Wire- and magnetic-seed-guided localization of impalpable breast lesions: iBRA-NET localisation study

SCOUT® radar reflectors for impalpable lesion localisation in the breast and axilla: our experience in the first 500 patients

AIM

This study aimed to detail our experience of using SCOUT® radar reflector for lesion localisation in the breast and axilla.

MATERIALS AND METHODS

This is a prospective cohort study describing our clinical experience with the first 500 patients who received SCOUT® to localise lesions in the breast and axilla (from 23 July 2020 to 4 April 2022). Study measures include patient demographics, lesion location, diagnostic pathways (screening or symptomatic), imaging, and surgical and pathology outcomes.

RESULTS

Of the 500 patients, most patients (n = 424; 84.8%) had a single device inserted. A total of 361 had SCOUT® inserted under ultrasound guidance, 128 under stereotactic guidance, and 11 under dual mammographic and ultrasonographic guidance. We successfully inserted SCOUT® in 33 patients for lymph node identification for potential targeted axillary dissection. The mean time between SCOUT® insertion and the planned surgical procedure was 40.6 days.

CONCLUSION

Our results suggest that SCOUT® is a promising preoperative localisation device for nonpalpable breast and axillary lesions. Its implementation has the potential to optimise the clinical workflow by eliminating the need for a separate localisation procedure using conventional localisation markers and streamlining the treatment pathway.

Reflector-guided localization compared with wire-guided localization for non-palpable breast cancer resection: organizational impacts and costs analysis

BACKGROUND

Wire-guided localization (WGL) for non-palpable breast cancer lesions has drawbacks like wire migration, localization difficulties, and logistical challenges. Wireless methods, such as reflector-guided localization (RGL), address these issues and are compatible with breast MRI. This study evaluates the organizational and cost impacts of RGL compared to WGL.

RESEARCH DESIGN AND METHODS

Our retrospective study compared the organizational impacts and costs of RGL and WGL at a university hospital. Quantitative and qualitative assessments included operating time and a questionnaire for surgeons and radiologists. Cost analysis covered device costs.

RESULTS

The study involved 60 patients (30 with RGL and 30 with WGL). The RGL group had a significantly longer duration between device insertion and surgery (3.73 ± 5.5 days) compared to the WGL group (same day or day before surgery). The WGL group required more devices whereas cost were higher for RGL. Health professionals reported a major positive impact of RGL on healthcare processes and safety, with minor negative impact on training.

CONCLUSIONS

RGL offers flexible scheduling by decoupling radiology and surgery but is limited by high costs. Further data is needed to identify ideal candidates, assess patient satisfaction, and evaluate its long-term benefits in breast cancer care.

Breast and axillary marking in the neoadjuvant setting: survey results from experts of the Brazilian society of mastology

Introduction/objectives

The precise location of the tumor site is essential for the success of surgical treatment. Neoadjuvant chemotherapy (NAC) is a challenge for preoperative tumor and node localization. Thus, the knowledge and attitudes of the affiliated members of the Brazilian Society of Mastology (SBM) regarding breast and axilla marking were evaluated and a consensus regarding management and treatment was reached.

Methods

This was an online survey conducted between June and December 2022. All 1,742 active mastologists affiliated to the SBM were invited anonymously. The online form contained 28 objective questions, of which 22 were formulated on a Likert scale. These questions addressed relevant aspects related to breast and axilla marking in the neoadjuvant setting. Responses that reached 70% agreement were considered consensual. Statistical analysis was performed using the SPSS program version 26.0. Post hoc analysis was performed when appropriate and the significance level was set at p < 0.05. Polychoric regression analyses were conducted using `VGAM` package.

Results

In total, 468 mastologists answered the questionnaire (26.8%), with a predominance of professionals aged between 40-49 years (32.1%). Most professionals were board-certified (84,8%). The indication of tumor marking in the breast prior to NAC was consensual (96.4%) and the metal clip was the preferred method (69.7%). There was no consensus regarding the indication of pre-NAC histologically positive lymph node marking (49.8% disagree and 42.8% agree). However, there was consensus that the clinical and imaging evaluation was insufficient for staging the axilla as N1 (71.6%). The contraindication of breast and node marking in T4b tumors (71.2%) was consensual. There was consensus on the indication of sentinel lymph node biopsy (SLNB) for initially cN1 (92.3%) or cN2 (72.7%) tumors that became cN0 after NAC, with 67.5% opting for dual staining with technetium and patent blue. When <3 lymph nodes were retrieved 41.0% of mastologists performed axillary lymphadenectomy. Among the 28 questions, consensus was reached on only 11 (39.3%).

