Radioactive seed localization is the preferred technique in nonpalpable breast cancer compared with wire-guided localization and radioguided occult lesion localization

Radioactive Seed Localization for Nonpalpable Breast Lesions: Systematic Review and Meta-Analysis

BACKGROUND

This study is a systematic review with meta-analysis comparing radioactive seed localization (RSL) versus radio-guided occult lesion localization (ROLL) and wire-guided localization (WGL) for patients with impalpable breast cancer undergoing breast-conserving surgery and evaluating efficacy, safety, and logistical outcomes. The protocol is registered in PROSPERO with the number CRD42022299726.

METHODS

A search was conducted in the Embase, Lilacs, Pubmed, Scielo, Web of Science, and clinicaltrials.gov databases, in addition to a manual search in the reference list of relevant articles, for randomized clinical trials and cohort studies. Studies selected were submitted to their own data extraction forms and risk of bias analysis according to the ROB 2 and ROBINS 1 tools. A meta-analysis was performed, considering the random effect model, calculating the relative risk or the mean difference for dichotomous or continuous data, respectively. The quality of the evidence generated was analyzed by outcome according to the GRADE tool. Overall, 46 articles met the inclusion criteria and were included in this systematic review; of these, 4 studies compared RSL and ROLL with a population of 1550 women, and 43 compared RSL and WGL with a population of 19,820 women.

RESULTS

The results showed that RSL is a superior method to WGL in terms of surgical efficiency in the impalpable breast lesions' intraoperative localization, and it is at least equivalent to ROLL. Regarding security, RSL obtained results equivalent to the already established technique, the WGL. In addition to presenting promising results, RSL has been proven to be superior to WGL and ROLL technologies.

Radioguided surgery of mesenchymal tumors with 125I seeds

INTRODUCTION

Radioguided surgery uses radioactive substances to identify and remove hard-to-locate lesions. Mesenchymal tumors constitute a heterogeneous group of neoplasms derived from the mesoderm, including benign lesions and malignant sarcomas. The aim of this study was to evaluate the ability of 125I radioactive seeds to guide intraoperative localization of mesenchymal tumors, analyzing the complication rates and evaluating the margins of the surgical specimens retrieved.

METHODS

Retrospective observational study of all consecutive patients undergoing radioguided surgery of a mesenchymal tumor with a 125I radioactive seed from January 2012 to January 2020 at a tertiary referral center in Spain. The seed was inserted percutaneously guided by ultrasound or computed tomography in an outpatient setting.

RESULTS

Fifteen lesions were resected in 11 interventions in 11 patients, recovering all lesions marked (100%) with a 125I seed. The lesions included areas of benign fibrosis (26.7%), cellular angiofibroma (6.7%), desmoid tumor (20%), solitary fibrous tumor (13.3%), chondrosarcoma (6.7%), and pleomorphic sarcoma (26.7%), with a high rate of recurrent tumors (60%). There was only one complication (6.7%) due to the seed falling within the surgical bed. According to the UICC classification of residual tumors, 80% of the lesions resulted in an R0 resection, 6.7% were R1 resections, and 13.3% were R2 resections.

CONCLUSION

Radioguided surgery is an accurate technique for the resection of hard-to-locate mesenchymal tumors.

125I Radioactive Seed Localization vs. Conventional Surgery for the Treatment of Mesenchymal Tumours: A Propensity Score Matching Analysis

PURPOSE

Radioguided localization can assist the surgery of hard-to-find lesions. The aim was to evaluate the results of the 125I Radioactive Seed Localization (RSL) technique to guide a margin-free tumoral resection of mesenchymal tumours compared to conventional surgery and its influence in oncological outcomes.

METHODS

Retrospective observational study of all consecutive patients who underwent 125I RSL for the surgery of a mesenchymal tumour from January 2012 to January 2020 in a tertiary referral centre in Spain. The control group was formed by patients with conventional surgery in the same period and centre. A Propensity Score matching at 1:4 ratio selected the cases for analysis.

RESULTS

A total of 10 lesions excised in 8 radioguided surgeries were compared to 40 lesions excised in 40 conventional surgeries, with equal proportion of histological subtypes in each group. There was a higher proportion of recurrent tumours in the RSL group (80 % [8/10] vs. 27.5 % [11/40]; p: 0.004). An R0 was achieved in 80 % (8/10) of the RSL group and 65 % (26/40) of the conventional surgery group. The R1 rate was 0 % and 15 % (6/40), and the R2 rate was 20 % (2/10 and 8/40) in the RSL group and conventional surgery group, respectively (p: 0.569). No differences were detected in disease-free or overall survival between the different histological subtypes in the subgroup analysis.

