Preoperative localization and surgical margins in conservative breast surgery

An exploratory clinical trial of preoperative non-invasive localization before breast-conserving surgery using augmented reality technology

PURPOSE

This single-center, randomized, prospective, exploratory clinical trial was conducted to assess the clinical efficacy of an augmented reality (AR)-based breast cancer localization imaging solution for patients with breast cancer.

METHODS

This clinical trial enrolled 20 women who were diagnosed with invasive breast cancer between the ages of 19 and 80, had a single lesion with a diameter ≥ 5 mm but ≤ 30 mm, had no metastases to other organs, and had not received prior chemotherapy. All patients underwent mammography, ultrasound, computed tomography, and magnetic resonance imaging for preoperative assessment. Patients were randomly assigned to ultrasound-guided skin marking localization (USL) and AR-based localization (ARL) groups (n = 10 in each group). Statistical comparisons between USL and ARL groups were made based on demographics, radiologic features, pathological outcomes, and surgical outcomes using chi-square and Student t-tests.

RESULTS

Two surgeons performed breast-conserving surgery on 20 patients. Histopathologic evaluation of all patients confirmed negative margins. Two independent pathologists evaluated the marginal distances, and there were no intergroup differences in the readers' estimates (R1, 6.20 ± 4.37 vs. 5.04 ± 3.47, P = 0.519; R2, 5.10 ± 4.31 vs. 4.10 ± 2.38, P = 0.970) or the readers' average values (5.65 ± 4.19 vs. 4.57 ± 2.84, P = 0.509). In comparing the tumor plane area ratio, there was no statistically significant difference between the two groups in terms of either reader's mean values (R1, 15.90 ± 9.52 vs. 19.38 ± 14.05, P = 0.525; R2, 15.32 ± 9.48 vs. 20.83 ± 12.85, P = 0.290) or the overall mean values of two readers combined (15.56 ± 9.11 vs. 20.09 ± 13.38, P = 0.388). Convenience, safety, satisfaction, and reusability were all superior in the AR localization group (P < 0.001) based on the two surgeons' responses.

CONCLUSION

AR localization is an acceptable alternative to ultrasound-guided skin marking with no significant differences in surgical outcomes.

Cost-Effectiveness of Radar Localisation Versus Wire Localisation for Wide Local Excision of Non-palpable Breast Cancer

BACKGROUND

Wire localisation (WL) is the "gold standard" localisation technique for wide local excision (WLE) of non-palpable breast lesions but has disadvantages that have led to the development of wireless techniques. This study compared the cost-effectiveness of radar localisation (RL) to WL.

METHODS

This was a single-institution study of 110 prospective patients with early-stage breast cancer undergoing WLE using RL with the SCOUT® Surgical Guidance System (2021-2023) compared with a cohort of 110 patients using WL. Margin status, re-excision rates, and surgery delays associated with preoperative localisation were compared. Costs from a third-party payer perspective in Australian dollars (AUD$) calculated by using microcosting, break-even point, and cost-utility analyses.

RESULTS

A total of 110 WLEs using RL cost a total of AUD$402,281, in addition to the device cost of AUD$77,150. The average additional cost of a surgery delay was AUD$2318. Use of RL reduced the surgery delay rate by 10% (p = 0.029), preventing 11 delays with cost savings of AUD$25,496. No differences were identified in positive margin rates (RL: 11.8% vs. WL: 17.3%, p = 0.25) or re-excision rates (RL: 14.5% vs. WL: 21.8%, p = 0.221). In total, 290 RL cases are needed to break even. The cost of WLE using RL was greater than WL by AUD$567. There was a greater clinical benefit of 1.15 quality-adjusted life-years (QALYs) and an incremental cost-utility ratio of AUD$493 per QALY favouring RL.

CONCLUSIONS

Routine use of RL was a more cost-effective intervention than WL. Close to 300 RL cases are likely needed to be performed to recover costs of the medical device.

CLINICAL TRIAL REGISTRATION

ACTRN12624000068561.

Does Nipple-Ward Positive Margin Contribute to a Higher Rate of Re-Excision Procedures After a Lumpectomy with Pathology-Confirmed Positive Margins? A Retrospective Study

Background

Positive margins on lumpectomy specimens are associated with a twofold increased risk of local breast tumor recurrence. Prior literature has demonstrated various techniques and modalities for assessing margin status to reduce re-excision rates. However, there is paucity of literature analyzing which margin contributes to the highest re-excision rates. Therefore, the primary aim of the study was to investigate whether the nipple-ward margins resulted in a higher rate of re-excision in our patient population.

Methods

 A retrospective chart review was performed on patients who had re-excision surgery. Nipple-ward margin was identified by correlating radiological and pathological reports. A cut-off of more than 25% was used to demonstrate correlation between nipple-ward margin and re-excision rate.

Results

A total of 98 patients' data were analyzed, with 41 (41.8%), 14 (14.3%), 5 (5.1%), and 38 (38.8%) diagnosed with DCIS, IDC, ILC, and mixed pathology on their margins, respectively. Overall, 48% (n=47) of the positive margins were nipple-ward, with 44.7% (n=21) reporting DCIS. Upon stratification, 45 (45.9%) cases were single-margin positive, with 26 (57.8%) being nipple-ward. Furthermore, the remaining 53 (54.1%) patients had multiple positive margins, with 21 (39.6.7%) nipple-ward cases.