Conclusion

The indication of pre-NAC breast marking is consensual among Brazilian mastologists, although axillary nodal marking is not. There is a great divergence of attitudes among Brazilian surgeons in relation to the many issues related to pre-NAC breast and axilla marking.

Surgical marker navigation system in breast conserving surgery and excision of non-palpable lesions: first Spanish single-center experience

BACKGROUND

Due to the establishment of screening mammography for breast cancer detection, the number of non-palpable lesions has increased. Thus, an optimal localization system is mandatory for the excision of non-palpable breast tumors.

OBJECTIVE

The aim of the study is to report the feasibility Surgical Marker Navigation (SMN) system Sirius Pintuition® for the excision of non-palpable breast tumors and non-palpable axillary lymph nodes.

METHODS

A retrospective observational study of patients undergoing breast-conserving surgery and lymph node excision guided by SMN between December 2022 and May 2023 was performed.

RESULTS

A total of 84 patients underwent excision of non-palpable breast tumors (77; 91.7%) or non-palpable axillary lymph-nodes (7; 8.3%) using SMN. In total, 94 markers were placed, in 74 patients (88.1%) only one marker was placed, whereas in 10 patients (11.9%) two markers were placed to correctly localize the lesion in the operating room. Most markers were placed using ultrasonographic guidance (69; 82.1%). Seventy-seven patients underwent breast-conserving surgery (91.7%) and 7 (8.3%) lymph node excision. In 10 cases (11.9%), the marker was accidentally displaced during surgery due to the use of magnetized instruments, although the specimen could be removed. In sum, all the markers were removed from the patients, although the marker retrieval rate, as we defined it (percentage of patients in whom the initial excised specimen contained the marker divided by the total number of patients), was 88.1%.

CONCLUSION

The use of Sirius Pintuition® SMN for non-palpable breast tumors and non-palpable lymph nodes is feasible, with a retrieval rate of 88.1%.

Non-palpable breast lesions localization techniques - A new priority: Results of a Senonetwork survey among breast centers in Italy

INTRODUCTION

Non palpable breast tumors are increasingly diagnosed because of screening programs, and their localization during surgery is essential to ensure an adequate resection. Little is known regarding which techniques are used in "real world".

MATERIALS AND METHODS

A national web-based survey, with a 21-items questionnaire, was conducted among Breast Centers (BCs) in Italy in 2023.

RESULTS

Among 153 BCs, 110 (72 %) participated. Wire-guided localization was reported to be the most used technique, regardless of the volume of malignant tumors treated by each Center (N = 36, 33 %). However, newer techniques such as Radioactive occult lesion localization and magnetic seeds, were reported to be employed in 34 (31 %) BCs, and more often among high-volume BCs (>300 cases/year) (N = 32, 29 % vs. N = 13, 12 %; p = 0.02). Logistic problems of localization were reported to cause delays to the scheduled surgery at least once or in multiple occasions in 26 (24 %) and in 4 (3.5 %) BCs, respectively. Although the majority of BCs declared they were satisfied (N = 48, 44 %) or somewhat satisfied (N = 41, 37 %) with the procedure used in their center, responders stated that they would change their technique, or that they were strongly considering this possibility in 24 (22 %) and in 38 (35 %) cases, respectively. The main barrier to introducing a new technique was associated with procedure costs (90 BCs, 82 %).

CONCLUSIONS

There are several critical issues regarding localization techniques at a national level. This should be recognized as a priority because of its impact on both patients and clinical practices.

The Effect of Wire Versus Magnetic Seed Localization on Lumpectomy Cavity Size

PURPOSE

Our purpose was to assess whether an association exists between surgical localization technique and lumpectomy cavity size on radiation therapy planning computed tomography (CT) scan.

METHODS AND MATERIALS

A single-institution retrospective review was conducted of women undergoing breast conserving surgery with wire or magnetic seed guided lumpectomy followed by adjuvant radiation therapy from 2018 to 2021. Patients of a surgeon only performing 1 localization technique or undergoing bracketed localization were excluded. The primary outcome was lumpectomy cavity size on simulation CT. Confounding due to imbalance in patient and tumor factors was addressed with overlap weights derived from a propensity score analysis and used in a weighted multivariable analysis. Secondary outcomes included positive margins, total pathologic volume, boost delivery, and boost modality.