CONCLUSION

The 125I RSL technique of a challenging sample of mesenchymal tumours achieved a similar margin-free tumoral resection and oncological outcomes as conventional surgery.

Optimal localization strategies for non-palpable breast cancers –A network meta-analysis of randomized controlled trials

Purpose

Mammographic screening programmes have increased detection rates of non-palpable breast cancers. In these cases, wire-guided localization (WGL) is the most common approach used to guide breast conserving surgery (BCS). Several RCTs have compared WGL to a range of novel localization techniques. We aimed to perform a network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing methods of non-palpable breast cancer localization.

Methods

A NMA was performed according to PRISMA-NMA guidelines. Analysis was performed using R packages and Shiny.

Results

24 RCTs assessing 9 tumour localization methods in 4236 breasts were included. Margin positivity and reoperation rates were 16.9% (714/4236) and 14.3% (409/2870) respectively. Cryo-assisted localization had the highest margin positivity (28.2%, 58/206) and reoperation (18.9%, 39/206) rates. Compared to WGL (n = 2045 from 24 RCTs) only ultrasound guided localization (USGL) (n = 316 from 3 RCTs) significantly lowered margin positivity (odds ratio (OR): 0.192, 95% confidence interval (CI): 0.079–0.450) and reoperation rates (OR: 0.182, 95%CI: 0.069–0.434). Anchor-guided localization (n = 52, 1 RCT) significantly lowered margin positivity (OR: 0.229, 95%CI: 0.050–0.938) and magnetic-marker localization improved patient satisfaction (OR: 0.021, 95%CI: 0.001–0.548). There was no difference in operation duration, overall complications, haematoma, seroma, surgical site infection rates, or specimen size/vol/wt between methods.

Conclusion

USGL and AGL are non-inferior to WGL for the localization of non-palpable breast cancers. The reported data suggests that these techniques confer reduced margin positivity rates and requirement for re-operation. However, caution when interpreting results relating to RCTs with small sample sizes and further validation is required in larger prospective, randomized studies.

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Ultrasound-guided (USGL) and anchor-guided (AGL) localization had optimal outcomes.

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These methods significantly lowered margin positivity (odds ratio: 0.192 & 0.229).

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However, small sample sizes in trials evaluating USGL and AGL limit these results.

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Operation duration, complications, or specimen data were comparable for all methods.

Cosmetic outcomes following wide local excision of impalpable breast cancer: is radioguided occult lesion localization using iodine-125 seeds better than hookwire localization?

BACKGROUND

Hookwire localization (HWL) is the gold standard for localizing impalpable tumours for breast conserving surgery. An alternative technique, radioguided occult lesion localization using iodine-125 seeds (ROLLIS), has been associated with lower re-excision rates. This paper investigates if cosmetic outcomes differ in women undergoing breast conserving surgery with HWL or ROLLIS.

METHODS

Women who had ROLLIS or HWL guided excision for impalpable breast cancer within a multicentre randomized controlled trial (RCT) (ANZCTR 12613000655741) were recruited. Exclusions were level 2 oncoplasty and mastectomy. Cosmetic outcome was calculated using BCCT.core, the Hopwood Body Image Scale and estimated percentage breast volume excised. Chi-squared analysis was used to determine the difference between the intervention groups.

RESULTS

Analysis was performed for 123 participants (66 ROLLIS and 57 HWL). The cosmetic outcome determined by BCCT.core for all participants was good with no significant difference between the ROLLIS and HWL groups. When reviewing the number of patients who experienced either a good or excellent result, there was a significantly higher number of patients in the ROLLIS group (n = 53, 82%) compared to the HWL group (n = 42, 74%, P = 0.02. There were no differences in Hopwood Body Image Scale or estimated percentage breast volume excised between groups. There was a reduction in the frequency of re-excision in the ROLLIS group (n = 3, 4.5%) versus HWL group (n = 8, 14%); however, this was not significant (P = 0.06).

CONCLUSION

Pre-operative localization of impalpable breast lesions using either ROLLIS or HWL resulted in a good cosmetic outcome with no significant difference between localization techniques.

How to Safely Perform Magnetic Resonance Imaging-guided Radioactive Seed Localizations in the Breast

When a breast lesion is seen on only magnetic resonance imaging (MRI) and needs to be excised, pre-operative MRI-guided radioactive seed localization (RSL) is preferred. However, MRI safety and radiation safety issues associated with the inability to recover a potentially lost seed in the MRI scanner room (Zone IV) have precluded this in the past. This manuscript provides a protocol for MRI-guided RSLs that meets MRI safety and radiation safety criteria established by the American College of Radiology and the Nuclear Regulatory Commission. To the authors’ best knowledge, this has never been published in the literature. The complete protocol is provided.