Conclusion

Positive nipple-ward margins significantly contribute to a higher re-excision rate p < 0.001; 48% of re-excision surgeries had positive nipple-ward margins, and 57.8% of positive single-margin cases were nipple-ward. Taking an additional shave during initial lumpectomy decreases re-excision rates. However, planning a lumpectomy procedure with a more elliptical rather than a spherical resection with additional cavity shave (ie, larger volume) in the nipple-ward direction and minimizing the remaining cavity shaves so the total volume resected remains unchanged. Nevertheless, future studies with larger sample sizes are required to bolster our findings.

Evaluating breast biopsy practice and breast biopsy marker utilisation in the clinical setting

INTRODUCTION

Breast Screen Australia and Breast Screen Aotearoa guidelines recommend breast biopsy marker (BBM) use in indicated patients. This study aims to evaluate breast biopsy practice and BBM utilisation by modality.

METHODS

An online survey was disseminated to radiologists who identified 'breast imaging' as their area of practice in the Royal Australian and New Zealand College of Radiologists (RANZCR) customer relationship management system. Survey questions addressed participant demographics and factors relating to BBM use.

RESULTS

Most respondents (72%) place between 1 and 4 BBMs per week. Almost all (99%) respondents perform ultrasound-guided biopsy of the breast or axillary nodes, with 85% performing stereotactic or tomosynthesis-guided breast biopsy and 27% performing MRI-guided breast biopsy. BBM utilisation differs by modality, with 97% respondents always placing a BBM post-MRI-guided breast biopsy, 50% always placing a BBM post-stereotactic-guided biopsy and 3% always placing a BBM post-ultrasound-guided breast biopsy.

CONCLUSIONS

Almost all radiologists perform breast biopsy using ultrasound, stereotactic/tomosynthesis or MRI guidance. BBM utilisation varies by modality, with 72% of respondents placing between 1 and 4 clips per week. Reasons for placing or not placing BBM aligned with prior studies. This is the first study to evaluate the number of breast biopsies performed by radiologists on a weekly or monthly basis, providing a useful platform for comparison in the local setting.

Magnetic marker localisation in breast cancer surgery

Since mammographic screening programmes were initiated, the spectrum of breast cancer has changed in terms of impalpable tumours, thus causing the development of new localisation methods, including magnetic markers. We offer herein an up-to-date review focused on two magnetic markers (Magseed, MaMaLoc) currently used in breast cancer surgery for the localisation of breast tumours or pathological axillary nodes. Magnetic marker localisation presents a safe and reliable method for breast tumour marking. Four currently available prospective studies demonstrate that the Magseed system has a negative margin rate and a successful localisation rate, both of which are comparable to standard marking systems used in breast cancer surgery. The main benefits of magnetic markers are that they require no radiation safety measures, and they offer the possibility of longer deployment times, thus simplifying surgery scheduling. The most important drawbacks are cost of the system, depth limitation and need for frequent probe recalibration.

Characterization and Evaluation of Injectable Biodegradable Polymer Multimodality Radiologic Markers in an In Vivo Murine Model

Biodegradable polymer clips as multidimensional soft tissue biopsy markers were developed with better biocompatibility and imaging features. Unlike the commercially available metallic biopsy markers, the developed polymer clips are temporary implants with similar efficacies as metal markers in imaging and detection and get absorbed within the body with time. Herein, we evaluate the degradation rate of three resorbable polymer-based marker compounds in an in vivo murine model. Three polymers, abbreviated as Polymer A (PLGA poly(lactic-co-glycolic acid)50:50), Polymer B (PLGA (poly(lactic-co-glycolic acid)) 75:25), and Polymer C (polycaprolactone (PCL)), mixed with 20% lipiodol and 0.2% iron oxide and a control polymer were implanted into nine mice, followed by CT and MRI imaging. Images were evaluated for conspicuity. Specimens were examined for tissue analysis of iodine and iron contents. Significant differences in polymer resorption and visualization on CT were noted, particularly at 8 weeks (p < 0.027). Polymers A, B, and C were visible by CT at 4, 6, and 8 weeks, respectively. All marker locations were detected on MRI (T1 and SWI) after 24 weeks, with tattooing of the surrounding soft tissue by iron deposits. CT and MR visible polymer markers can be constructed to possess variable resorption, with stability ranging between 4 and 14 weeks post placement, making this approach suitable for distinct clinical scenarios with varying time points.

A New Look into Cancer-A Review on the Contribution of Vibrational Spectroscopy on Early Diagnosis and Surgery Guidance

Simple Summary

Cancer is a leading cause of death worldwide, with the detection of the disease in its early stages, as well as a correct assessment of the tumour margins, being paramount for a successful recovery. While breast cancer is one of most common types of cancer, head and neck cancer is one of the types of cancer with a lower prognosis and poor aesthetic results. Vibrational spectroscopy detects molecular vibrations, being sensitive to different sample compositions, even when the difference was slight. The use of spectroscopy in biomedicine has been extensively explored, since it allows a broader assessment of the biochemical fingerprint of several diseases. This literature review covers the most recent advances in breast and head and neck cancer early diagnosis and intraoperative margin assessment, through Raman and Fourier transform infrared spectroscopies. The rising field of spectral histopathology was also approached. The authors aimed at expounding in a more concise and simple way the challenges faced by clinicians and how vibrational spectroscopy has evolved to respond to those needs for the two types of cancer with the highest potential for improvement regarding an early diagnosis, surgical margin assessment and histopathology.

