Improve Surgical Outcomes, a Single-Center Experience

BACKGROUND

This study aims to describe the surgical management of breast cancer patients after neoadjuvant chemotherapy, with attention to the impact on surgical outcomes of a clip-based marking technique.

METHODS

Patients who underwent NACT at the Breast Unit of the A. O Ordine Mauriziano of Turin from January 2018 and had a surgical intervention by January 2022 were included. Data on the feasibility of clip insertion, after-treatment visibility, and successful removal during surgery were collected prospectively. Surgical outcomes in terms of breast-conserving surgery and axillary dissection reduction were described.

RESULTS

In 51 patients who had surgery after NACT, 55 clips were placed (34 breast and 21 axillary clips). Ultrasound visibility of the clips was optimal (91%) as well as preoperative localization and retrieval within the surgical specimen. Moreover, the use of the clip positively affected surgical outcomes. In our study, clip insertion allowed to avoid mastectomy and axillary dissection in patients with a complete radiological response.

CONCLUSIONS

In our findings, the use of breast and/or lymph node clips has proved to be a simple and effective method to improve surgical conservative management of breast cancer patients after NACT.

Application of ultrasound-guided placement of markers for locating axillary lymph nodes of breast cancer

BACKGROUND

With the continuous improvement of pathological complete response (pCR) rate after neoadjuvant therapy (NAT), it is necessary to locate the tumor bed and axillary lymph nodes (ALNs) for subsequent surgery. Therefore, breast tissue markers emerge. This study aims to evaluate the feasibility and accuracy of ultrasound (US)-guided placement of markers for locating ALNs of breast cancer.

METHODS

A total of 285 patients who received US-guided placement of markers for locating ALNs in our hospital were selected. Among these patients, 87 patients were in the early breast cancer (EBC) group with negative ALNs and 198 ones were in the NAT group with positive ALNs. Data including the basic information of patients, position and size of ALN, process of US-guided marker placement, placement success rate, complications, detection rate of marker by imaging, and shift rate were recorded.

RESULTS

All patients were successfully undergone US-guided marker placement. And the average operation time was 2 minutes with no adverse reactions. All the patients underwent surgery successfully. US, computer tomography (CT) and magnetic resonance imaging (MRI) were used to detect the marker. The detection rate of markers by US and CT/MRI were 100% (87/87) in EBC group, and 98.5% (195/198) and 100% (198/198) by US and CT/MRI, respectively, in NAT group. The postoperative marker shift rate was 2.1% (6/285), including 3.4% (3/87) marker shift rate in EBC group and 1.5% (3/198) in NAT group, with no statistically significant difference between them.

CONCLUSIONS

US-guided marker placement in ALNs of breast cancer is simple and safe, with firm positioning and low shift rate, which is convenient for clinical promotion.

Comparison of resection margin status after single or double radiopaque marker insertion for tumor localization in breast cancer patients receiving neoadjuvant chemotherapy

PURPOSE

Insertion of radiopaque markers is helpful for tumor localization in patients receiving neoadjuvant chemotherapy (NAC) followed by breast-conserving surgery (BCS). The aim of this retrospective study was to investigate the pathologic margin status in patients with single or double marker insertion.

METHODS

We reviewed the records of 130 patients with marker insertion prior to NAC followed by BCS from January 2016 to September 2019. Under ultrasonography guidance, single or double markers were inserted to localize a tumor in the breast. The incidence of additional resection after frozen biopsy and re-excision after permanent pathologic diagnosis was analyzed.

RESULTS

In a total of 130 patients, 104 had a single marker in the center of the tumor and 26 had double markers at the periphery of the tumor before NAC. Among 69 patients with residual invasive tumors after NAC, there was no difference in the additional resection rate after frozen biopsy (single vs. double markers; 14.3% vs. 38.5%, P = .059) or the re-excision rate after final pathologic diagnosis (0% vs. 7.7%, P = .188). After propensity score matching for tumor size and subtypes, the two groups showed no differences in the additional resection rate after frozen biopsy (7.7% vs. 19.2%, P = .139) or the re-excision rate (0% vs. 3.8%, P = .308). After a median follow-up of 19 months (range 8-48 months), local recurrence-free survival did not differ between the two groups (log-rank P = .456).

CONCLUSIONS

Number of inserted markers for tumor localization did not affect the pathologic margin status after BCS.

Analysis of Oncological Second Opinions in a Certified University Breast and Gynecological Cancer Center Regarding Consensus between the First and Second Opinion and Conformity with the Guidelines

Introduction

Oncological second opinions are becoming increasingly important in the era of complex treatments and established certified cancer centers. Oncological guidelines with the highest levels of evidence are available, but these can only be effective to the extent that they are implemented. Therefore, we analyzed the effects of second opinions with regard to their agreement with first opinions and conformity with guidelines.

Methods

In 164 patients with a diagnosis of breast cancer or gynecological malignancy who requested a second opinion, the first and second opinions, established at the interdisciplinary tumor conference, and conformity with the guidelines were evaluated.