Evaluation of the nonradioactive inducible magnetic seed system Magseed for preoperative localization of nonpalpable breast lesions - initial clinical experience

INTRODUCTION

Many early-stage breast cancers are not palpable and thus must be localized before surgery. Detecting these lesions is crucial before they become clinically symptomatic to avoid morbidity and mortality. Nowadays, there are several new alternative techniques to traditional needle/wire localization available. These methods allow for better surgical margins, decreased costs and operating room delays, as well as improved patient satisfaction. The purpose of this study is to evaluate the nonradioactive inducible magnetic seed system Magseed (Endomagnetics Ltd, Cambridge, UK) for preoperative localization of nonpalpable breast lesions. To our knowledge, this report documents the first clinical experience with Magseed in Poland.

MATERIAL AND METHODS

A single-institution case report of 10 women with nonpalpable breast lesions localized and excised by using the Magseed surgical guidance system between November 2017 and May 2018.

RESULTS AND CONCLUSIONS

Magseed is an easy, sensitive and effective localization method. It is beneficial for oncoplastic outcomes and for scheduling efficiency, which overcomes many limitations of other localization methods. Surgical specimen margins were evaluated in 90% of cases as negative, with no additional re-excision. Only one patient with ductal carcinoma in situ had a positive tumor margin at the axillary side.

The role of Micro-CT in imaging breast cancer specimens

PURPOSE

The goal of breast cancer surgery is to remove all of the cancer with a minimum of normal tissue, but absence of full 3-dimensional information on the specimen makes this difficult to achieve.

METHOD

Micro-CT is a high resolution, X-ray, 3D imaging method, widely used in industry but rarely in medicine.

RESULTS

We imaged and analyzed 173 partial mastectomies (129 ductal carcinomas, 14 lobular carcinomas, 28 DCIS). Imaging was simple and rapid. The size and shape of the cancers seen on Micro-CT closely matched the size and shape of the cancers seen at specimen dissection. Micro-CT images of multicentric/multifocal cancers revealed multiple non-contiguous masses. Micro-CT revealed cancer touching the specimen edge for 93% of the 114 cases judged margin positive by the pathologist, and 28 of the cases not seen as margin positive on pathological analysis; cancer occupied 1.55% of surface area when both the pathologist and Micro-CT suggested cancer at the edge, but only 0.45% of surface area for the "Micro-CT-Only-Positive Cases". Thus, Micro-CT detects cancers that touch a very small region of the specimen surface, which is likely to be missed on sectioning.

CONCLUSIONS

Micro-CT provides full 3D images of breast cancer specimens, allowing one to identify, in minutes rather than hours, while the patient is in OR, margin-positive cancers together with information on where the cancer touches the edge, in a fashion more accurate than possible from the histology slides alone.

Surgical clips vs. iodine-125 (125I) seeds for marking the location of nonpalpable malignant breast lesions: preliminary results

OBJECTIVES

To assess the usefulness of iodine-125 (125I) seeds as an alternative to surgical clips for marking the location of nonpalpable malignant breast lesions for surgery.

MATERIAL AND METHODS

We included patients with histologically confirmed nonpalpable malignant lesions treated by surgery in 2015 or 2016. Patients were randomly assigned to presurgical marking with metallic clips (Group A) or with 125I seeds (Group B). In both groups, marking was guided by ultrasound and/or mammography depending on the radiologic characteristics of the lesion. During surgery, a gamma probe was used and afterward the presence of seeds in the surgical specimen was checked radiologically. In the histological analysis, the absence of tumor in the stain was considered free margins. We analyzed the following variables: age, lesion characteristics (laterality, mean size on MRI and in the surgical specimen, radiological type), and presence/absence of free margins.

RESULTS

In Group A (n=53), the most common histologic subtypes were infiltrating ductal carcinoma (IDC, 84.9%) and luminal A (LA, 49.1%); the mean size of the lesions was 1.8cm. In Group B (n=45), the most common histologic subtypes were IDC (82.2%) and LA (46.5%); the mean size of the lesions was 1.5cm. In Group A, 13.2% had involved margins and 13.2% underwent a second surgical intervention. In Group, B 11.4% had involved margins and 7.5% underwent a second surgical intervention. The differences between groups were not significant (p=0.7 for involved margins and p=0.5 for reintervention). The volume of the surgical specimens was significantly lower in Group B than in Group A (128.68cm3 vs. 189.37cm3; p<0.05).

CONCLUSIONS

Using 125I seeds was feasible and enabled significantly smaller surgical specimens than using metallic clips.