Abstract

In 2020, approximately 10 million people died of cancer, rendering this disease the second leading cause of death worldwide. Detecting cancer in its early stages is paramount for patients’ prognosis and survival. Hence, the scientific and medical communities are engaged in improving both therapeutic strategies and diagnostic methodologies, beyond prevention. Optical vibrational spectroscopy has been shown to be an ideal diagnostic method for early cancer diagnosis and surgical margins assessment, as a complement to histopathological analysis. Being highly sensitive, non-invasive and capable of real-time molecular imaging, Raman and Fourier transform infrared (FTIR) spectroscopies give information on the biochemical profile of the tissue under analysis, detecting the metabolic differences between healthy and cancerous portions of the same sample. This constitutes tremendous progress in the field, since the cancer-prompted morphological alterations often occur after the biochemical imbalances in the oncogenic process. Therefore, the early cancer-associated metabolic changes are unnoticed by the histopathologist. Additionally, Raman and FTIR spectroscopies significantly reduce the subjectivity linked to cancer diagnosis. This review focuses on breast and head and neck cancers, their clinical needs and the progress made to date using vibrational spectroscopy as a diagnostic technique prior to surgical intervention and intraoperative margin assessment.

Image-Guided Breast Interventions: Biopsy and Beyond

Breast interventions primarily comprise of biopsy of the suspicious breast lesions to obtain accurate pathological diagnosis. Generally, image-guided breast biopsy is required for nonpalpable lesions, however, even in palpable lesions, image-guided biopsy should be performed as it improves the accuracy of diagnosis. Image-guided breast interventions have progressed well beyond biopsy, making the radiologist an important part of the multidisciplinary management of breast cancer. Preoperative localization of nonpalpable abnormalities guides optimal surgical excision to obtain negative margins without sacrificing the normal tissue. Ablative procedures for breast cancer treatment such as radiofrequency ablation (RFA) and high-intensity focused ultrasound ablation can sometimes replace surgery in older patients with comorbidities. This article enumerates and describes the expanding spectrum of image-guided interventions performed by breast radiologist.

Magnetic Seed (Magseed) Localisation in Breast Cancer Surgery: A Multicentre Clinical Trial

INTRODUCTION

The aim of this study was to evaluate the accuracy and reliability of the Magseed magnetic marker in breast cancer surgery.

METHODS

Thirty-nine patients with 41 implanted Magseeds undergoing surgical treatment in 3 surgical oncology departments were included in the retrospective trial to study pilot use of the Magseed magnetic marker in the Czech Republic for localisation of breast tumours or pathological axillary nodes in breast cancer patients.

RESULTS

Thirty-four breast cancer and 7 pathological lymph node localisations were performed by Magseed implantation. No placement failures, or perioperative detection failures of Magseeds were observed (0/41, 0.0%), but one case of Magseed migration was present (1/41, 2.4%). All magnetic seeds were successfully retrieved (41/41, 100.0%). Negative margins were achieved in 29 of 34 (85.3%) breast tumour localisations by Magseed.

CONCLUSION

Magseed is a reliable marker for breast tumour and pathological axillary node localisation in breast cancer patients. Magseed is comparable to conventional localisation methods in terms of oncosurgical radicality and safety.

Reflector-Guided Localisation of Non-Palpable Breast Lesions: A Prospective Evaluation of the SAVI SCOUT® System

Simple Summary

Marking impalpable areas of breast cancer prior to surgery is an important part of the modern treatment of breast cancer. Traditionally, the target lesion would be marked by a wire just before surgery under image guidance and would help the surgeon locate the tumour during surgery. However, this method has some drawbacks, such as patient discomfort, the risk of migration and dislodgement, and the need to couple surgical and radiological schedules. Therefore, there has been a growing interest in this system, thus supporting its potential. In this study, we have evaluated one such system, SAVI SCOUT^®, in 63 consecutive patients. Our experience with this system supported its potential role in modern breast surgery.

Abstract

Wire-guided localisation (WGL) has been the mainstay for localising non-palpable breast lesions before excision. Due to its limitations, various wireless alternatives have been developed. In this prospective study, we evaluate the role of radiation-free wireless localisation using the SAVI SCOUT^® system at the London Breast Institute. A total of 72 reflectors were deployed in 67 consecutive patients undergoing breast conserving surgery for non-palpable breast lesions. The mean interval between deployment and surgery for the therapeutic cases was 18.8 days (range: 0–210). The median deployment duration was 5 min (range: 1–15 min). The mean distance from the lesion was 1.1 mm (median distance: 0; range: 0–20 mm). The rate of surgical localisation and retrieval of the reflector was 98.6% and 100%, respectively. The median operating time was 28 min (range: 15–55 min) for the therapeutic excision of malignancy and 17 min (range: 15–24) for diagnostic excision. The incidence of reflector migration was 0%. Radial margin positivity in malignant cases was 7%. The median weight for malignant lesions was 19.6 g (range: 3.5–70 g). Radiologists and surgeons rated the system higher than WGL (93.7% and 98.6%, respectively; 60/64 and 70/71). The patient mean satisfaction score was 9.7/10 (n = 47, median = 10; range: 7–10). One instance of signal failure was reported. In patients who had breast MRI after the deployment of the reflector, the MRI void signal was <5 mm (n = 6). There was no specific technique-related surgical complication. Our study demonstrates that wire-free localisation using SAVI SCOUT^® is an effective and time-efficient alternative to WGL with excellent physician and patient acceptance.

