Wire- and Ultrasound-Guided Localization: A Novel Technique for Excision of Nonpalpable Breast Tumors

Assessment of Pathological Complete Response Using Vacuum-Assisted Biopsy in Breast Cancer Patients Who Have Clinical and Radiological Complete Response After Neo-Adjuvant Chemotherapy

Background

Any treatment protocol that leads to complete elimination of surgery may lead to a better patient acceptance of breast cancer treatments.

Objectives

We conducted this study to assess the feasibility of preoperative vacuum-assisted biopsies in identifying pathological complete response (pCR) and its accuracy in correlation to final histopathology report (HPR), in an Indian setting.

Methods

This was a prospective study conducted between October 1, 2019, and March 31, 2021. Patients with early breast cancer, estrogen and progesterone receptors negative and either Her2 positive or negative, and who were fit to undergo marker placement at the centre of the tumour and to receive third-generation chemotherapy (4 cycles of 3 weekly doxorubicin and cyclophosphamide followed by 4 cycles of 3 weekly docetaxel) were included in the study. Following the enrolment, a tissue marker was placed at the centre of the tumour and appropriate chemotherapy was started. Patients who achieved clinical complete response were subjected to ultrasound-guided vacuum-assisted biopsy (VAB) from the tumour bed before surgery. Pathology results of the VAB and resected specimen were then compared. Descriptive statistics were used in the study.

Results

Eighteen patients were enrolled in the study, with a mean age of 43.6 ± 9.8 years. However, only 10 were eligible for VAB procedure, and sensitivity and specificity were calculated based on the results of these 10 patients only. Vacuum-assisted biopsy showed sensitivity of 50% and specificity of 100% in identifying pCR. Combination of mammography, ultrasonography, and VAB showed sensitivity of 77.8% and specificity of 66.7% in identifying pCR.

Conclusion

Vacuum-assisted biopsy of tumour bed may not be sensitive enough to eliminate surgery even in patients who have had exceptional response to neo-adjuvant chemotherapy.

Ultrasound Guided Intraoperative Wire Localization Under General Anesthesia in Breast-Conserving Surgery

Breast-conserving surgery (BCS) is becoming an increasingly preferred surgical technique for treating breast cancer. For the last several decades, using a preoperative wire placed by a radiologist has been the gold standard to help guide surgeons to excise a suspicious mass. In recent years, there has been an increasing focus on using surgeon-performed intraoperative ultrasound (IOUS) during breast-conserving therapy, suggesting improved cosmetic outcomes and a decreased need for re-excision. However, studies have also highlighted that ultrasound may be uncomfortable for surgeons who have become most familiar with a wire-localization technique. Wire localization and intraoperative ultrasound are valuable tools that can improve the accuracy of tumor localization and reduce the need for re-excision. We present a 45-year-old female with a right breast mass, measuring breast imaging reporting and data system (BIRADS) 4A on preoperative ultrasound. Intraoperative wire-localization was performed by the surgeon utilizing ultrasound guidance. The right breast lesion was successfully excised with negative margins. The patient was discharged home and recovered well. Surgeon-performed intraoperative ultrasound can be combined with surgeon-performed wire localization to reduce the need for re-excision surgery and allow the surgeon to retain the familiarity of utilizing a gold-standard technique. Further research is needed to determine the optimal use of surgeon-performed IOUS and wire-localization, and its impact on long-term outcomes.

OUP accepted manuscript

Prostate cancer is the second most frequent cancer type among men worldwide. With the development of Radiology and Nuclear Medicine technologies, early diagnosis is increasingly common, and the possibility of using new minimally invasive techniques increases. With a narrative review of the literature, this case report describes an alternative radioisotope-guided laparoscopy technique for tumors in the peritoneal cavity. There may be benefits in associating nuclear medicine techniques in the management of patients with non-palpable tumors that are difficult to locate in the peritoneal cavity, enabling the use of less invasive and safer surgical procedures for diagnosis, staging and treatment.