RESULTS

Of 617 women who received lumpectomy during the study period, 387 were included in final analysis. Tumors of patients undergoing seed localization were more likely unifocal, assessable by ultrasound, and smaller. Seed use rates ranged from 27.7% to 70.7% per surgeon. There was no difference in positive margins (6.4 vs 5.4%, P = .79) or second surgeries (9.4 vs 8.1%, P = .79) between groups. Close margin rates were similar for ductal carcinoma in situ (P = .35) and invasive carcinoma (P = .97). In unadjusted bivariable analyses, wire localization was associated with larger total pathology volume (P = .004), but localization technique showed no association with CT cavity volume (P = .15). After adjusting for potentially confounding variables, multivariable analysis failed to show an association between localization technique and either CT cavity (P = .35) or total path volume (P = .08). There was no difference in indicated-boost delivery (P = .15) or electron boost (P = .14) by localization technique.

CONCLUSIONS

There was no significant difference in CT cavity size by localization technique, suggesting choice between surgical techniques does not impede radiation therapy boost delivery.

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.

Magnetic Seed vs Guidewire Breast Cancer Localization With Magnetic Lymph Node Detection: A Randomized Clinical Trial

Importance

Guidewires have been the standard for breast lesion localization but pose operative and logistic challenges. Paramagnetic seeds have shown promising results, but to the authors' knowledge, no randomized comparison has been performed.

Objective

To determine whether the combination of a paramagnetic seed and superparamagnetic iron oxide (SPIO) is equivalent to guidewire and SPIO for breast cancer localization and sentinel lymph node detection (SLND).

Design, Setting, and Participants

This was a phase 3, pragmatic, equivalence, 2-arm, open-label, randomized clinical trial conducted at 3 university and/or community hospitals in Sweden from May 2018 to May 2022. Included in the study were patients with early breast cancer planned for breast conservation and SLND. Study data were analyzed July to November 2022.

Interventions

Participants were randomly assigned 1:1 to a paramagnetic seed or a guidewire. All patients underwent SLND with SPIO.

Main Outcomes and Measures

Re-excision rate and resection ratio (defined as actual resection volume / optimal resection volume).

Results

A total of 426 women (median [IQR] age, 65 [56-71] years; median [IQR] tumor size, 11 [8-15] mm) were included in the study. The re-excision rate was 2.90% (95% CI, 1.60%-4.80%), and the median (IQR) resection ratio was 1.96 (1.15-3.44). No differences were found between the guidewire and the seed in re-excisions (6 of 211 [2.84%] vs 6 of 209 [2.87%]; difference, -0.03%; 95% CI, -3.20% to 3.20%; P = .99) or resection ratio (median, 1.93; IQR, 1.18-3.43 vs median, 2.01; IQR, 1.11-3.47; P = .70). Overall SLN detection was 98.6% (95% CI, 97.1%-99.4%) with no differences between arms (203 of 207 [98.1%] vs 204 of 206 [99.0%]; difference, -0.9%; 95% CI, -3.6% to 1.8%; P = .72). More failed localizations occurred with the guidewire (21 of 208 [10.1%] vs 4 of 215 [1.9%]; difference, 8.2%; 95% CI, 3.3%-13.2%; P < .001). Median (IQR) time to specimen excision was shorter for the seed (15 [10-22] minutes vs 18 [12-30] minutes; P = .01), as was the total operative time (69 [56-86] minutes vs 75.5 [59-101] minutes; P = .03). The experience of surgeons, radiologists, and surgical coordinators was better with the seed.

Conclusions and Relevance

The combination of SPIO and a paramagnetic seed performed comparably with SPIO and guidewire for breast cancer conserving surgery and resulted in more successful localizations, shorter operative times, and better experience.

Trial Registration

ISRCTN.org Identifier: ISRCTN11914537.

The association of breast surgery ASPIRE: breast pain pathway rapid evaluation project - study protocol

Background

Breast pain accounts for 20-40% of new referrals to breast units in the UK and these patients have a very low risk of breast cancer. Patients have previously been assessed in resource-intensive, cancer-exclusion, one stop clinics, which are now failing to meet government targets due to excessive demand. UK Breast units are increasingly piloting Breast Pain-only Pathways (BPP) to assess these patients, and there is no consensus for the optimal pathway. The aim of this prospective multicentre study is to assess the safety and patient satisfaction of different BPPs to inform future BPP design and implementation.