Intraoperative Evaluation of Resection Margins in Breast-Conserving Surgery for In Situ and Invasive Breast Carcinoma

Background:

The challenge of breast-conserving surgery (BCS) is to remove the entire tumour with free margins and avoid secondary excision that may adversely affect the cosmetic outcome. Consequently, intraoperative evaluation of surgical margins is critical. The aims of this study were multiple. First, to analyse our methodology of intraoperative examination of the resection margins and to evaluate radiological and pathological methods in the assessment of the surgical margins. Second, to evaluate the factors associated with positive margins in our patient population.

M&m:

The data on the resection margin status of 290 patients who underwent BCS for invasive carcinoma or ductal carcinoma in situ (DCIS) between 2009 and 2016 were reviewed.

Results:

In the cohort of BCS with invasive carcinoma, the negative predictive value was 97.4% for intraoperative assessment by radiography and 81.8% for intraoperative assessment by pathology. The re-operation rate among cases without intraoperative assessment was 23.6% compared to 7.3% among cases with intraoperative assessment (P = .003). Margin status was significantly associated with tumour size, histological subtype (invasive lobular carcinoma), and multifocality. In the population of BCS with DCIS, margin status was significantly associated with preoperative localisation and intraoperative margin assessment (P = .03).

Conclusion:

There is no statistical difference between pathological and radiological intraoperative assessment. Tumour size, lobular subtype, and multifocality were found to be significantly associated with positive margins in cases with invasive carcinoma, whereas absence of intraoperative margin assessment was significantly associated with positive margins in cases with DCIS. Therefore, intraoperative margin assessment improves the likelihood of complete excision of the lesion.

In Search of the Lost Clip: Outcome of Women After Needle-Guided Lumpectomy of a Marking Clip

BACKGROUND

Needle localization of a marking clip is required to guide accurate removal of many breast lesions. When the clip is not visualized on specimen radiography, concerns regarding the completeness of cancer removal and long-term outcomes arise. Using a large cohort of women undergoing breast conservation, we examined the magnitude of the problem and the outcome of women with a missing clip.

METHODS

We conducted a case-control study including all women undergoing mammographic wire-guided localization between 2013 and 2018 with a specimen radiograph showing a missing clip. The control group included women with successful removal of the clip(s). Data included demographics, cancer and treatment characteristics, and outcome. The groups were compared in regard to margin status, repeat surgery, and recurrence rates.

RESULTS

The research group included 43 women [5% of the cohort; 95% confidence interval (CI) 3.9-7.2] with a missing clip. Positive margins were comparable (7, 17% of cases; 29, 15% of 196 cases in the control group; p = 0.96). Eleven women (33%) had a residual clip visualized on post-operative mammography; in four cases, a percutaneous biopsy of the clip was successful, all with no residual tumor. There was no significant difference in re-excision rates (14% vs. 8%, p = 0.23) or in local or distant recurrence.

CONCLUSIONS

In the majority of women with a missing clip, the clip is not visualized on post-operative mammography. Those with a residual clip can be managed with percutaneous biopsy as long as the lesion was removed with clear margins, with comparable outcomes as women in whom the clip is visualized on specimen radiograph.

Usefulness of 3D-surgical guides in breast conserving surgery after neoadjuvant treatment

We used 3D printed-breast surgical guides (3DP-BSG) to designate the original tumor area from the pre-treatment magnetic resonance imaging (MRI) during breast-conserving surgery (BCS) in breast cancer patients who received neoadjuvant systemic therapy (NST). Targeting the original tumor area in such patients using conventional localization techniques is difficult. For precise BCS, a method that marks the tumor area found on MRI directly to the breast is needed. In this prospective study, patients were enrolled for BCS after receiving NST. Partial resection was performed using a prone/supine MRI-based 3DP-BSG. Frozen biopsies were analyzed to confirm clear tumor margins. The tumor characteristics, pathologic results, resection margins, and the distance between the tumor and margin were analyzed. Thirty-nine patients were enrolled with 3DP-BSG for BCS. The median nearest distance between the tumor and the resection margin was 3.9 cm (range 1.2–7.8 cm). Frozen sections showed positive margins in 4/39 (10.3%) patients. Three had invasive cancers, and one had carcinoma in situ; all underwent additional resection. Final pathology revealed clear margins. After 3-year surveillance, 3/39 patients had recurrent breast cancer. With 3DP-BSG for BCS in breast cancer patients receiving NST, the original tumor area can be identified and marked directly on the breast, which is useful for surgery. Trial Registration: Clinical Research Information Service (CRIS) Identifier Number: KCT0002272. First registration number and date: No. 1 (27/04/2016).