Results

The first opinion was not in agreement with the guidelines in 34.8% (15.2% diagnosis, 12.8% surgical therapy, 13.4% systemic therapy, and 5.5% radiotherapy), and the recommendations were optimized in the second opinion in 56.7% (28.7% diagnosis, 15.9% surgical therapy, 30.5% systemic therapy, and 8.5% radiotherapy).

Conclusions

Oncological second opinions showed significant effects and one-third of first opinions were not in conformity with the guidelines. In a significant proportion of cases, the existing treatment plan was changed or supplemented to allow modern and individualized treatment approaches.

Injectable Biodegradable Multimodal Mammography Marker

Introducing temporary markers for imaging studies is an idea, which in the proper clinical settings can be advantageous for patient compliance and in selected cases where a permanent marker is nondesirable. Hence, we developed injectable marker formulation using a biodegradable "pasty polymer" of poly(ricinoleic acid-co-sebacic acid) (PSA:RA) containing iodixanol and iron oxide as contrast agents that can serve as a visual marker for the region suspected to have tumor growth. The goal of this work is to noninvasively evaluate the visibility, shape, and degradation of the injectable PSA:RA formulation using magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound (US). Prescreening of the marker formulation was performed under MRI and CT scanning using agar gel phantom models with poly(l-lactide-co-ε-caprolactone) (PCL:LA) solid inserts (clips) that contained varying combinations of the contrast agents. The contrast agent combination with the PCL:LA clip that had the best visibility in both MRI and CT was selected and additionally tested as in PSA:RA formulation. Further, we evaluated the PSA:RA marker placement in bovine liver and poultry muscles. The PSA:RA formulation is predictable with good MRI, CT, and US visibility and shows no in vivo systemic toxicity symptoms when implanted subcutaneously in mice. Further, the advantage of PSA:RA formulation is its undefined shape and ease of injecting through a small gauge needle, making it possible to reach into the regions of the body.

Cost effectiveness of bilateral risk-reducing mastectomy and salpingo-oophorectomy

Background

Growing demand for risk-reducing surgery in individuals with inherited susceptibility to cancer leads to the question whether these procedures are cost effective for the executing hospitals. This study compared the clinical costs for bilateral risk-reducing mastectomy (BRRM) with and without different types of reconstruction, risk-reducing salpingo-oophorectomy (RRSO), and their combinations with corresponding reimbursements in the statutory health-care system in Germany.

Patients and methods

Real total costs of care for BRRM with and without reconstruction, RRSO, and their combinations were calculated as the sum of all personnel and technical costs. These costs calculated in a German University hospital were compared with the sum of all reimbursements in the German DRG-based health-care system.

Results

While sole RRSO, BRRM without reconstruction, and BRRM with secondary DIEP (deep inferior epigastric perforator)—reconstruction still result in a small benefit, we even found shortfalls for the hospital with all other prophylactic operations under consideration. The calculated deficits were especially high for BRRM with implant-based breast reconstruction and for combined operations when the risk reduction is achieved with a minimum of separate operations.

Conclusions

Risk-reducing surgery in BRCA-mutation carriers is frequently not cost-covering for the executing hospitals in the German health-care system. Thus, appropriate concepts are required to ensure a nationwide care.

Surgical Management of Breast Cancer Treated with Neoadjuvant Therapy

Neoadjuvant therapy (NAT) allows downstaging in some cases of breast cancer. By consequence, it may enable a more conservative surgical approach or make surgery possible in cases ineligible for surgery before NAT. In this article, we review the evidence and management recommendations for optimal surgical treatment in this setting.

Using a New Marker Clip System in Breast Cancer: Tumark Vision® Clip - Feasibility Testing in Everyday Clinical Practice

Background

This study presents first feasibility experiences with a new 3-dimensional (3D) marker clip system in clinical practice. The rate of clinical complete responses in the treatment of breast cancer patients is increasing; additionally, a change to targeted axillary dissection is being considered after neoadjuvant chemotherapy (NACT). Consequently, marker clips are needed which are reliable and easy to handle even in the axillary lymph node system.

Methods

A total of 50 patients from the Breast Care Unit of the Kliniken Essen Mitte were included. Clip marking of all 50 primary breast cancer lesions as well as 23 lymph nodes was performed using the Tumark Vision® clip. Following application, the position and visibility of the marker clip were monitored and documented in 2 axes.

Results

The feasibility of the Tumark Vision clip was excellent in everyday clinical practice as none of the markers dislocated. After clip marking of the tumor region and/or suspicious lymph nodes, all Tumark Vision clips could be detected in both axes. The 3D shape could be observed in all cases after application.

Conclusion

The new 3D-shaped marker clip seems to be a promising tool for marking breast cancer lesions and even lymph nodes before NACT. As there are many studies ongoing to prove the feasibility of a shift from standard axillary dissection after NACT towards targeted axillary dissection, the Tumark Vision clip seems to provide good visibility even in lymph nodes after NACT. Further studies are warranted.