Methods

All UK breast units will be invited to join the ASPIRE study between January 2023 and December 2023. Units with a BPP are invited to submit their pathway for evaluation; and those without a BPP who see patients with breast pain-only in a one stop clinics setting are also invited to join the study to evaluate the traditional pathway model concurrently. Patient satisfaction assessments will be collected after their initial consultation and patient outcomes, including subsequent cancer diagnosis, will be followed up at 12 months to determine if they have cancer diagnosis after discharge to assess pathway safety.

Wire- and radiofrequency identification tag-guided localization of impalpable breast lesions: iBRA-NET localization study

A national cohort ideal stage 2a/2b study comparing the safety and effectiveness of Wire- and RFID -guided localisation for impalpable breast lesions.

Breast-Conserving Surgery Guided with Magnetic Seeds vs. Wires: A Single-Institution Experience

PURPOSE

The aim of this study is to describe our initial experience using magnetic seeds (Magseed®) to guide breast-conserving surgery in non-palpable breast lesions and compare the use of magnetic seed with wires to guide breast-conserving surgery in terms of clinical and pathological characteristics.

METHODS

We performed a retrospective study including all breast-conserving surgeries for non-palpable breast lesions under 16 mm from June 2018 to May 2021. We compared breast-conserving surgeries guided with magnetic seeds (Magseed®) to those guided with wires, analyzing tumor and patient characteristics, surgical time, and pathological results of the surgical specimens.

RESULTS

Data from 225 cases were collected, including 149 cases guided by magnetic seeds and 76 cases guided by wires. The breast lesion was localized in every case. Both cohorts were similar regarding clinical and pathological characteristics. We found significant statistical differences (p < 0.02) in terms of the median volume (cm3) of the excised specimen, which was lower (29.3%) in the magnetic seed group compared with the wire group (32.5 [20.5-60.0]/46.0 [20.3-118.7]). We did not find significant differences regarding surgical time (min) or the affected or close margins.

CONCLUSION

In our experience, the use of magnetic seed (Magseed®) is a feasible option to guide breast-conserving surgery of non-palpable lesions and enabled us to resect less breast tissue.

Locoregional Therapy: From Mastectomy to Reconstruction, Targeted Surgery, and Ultra-Hypofractionated Radiotherapy

Background

The past 3 decades have seen an unprecedented shift toward treatment de-escalation in surgical therapy of breast cancer.

Summary

Radical mastectomy has been replaced by breast-conserving and oncoplastic approaches in most patients, and full axillary lymph node dissection by less radical staging procedures, such as sentinel lymph node biopsy and targeted axillary dissection. Further, attempts have been made to spare healthy tissue while increasing the probability of removing the tumor with clear margins, thus improving cosmetic results and minimizing the risk of local recurrence. In this context, modern probe-guided localization techniques have been introduced to guide surgical excision. This progress was accompanied by the development of targeted systemic therapies. At the same time, radiotherapy for breast cancer has undergone significant changes. The use of hypofractionation has decreased the typical length of a treatment course from 5-6 weeks to 1-3 weeks. Partial breast irradiation is now a valid option for de-escalation in patients with low-risk features. Axillary radiotherapy achieves similar recurrence rates and decreases the risk of lymphedema in patients with limited sentinel node involvement.

Key Messages

Taken together, these advances are important steps toward individualization of locoregional management strategies. This highlights the importance of interdisciplinary approaches for de-escalation of locoregional therapies.

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.

Radio-frequency identification (RFID) tag localisation of non-palpable breast lesions a single centre experience

AIM

The purpose of this study is to report the surgical experience and outcomes with pre-operative localisation of non-palpable breast lesions using the RFID tag system.

METHODS

The cohort for this prospective study included patients over the age of 18 with biopsy proven, non-palpable indeterminate lesions, DCIS or breast cancer requiring pre-operative localisation before surgical excision between September 2020 and July 2022.

RESULTS

A total of 312 RFID tags were placed in 299 consecutive patients. Indications for localisation included non-palpable invasive cancer in 255 (85.3%) patients, in situ disease in 38 (12.7%) and indeterminate lesions requiring surgical excision in 6 (2.0%). Both in situ and invasive lesions had a median size of 13 mm (range 4-100 mm) on pre-operative imaging. The RFID tags were in situ for a median time of 21 days before surgery (range 0-233 days). Of the 213 tags, 292 (93.6%) were introduced using ultrasound (USS) guidance and stereotactically in 20 (6.4%). In 3 (1.0%) cases the RFID tag was either not satisfactorily deployed at the intended target or retrieved intra-operatively. Following discussion of post-operative histology by the multi-disciplinary team, further surgery for close or involved margins was for 26 (8.7%) patients.