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.

Are breast biopsy markers underused?

INTRODUCTION

To evaluate current use of breast biopsy markers (BBM) amongst Australian and New Zealand radiologists.

METHODS

Radiologists attending a national breast conference were invited to complete an online survey addressing demographics, BBM use following ultrasound, stereotactic, tomosynthesis and MRI-guided biopsy, frequency of early BBM displacement, preoperative lesion localisation (PLL) and axillary BBM use.

RESULTS

Overall response rate was 52% (60/115). The majority (n = 45) 75% practiced in Australia. 98% had BBMs available in their practice, 40% reported BBM costs weren't covered by insurance. 27% would use BBMs more often if they were, with some utilising smaller gauge devices for lesion sampling to minimise need for BBM use and patient out-of-pocket costs. Ultrasound-guided procedures were associated with lower rates of clinically significant BBM displacement (P = 0.001). Considering PLL, 44% were able to perform US-guided PLL in <25% of cases. Poor sonographic visibility was the commonest reason why this wasn't possible. In the axilla, BBMs were mainly used to mark positive nodes in pre-neoadjuvant chemotherapy patients.

CONCLUSION

This survey is the first to provide data on BBM use amongst a sample of predominantly Australian and New Zealand radiologists, and provides compelling evidence of significantly lower incidence of BBM displacement with US-guided procedures. Our results suggest some radiologists may hesitate to use BBMs due to cost, and this can influence their choice of biopsy technique. Provision of a Medicare item Number for BBMs may lead to increased adoption of best practice guidelines for preoperative diagnosis of breast lesions.

Patient and clinician satisfaction and clinical outcomes of Magseed compared with wire-guided localisation for impalpable breast lesions

Background

Guide-wire localisation remains the most commonly used technique for localisation of impalpable breast lesions in the UK. One alternative is magnetic seed localisation. We aimed to investigate patient and clinician satisfaction in two consecutive cohorts, describe re-excision and positive margin rates, and explore reasons for positive margins and the implications for localisation techniques.

Methods

A single-institution prospective service evaluation of two cohorts of consecutive cases of wire and then Magseed localisation was carried out. Data were collected on patient and clinician satisfaction, clinico-pathological findings, and causes of involved margins. T tests were used to compare continuous variables and Chi-squared test for satisfaction outcomes.

Results

168 consecutive cases used wire-guided localisation (WGL) and 128 subsequent cases used Magseeds. Patients reported less anxiety between localisation and surgery in the Magseed group, and clinicians reported greater ease of use of Magseeds. There were no differences in lesion size, surgical complexity, or re-excision rate between the groups. In a subset of patients receiving standard wide local excision (i.e., excluding mammoplasties), the impact on margin involvement was investigated. There was no significant difference in radiological under-sizing or accuracy of localisation. However, specimen weight and eccentricity of the lesion were statistically significantly lower in the Magseed group. Despite this, re-excision rates were not significantly different (p = 0.4).

Conclusions

This is the first large study of satisfaction with localisation and showed clinician preference for Magseed and a reduction in patient anxiety. It also demonstrated similar positive margin rates despite smaller specimen weights in the Magseed group. Magnetic seed localisation offers an acceptable clinical alternative to guide wire localisation. The impact on local service provision should also be considered.

The shape of breast cancer

PURPOSE

Little is known about the three-dimensional shape of breast cancer. Implicit to approaches that localize the center of the tumor for breast-conserving surgery (BCS) of non-palpable cancers is the assumption that breast cancers are spherical about a central point, which may not be accurate.

METHODS

Pre-operative supine breast MRI images were obtained of 83 breast cancer patients undergoing partial mastectomy using supine MRI-guided resection techniques. Three-dimensional (3D) tumor models were derived after radiologists outlined tumor edges on successive MRI slices. Ideal resection volumes were determined by adding 1 cm in every dimension to the actual tumor volume. Geometrically defined parameters were used to define tumor shapes and associations between clinical variables and shapes were examined.

RESULTS

Seventy-five patients had invasive cancer. Breast cancers were categorized into four tumor shapes: 34% of tumors were discoidal, 29% segmental, 19% spherical, and 18% irregular. If hypothetical spherical excisions were performed, non-spherical cases would excise 143% more tissue than the ideal resection volume. When the 3D shape of each tumor was provided to the surgeon during MR-guided BCS, the percentage of tissue overexcised in non-spherical cases was significantly less (143% vs. 66%, p < 0.001).

CONCLUSIONS

Information obtained from a supine MRI can be used to generate 3D tumor models and rapidly classify breast tumor shapes. The vast majority of invasive cancers and DCIS are not spherical. Knowledge of tumor shape may allow surgeons to excise breast cancer more precisely.

Mapping of multifocal breast cancer to achieve negative margins: A new step in the evolution of conservative breast surgery(A cohort study)

•

Conservative breast surgery is the standard technique in breast cancer.

•

Multifocal breast cancer is a risk factor for involved margins.

•

Positive margins are considered one of the predictors for local recurrence.

•

Preoperative wire mapping after breast marking by the surgeon increase the chance to have negative margins.

Wireless Breast Localization Using Radio-frequency Identification Tags: The First Reported European Experience in Breast Cancer

BACKGROUND/AIM

Wire-guided localisation (WGL) has been the mainstay for localisation of clinically occult breast lesions before excision. However, it has restrictive scheduling requirements, and causes patient discomfort. This has prompted the development of various wireless alternatives. In this prospective study we shall evaluate the role of radiation-free wireless localisation using a radiofrequency identification (RFID) tag and a hand-held reader (LOCalizer™) in the management of occult breast lesions.

PATIENTS AND METHODS

This technique was evaluated in a prospective cohort of 10 patients. The evaluation focused on: i) successful deployment, ii) identification and retrieval, iii) the status of surgical margins and need for re-operation, iv) resected specimen weight, v) marker migration rates (>5mm), and vi) acceptance by patients, radiologists and surgeons.

RESULTS

RFID tags (n=11) were deployed under ultrasound guidance pre-operatively to localise occult breast lesions in 10 patients. The mean time for deployment of the RFID tag was 5.4 min (range=2-20). The mean distance from the lesion was 0.45 mm (range=0-3). The mean duration for retrieval was 10.2 min (range=6-20). Mean specimen weight was 19.6 g for malignant lesions (range=4.5-42). All tags were identified, and none had migrated. There were no positive margins, re-operations, nor complications. Patient feedback was highly positive. Both radiologists and surgeons rated the LOCalizer™ technique as better than WGL.

CONCLUSION

Our study demonstrates that wireless localisation using RFID is an effective and time-efficient alternative to WGL, with low margin positivity and re-operation rates, and high patient, radiologist and surgeon acceptance.

Preoperative Localization of Breast MRI Lesions: MRI-guided Marker Placement With Radioactive Seed Localization as an Alternative to MRI-guided Wire Localization

Objective

Preoperative MRI-guided wire localization (MWL) presents challenges to both the physician and patient. In this study, we examined the efficiency and outcome of MRI-guided marker placement followed by mammographic-guided radioactive seed localization (MMP/RSL) as an alternative localization method. The primary outcome parameter was pathology upon excision. The secondary outcome parameters were total procedure time and clinical indication for localization.

Methods

A retrospective review of a large tertiary cancer center's breast imaging database was performed. Records of 21 patients with MMP/RSL (24 markers) from August 2013 to January 2019 were compared with 34 patients receiving MWL (48 wires) from January 2016 to January 2019. Multiple factors, including age, prelocalization pathology, postsurgical pathology, concordance, re-excision rates, and total procedure time required for each technique, were compared. Univariate and descriptive statistical analyses were performed.

Results

Mean patient age in years (MMP/RSL = 54.1 ± 13.1, MWL = 55.1 ± 10.8, P = 0.389), time in MR scanner in minutes (MMP/RSL = 31.7 ± 12.0, MWL = 35.8 ± 13.1, P = 0.678), and postsurgical pathology malignancy rates (MMP/RSL = 71.4%, MWL = 65.7%, P = 0.7715) were similar without statistically significant differences. As expected, the mean total procedure time was slightly longer without a statistically significant difference (47.3 ± 19.8 min versus 35.8 ± 13.1 min, P = 0.922) for the MMP/RSL group. All patients in both groups underwent successful localization with 100% radiologic-pathology concordance. Re-excision rates were lower for the MMP/RSL group (9.5%) versus the MWL group (16.7%); however, they were not found to be statistically significant (P = 0.7104).

Conclusion

MMP/RSL is a feasible alternative to MWL and may alleviate many challenges presented by MWL. Further studies are needed.

Extent of Peritoneal Resection for Peritoneal Metastases: Looking Beyond a Complete Cytoreduction

Completeness of cytoreduction is one of the most important prognostic factors impacting outcomes of cytoreductive surgery (CRS). To what extent the surrounding normal peritoneum needs to be removed is not known. We hypothesized that the extent of peritoneal resection should be different for different tumors and performed this study to find evidence to support this rationale. To determine the extent of resection of surrounding tissue for any tumor, the mechanisms of tumor development and spread, tumor morphology, the possibility of finding disease in the surrounding normal tissue, and the pattern of lymph node metastases should be known. Surgical resections also depend on patterns of recurrence and the impact of varying extent of resection on survival. We performed a review of literature pertaining to pathways and patterns of peritoneal cancer spread to determine the scientific basis for the extent of peritonectomy. We also reviewed studies comparing less and more extensive peritoneal resection. There is no consensus on the extent of lymphadenectomy required for most PM. Based on this review, we provide recommendations for the extent of peritoneal resection and the extent of lymph node dissection that should be performed for some common peritoneal tumors and identify areas that require further research. We propose that a systematic method of synoptic reporting of pathological specimens of CRS should be developed to capture information regarding the disease distribution within the peritoneal cavity and morphology of PM from different tumors. This can in future be used to establish standard guidelines for such resections.