CONCLUSION

The Hologic RFID tag system can be used for accurate pre-operative localisation of non-palpable masses as well as diffuse abnormalities such as mammographic distortions and calcifications. It has advantages of flexibility for scheduling image-guided insertion independently of scheduled operating lists and can be placed to localise lesions prior to initiating neoadjuvant systemic treatment.

Clinical experience of the Magseed® magnetic marker to localize non-palpable breast lesions: a cohort study of 100 consecutive cases

Background

The aim of this study was to report on a cohort of 100 patients where the Magseed® paramagnetic marker was used to localize non-palpable breast lesions.

Methods

Data were collected from a cohort of 100 patients with non-palpable breast lesions, who underwent localization using the Magseed® marker. This marker consists of a paramagnetic seed that can be seen on mammography or ultrasound and intraoperatively detected with the use of the Sentimag® probe. The data were collected over a period of 23 months (May 2019 to April 2021).

Results

All 111 seeds were successfully placed in the breasts of 100 patients under ultrasound or via stereotactic guidance. Eighty-nine seeds were inserted in single lesions or small microcalcification clusters in a single breast, 12 seeds were deployed to a bracket microcalcification clusters and 10 to help localize two tumors within the same breast. Most Magseed® markers (88.3%) were placed in the center of the lesion (≤1 mm). The re-excision rate was 5%. All Magseed® markers were successfully retrieved and no surgical complications were observed.

Conclusions

This study reports our experience in a Belgian breast unit using the Magseed® magnetic marker and it highlights the many advantages of the Magseed® marker system. With this system, we successfully identified subclinical breast lesions and extended microcalcification clusters, targeting multiple sites within the same breast.

Wire-Free, Nonradioactive Localization Techniques to Guide Surgical Excision of Nonpalpable Breast Tumours: A Health Technology Assessment

Background

The current standard treatment for nonpalpable breast tumours is surgical excision; however, it is nearly impossible to locate these small masses during surgery. Therefore, a marker must be implanted into the abnormal tissue under mammography or ultrasound guidance prior to surgery to guide the surgeon to the location of the tumour. Two techniques to localize nonpalpable breast tumours are currently used in Ontario: wire-guided localization and radioactive seed localization.However, these techniques have some limitations. New wire-free, nonradioactive technologies that address these limitations are now available. We conducted a health technology assessment of wire-free, nonradioactive localization techniques available in Canada that are used to localize nonpalpable breast tumours for surgical excision. This report includes an evaluation of the effectiveness, safety, and budget impact of publicly funding these techniques, as well as an evaluation of patient preferences and values.

Methods

We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the ROBINS-I tool and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature search, and we analyzed the budget impact of publicly funding wire-free, nonradioactive localization techniques to guide surgical excision of nonpalpable breast tumours in Ontario. We did not conduct a primary economic evaluation because of the limited data available to use as model inputs. To contextualize the potential value of wire-free, nonradioactive localization techniques, we spoke with people who had undergone a localization procedure for the surgical excision of a nonpalpable breast tumour.

Results

We included 16 studies in the clinical evidence review, of which 15 were comparative studies and one was a single-arm study. The results of our analysis of the comparative studies suggest that the re-excision rate for the wire-guided, nonradioactive devices included in this review is either lower or not different from the rate for conventional localization methods (GRADE: Moderate/Low). We found no difference in postoperative complications or operation time between the new and the conventional techniques (GRADE: Moderate). In a feasibility study of a newly developed magnetic seed device in Ontario, no patient required re-excision (GRADE: not assessed). Our economic evidence review identified two costing studies that found that wire-free, nonradioactive localization techniques were more expensive than wire-guided and radioactive seed localization. We were unable to identify any published cost-effectiveness evidence for wire-free, nonradioactive localization techniques. The annual budget impact of publicly funding wire-free, nonradioactive localization techniques in Ontario over the next 5 years ranges from an additional $0.51 million in year 1 to an additional $2.61 million in year 5, for a total 5-year budget impact of $7.73 million. The people we spoke with who had undergone a localization procedure reported valuing surgical interventions that are clinically effective, timely, and patient centred. They responded positively to the potential public funding of wire-free, nonradioactive localization techniques and felt that equitable access should be a requirement of implementation.