Charcoal granuloma mimicking breast cancer: an emerging diagnosis

BACKGROUND

Image-guided charcoal injection in suspicious breast lesions for preoperative localization is a procedure that has been increasing over the years because it is safer, faster, and more affordable when compared to needle-wire preoperative localization. To date, no complications have been associated with the method. However, in recent years there have been some reports about charcoal granulomas mimicking malignant lesions in some postoperative patients or in a conservative follow-up.

PURPOSE

To report a series of 11 cases which had suspicious imaging findings for malignancy and resulted in charcoal granulomas on histopathological analysis.

MATERIAL AND METHODS

A database of 1650 patients that attended our center from January 2007 to June 2018 was reviewed and detected 495 patients who had been previously submitted to ultrasound-guided charcoal marking in a breast lesion. Then, patients whose imaging studies were compatible with new suspicious lesions on mammography, breast ultrasound, and/or magnetic resonance imaging and biopsy of this new lesion indicating charcoal granuloma were selected.

RESULTS

From 495 patients who had undergone charcoal localization injections in previous biopsies, we selected 11 who had new lesions with malignant characteristics on imaging studies but histopathological analysis resulted in charcoal granuloma.

CONCLUSION

Charcoal granuloma should be considered in patients with previous preoperative injection localization, since the residual charcoal in the breast tissue may form granulomas and mimic malignant lesions on follow-up imaging studies.

Ultrasound-guided preoperative localization of breast lesions: a good choice

PURPOSE

The aim of the study was to verify whether ultrasound (US)-guided preoperative localization of breast lesions is an adequate technique for correct and safe surgical resection and to contribute positively and effectively to this topic in the literature with our results.

METHODS

From June 2016 to November 2016, 155 patients with both benign and malignant breast lesions were selected from our institute to undergo US localization before surgery. The lesions included were: sonographically visible and nonpalpable lesions; palpable lesions for which a surgeon had requested US localization to better evaluate the site and extension; sonographically visible, multifocal breast lesions, both palpable and nonpalpable. US localization was performed using standard linear transducers (Siemens 18 L6, 5.5-8 MHz, 5.6 cm, ACUSON S2000 System, Siemens Medical Solutions). The radiologist used a skin pen to mark the site of the lesion, and the reported lesion's depth and distance from the nipple and pectoral muscle were recorded. The lesions were completely excised by a team of breast surgeons, and the surgical specimens were sent to the Radiology Department for radiological evaluation and to the Pathology Department for histological assessment.

RESULTS

In 155 patients who underwent to preoperative US localization, 188 lesions were found, and the location of each lesion was marked with a skin pen. A total of 181 lesions were confirmed by the final histopathologic exam (96.28%); 132 of them (72.92%) were malignant, and 124 of these (93.93%) showed free margins.

CONCLUSIONS

US-guided preoperative localization of sonographically visible breast lesions is a simple and nontraumatic procedure with high specificity and is a useful tool for obtaining accurate surgical margins.

Costs and effects of intra-operative fluorescence molecular imaging - A model-based, early assessment

Introduction

Successful breast conserving cancer surgeries come along with tumor free resection margins and account for cosmetic outcome. Positive margins increase the likelihood of tumor recurrence. Intra-operative fluorescence molecular imaging (IFMI) aims to focus surgery on malignant tissue thus substantially lowering the presence of positive margins as compared with standard techniques of breast conservation (ST). A goal of this paper is to assess the incremental number of surgeries and costs of IFMI vs. ST.

Methods

We developed a decision analytical model and applied it for an early evaluation approach. Given uncertainty we considered that IFMI might reduce the proportion of positive margins found by ST from all to none and this proportion is assumed to be reduced to 10% for the base case. Inputs included data from the literature and a range of effect estimates. For the costs of IFMI, respective cost components were added to those of ST.

Results

The base case reduction lowered number of surgeries (mean [95% confidence interval]) by 0.22 [0.15; 0.30] and changed costs (mean [95% confidence interval]) by €-663 [€-1,584; €50]. A tornado diagram identified the Diagnosis Related Group (DRG) costs, the proportion of positive margins of ST, the staff time saving factor and the duration of frozen section analysis (FSA) as important determinants of this cost.

Conclusions

These early results indicate that IFMI may be more effective than ST and through the reduction of positive margins it is possible to save follow-up surgeries–indicating further health risk–and to save costs through this margin reduction and the avoidance of FSA.

The Value of Preoperative Lesion Dedicated Ultrasound of Breast Cancer before Conserving Surgery for Optimizing Margins

To investigate the effect of US performed immediately before breast conserving surgery (BCS) by radiologist accompanied by the surgeon. All patients scheduled for BCS in the last year (group 1, n = 46) were evaluated with US immediately before surgery. About 108 patients (group 2) who were treated with BCS before the study were included as the control group. Tumor size and localization, the distances between tumor-skin and tumor-pectoralis muscle fascia were noted. Re-excision rate due to positive margins was significantly lower in group 1. Statistically significant difference was detected in re-excision rates for nonpalpable tumors. Preoperative US is an effective and practical method.

A prospective comparative study to evaluate the displacement of four commercially available breast biopsy markers

OBJECTIVE

Radiopaque markers are commonly deployed following breast biopsies to indicate the location of the targeted lesion. A frequently encountered complication is the displacement of these markers. This study compared the degree of displacement among four newer generation markers after stereotactic core needle biopsy.

METHODS

80 consecutive biopsies were performed at three breast centre sites. The markers included: HydroMARK(®) (Mammotome, Cincinnati, OH), MammoMARK™ (Mammotome, Cincinnati, OH), MammoStar™ (Mammotome, Cincinnati, OH) and SecurMark(®) (Hologic, Bedford, MA). Each marker was composed of a radiopaque core with a unique polymeric encasing component. Post-procedure mammograms were obtained and the degree of marker displacement was measured.

RESULTS

MammoMARK™ exhibited the greatest mean net displacement, followed by HydroMARK(®), SecurMark(®) and MammoStar™ (13.9, 7.7, 5.8 and 4.7 mm, respectively), although these differences did not reach statistical significance (p = 0.398). 73% of the markers did not displace at all. However, in the 19 of 22 markers in which displacement occurred, the distance from the biopsy cavity was >10 mm. No statistically significant contributing factors to predict displacement were found.

CONCLUSION

Newer generation biopsy markers perform comparably with one another. However, clinically significant and unpredictable marker displacement persists. Compared with multiple similar studies of older generation bare metallic markers, the overall displacement rate of newer generation markers seems to be lower, possibly owing to the use of polymeric embedding agents that self-expand within the biopsy cavity.

ADVANCES IN KNOWLEDGE

This article compares the post-procedure displacement of breast biopsy markers, which have not been evaluated or discussed in detail since markers with polymeric embedding agents gained widespread use.

Charcoal suspension tattoo: new tool for the localization of malignant laterocervical lymph nodes

We present a retrospective study to evaluate safety and effectiveness of ultrasound (US)-guided tattooing with charcoal of suspicious laterocervical lymph nodes. When an open biopsy of a laterocervical lymph node is needed, the choice of the lymph node to excise and examine is fundamental to avoid rebiopsy. Surgeons tend to choose the most surgical approachable enlarged lymph node that does not always correspond to the one with worst echographic aspect. We present 16 cases of patients with laterocervical adenopathy with inconclusive or non-adequate results at fine needle aspiration cytology addressed to open biopsy. Those patients underwent US-guided preoperative injection of a charcoal suspension inside the lymph node to excise to mark it, and then excisional biopsy was performed. Sixteen marked lesions (100 %) were detected intraoperatively and dissected. The injected charcoal was detected intraoperatively in all cases. In 14 patients (87, 5 %) it was inside the lesion; in two cases (12, 5 %), the charcoal suspension was found in the tissues above the lesion. The procedure was well tolerated in all cases. No major procedure-related complications were encountered. US-guided charcoal tattooing is a new, safe, well-tolerated, and easy-to-perform technique for the marking of US suspicious laterocervical lymph nodes. This preliminary study shows a high technical success rate (76 %) and high percentage of intraoperative detection of marked lesions (100 %) with a low rate of complications.

Image-Guided Embolization Coil Placement for Identification of an Endophytic, Isoechoic Renal Mass During Robotic Partial Nephrectomy

Background: Intraoperative ultrasonography has proven to be a useful tool for tumor identification during robot-assisted laparoscopic partial nephrectomy (RALPN). However, its utility is limited in renal tumors that are completely endophytic and isoechoic in nature. We present a novel approach to intraoperative tumor identification using preoperative percutaneous intratumoral embolization coil placement that may be utilized in the management of such cases.

Case Presentation: A 42-year-old Caucasian male was referred with an incidentally discovered right renal mass that was posterior and completely endophytic. He desired a RALPN; however, preoperative renal ultrasound demonstrated an isoechoic lesion. Thus, the patient underwent preoperative image-guided placement of an embolization coil within the tumor. This facilitated identification of the tumor intraoperatively using intracorporeal ultrasound centered on the coil and enabled resection with negative margins.

Conclusion: Utilizing a novel approach analogous to preoperative localization of other solid malignancies, such as breast cancer, we were able to effectively identify and resect an isoechoic renal mass during RALPN.

Assessment of MRI Issues at 3 Tesla for a New Metallic Tissue Marker

Purpose. To assess the MRI issues at 3 Tesla for a metallic tissue marker used to localize removal areas of tissue abnormalities. Materials and Methods. A newly designed, metallic tissue marker (Achieve Marker, CareFusion, Vernon Hills, IL) used to mark biopsy sites, particularly in breasts, was assessed for MRI issues which included standardized tests to determine magnetic field interactions (i.e., translational attraction and torque), MRI-related heating, and artifacts at 3 Tesla. Temperature changes were determined for the marker using a gelled-saline-filled phantom. MRI was performed at a relatively high specific absorption rate (whole body averaged SAR, 2.9-W/kg). MRI artifacts were evaluated using T1-weighted, spin echo and gradient echo pulse sequences. Results. The marker displayed minimal magnetic field interactions (2-degree deflection angle and no torque). MRI-related heating was only 0.1°C above background heating (i.e., the heating without the tissue marker present). Artifacts seen as localized signal loss were relatively small in relation to the size and shape of the marker. Conclusions. Based on the findings, the new metallic tissue marker is acceptable or “MR Conditional” (using current labeling terminology) for a patient undergoing an MRI procedure at 3 Tesla or less.