Conclusions

The wire-free, nonradioactive localization techniques included in this review are effective and safe methods for the localization of nonpalpable breast tumours and are reasonable alternatives to wire-guided and radioactive seed localization. We estimate that publicly funding wire-free, nonradioactive localization techniques in Ontario would result in an additional cost of $7.73 million over the next 5 years. Broad access to wire-free, nonradioactive localization techniques may have a positive impact on patients undergoing surgical excision for a nonpalpable breast tumour. People with lived experience of a localization procedure value surgical interventions that are clinically effective, timely, and patient centred. They also value equitable access to surgical care.

Innovations and Challenges in Breast Cancer Care: A Review

Breast cancer care has seen tremendous advancements in recent years through various innovations to improve early detection, diagnosis, treatment, and survival. These innovations include advancements in imaging techniques, minimally invasive surgical techniques, targeted therapies and personalized medicine, radiation therapy, and multidisciplinary care. It is essential to recognize that challenges and limitations exist while significant advancements in breast cancer care exist. Continued research, advocacy, and efforts to address these challenges are necessary to make these innovations accessible to all patients while carefully considering and managing the ethical, social, and practical implications.

Bridging pre-surgical endocrine therapy for breast cancer during the COVID-19 pandemic: outcomes from the B-MaP-C study

PURPOSE

The B-MaP-C study investigated changes to breast cancer care that were necessitated by the COVID-19 pandemic. Here we present a follow-up analysis of those patients commenced on bridging endocrine therapy (BrET), whilst they were awaiting surgery due to reprioritisation of resources.

METHODS

This multicentre, multinational cohort study recruited 6045 patients from the UK, Spain and Portugal during the peak pandemic period (Feb-July 2020). Patients on BrET were followed up to investigate the duration of, and response to, BrET. This included changes in tumour size to reflect downstaging potential, and changes in cellular proliferation (Ki67), as a marker of prognosis.

RESULTS

1094 patients were prescribed BrET, over a median period of 53 days (IQR 32-81 days). The majority of patients (95.6%) had strong ER expression (Allred score 7-8/8). Very few patients required expedited surgery, due to lack of response (1.2%) or due to lack of tolerance/compliance (0.8%). There were small reductions in median tumour size after 3 months' treatment duration; median of 4 mm [IQR - 20, 4]. In a small subset of patients (n = 47), a drop in cellular proliferation (Ki67) occurred in 26 patients (55%), from high (Ki67 ≥ 10%) to low (< 10%), with at least one month's duration of BrET.

DISCUSSION

This study describes real-world usage of pre-operative endocrine therapy as necessitated by the pandemic. BrET was found to be tolerable and safe. The data support short-term (≤ 3 months) usage of pre-operative endocrine therapy. Longer-term use should be investigated in future trials.

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.

Results of shared learning of a new magnetic seed localisation device - A UK iBRA-NET breast cancer localisation study

INTRODUCTION

Shared learning is imperative in the assessment and safe implementation of new healthcare interventions. Magnetic seeds (Magseed®) potentially offer logistical benefit over wire localisation for non-palpable breast lesions but few data exist on outcomes comparing these techniques. A national registration study (iBRA-NET) was conducted to collate device outcomes. In order to share learning, thematic analysis was conducted to ascertain early clinical experiences of Magseed® and wire guided localisation and explore how learning events may be applied to improve clinical outcomes.

METHODS

A qualitative study of 27 oncoplastic surgeons, radiologists and physicians was conducted in January 2020 to ascertain the feasibility and challenges associated with Magseed® versus wire breast localisation surgery. Four focus groups were asked to discuss experiences, concerns and shared learning outcomes which were tabulated and analysed thematically.

RESULTS

Three key themes were identified comparing Magseed® and wire localisation of breast lesions relating to preoperative, intraoperative and postoperative learning outcomes. Percutaneous Magseed® detection, instrument interference and potential seed or wire dislodgement were the most common issues identified. Clinician experience suggested Magseed® index lesion identification was non-inferior to wire placement and improved the patient pathway in terms of scheduling and multi-site insertion.

CONCLUSIONS

Prospective shared learning suggested Magseed® offered additional non-clinical benefits over wire localisation, improving the efficiency of the patient pathway. Recommendations for improving breast localisation technique, appropriate patient selection and clinical practice through shared learning are discussed that may aid other surgeons in the adoption of this relatively new technique.