Intraoperative ultrasound in breast cancer surgery-from localization of non-palpable tumors to objectively measurable excision

Evolution of localization methods for non-palpable breast lesions: a literature review from a translational medicine perspective

Background and Objective

With an increasing number of non-palpable breast lesions detected due to improved screening, accurate localization of these lesions for surgery is crucial. This literature review explores the evolution of localization methods for non-palpable breast lesions, highlighting the translational journey from concept to clinical practice.

Methods

A comprehensive search of PubMed, Embase, and Scopus databases until September 2023 was conducted.

Key Content and Findings

Multiple methods have been developed throughout the past few decades. (I) Wire-guided localization (WGL) introduced in 1966, has become a reliable method for localization. Its simplicity and cost-effectiveness are its key advantages, but challenges include logistical constraints, patient discomfort, and potential wire migration. (II) Intraoperative ultrasound localization (IOUS) has shown promise in ensuring complete lesion removal with higher negative margin rates. However, its utility is limited to lesions visible on ultrasound (US) imaging. (III) Breast biopsy marker localization: the use of markers has improved the precision of localization without the need for wire. However, marker visibility remains a challenge despite improvements in their design. (IV) Radioactive techniques: radio-guided occult lesion localization (ROLL) and radioactive seed localization (RSL) offer flexibility in scheduling and improved patient comfort. However, they require close multidisciplinary collaboration and specific equipment due to radioactive concerns. (V) Other wireless non-radioactive techniques: wireless non-radioactive techniques have been developed in recent three decades to provide flexible and patient-friendly alternatives. It includes magnetic seed localization, radar techniques, and radiofrequency techniques. Their usage has been gaining popularity due to their safety profile and allowance of more flexible scheduling. However, their high cost and need for additional training remain a barrier to a wider adoption.

Conclusions

The evolution of breast lesion localization methods has progressed to more patient-friendly techniques, each with its unique advantages and limitations. Future research on patient-reported outcomes, cosmetic outcomes, breast biopsy markers and integration of augmented reality with breast lesion localization are needed.

Comparison of ultrasound guided surgery and radio-guided occult lesions localization (ROLL) for nonpalpable breast cancer excision

Background

There is little literature comparing intraoperative ultrasound (IOUS) with radio-guided occult lesions localization (ROLL) in nonpalpable invasive tumors in breast conserving surgery (BCS). There is a need to compare these two methods in terms of safety and efficacy.

Methods

This is an observational cohort study. All patients treated with BCS for nonpalpable invasive breast cancer using IOUS from March 2016 to March 2020 were included and compared with a historical reference control group operated on using ROLL from March 2013 to March 2017. For each detection method, the ability to locate tumors intraoperatively, tumor and surgical specimen sizes, total resection volume (TRV), optimal resection volume, excess of healthy tissue resected (ETR), margin status, re-excision rate, surgical time, complications and costs were studied.

Results

One hundred and fifty-eight were included, 83 with IOUS and 75 with ROLL. The mean tumor size is equivalent in both groups (11.88 mm IOUS vs. 12.29 mm ROLL, P=0.668). TRV is significantly lower with IOUS (24.92 vs. 60.32 cm3, P<0.001), and the ETR is also significantly lower in the IOUS group (21.74 vs. 58.37 cm3, P<0.001). The rate of positive margins did not differ (10.98% vs. 12.16%, P=1), nor did re-excision rate (10.98% vs. 8.11%, P=0.597). Complication rate did not differ (12.2% IOUS vs. 10.81% ROLL, P=0.808). Surgical time was shorter in IOUS (45.5 vs. 57 min, P>0.05).

Conclusions

IOUS in BCS for nonpalpable invasive breast cancer is more accurate than ROLL because it decreases excision volumes with the same rate of free margins and re-excision. Also, IOUS is a more efficient and comfortable technique, and just as safe as ROLL.

High wavenumber Raman spectroscopy for intraoperative assessment of breast tumour margins

Optimal oncological results and patient outcomes are achieved in surgery for early breast cancer with breast conserving surgery (BCS) where this is appropriate. A limitation of BCS occurs when cancer is present at, or close, to the resection margin - termed a 'positive' margin - and re-excision is recommended to reduce recurrence rate. This is occurs in 17% of BCS in the UK and there is therefore a critical need for a way to assess margin status intraoperatively to ensure complete excision with adequate margins at the first operation. This study presents the potential of high wavenumber (HWN) Raman spectroscopy to address this. Freshly excised specimens from thirty patients undergoing surgery for breast cancer were measured using a surface Raman probe, and a multivariate classification model to predict normal versus tumour was developed from the data. This model achieved 77.1% sensitivity and 90.8% specificity following leave one patient out cross validation, with the defining features being differences in water content and lipid versus protein content. This demonstrates the feasibility of HWN Raman spectroscopy to facilitate future intraoperative margin assessment at specific locations. Clinical utility of the approach will require further research.

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.

Three-dimensional virtual reality in surgical planning for breast cancer with reconstruction

Breast surgery is performed to achieve local control in patients with breast cancer. Visualization of the anatomy with a virtual reality software platform reconstructed from magnetic resonance imaging data improves surgical planning with regards to volume and localization of the tumor, lymph nodes, blood vessels, and surrounding tissue to perform oncoplastic tissue rearrangement. We report the use and advantages of virtual reality added to the magnetic resonance imaging assessment in a 36-year-old woman with breast cancer who underwent nipple sparing mastectomy with tissue expander reconstruction.

Image Translation of Breast Ultrasound to Pseudo Anatomical Display by CycleGAN

Ultrasound imaging is cost effective, radiation-free, portable, and implemented routinely in clinical procedures. Nonetheless, image quality is characterized by a granulated appearance, a poor SNR, and speckle noise. Specific for breast tumors, the margins are commonly blurred and indistinct. Thus, there is a need for improving ultrasound image quality. We hypothesize that this can be achieved by translation into a more realistic display which mimics a pseudo anatomical cut through the tissue, using a cycle generative adversarial network (CycleGAN). In order to train CycleGAN for this translation, two datasets were used, "Breast Ultrasound Images" (BUSI) and a set of optical images of poultry breast tissues. The generated pseudo anatomical images provide improved visual discrimination of the lesions through clearer border definition and pronounced contrast. In order to evaluate the preservation of the anatomical features, the lesions in both datasets were segmented and compared. This comparison yielded median dice scores of 0.91 and 0.70; median center errors of 0.58% and 3.27%; and median area errors of 0.40% and 4.34% for the benign and malignancies, respectively. In conclusion, generated pseudo anatomical images provide a more intuitive display, enhance tissue anatomy, and preserve tumor geometry; and can potentially improve diagnoses and clinical outcomes.

Toward Intraoperative Margin Assessment Using a Deep Learning-Based Approach for Automatic Tumor Segmentation in Breast Lumpectomy Ultrasound Images

There is an unmet clinical need for an accurate, rapid and reliable tool for margin assessment during breast-conserving surgeries. Ultrasound offers the potential for a rapid, reproducible, and non-invasive method to assess margins. However, it is challenged by certain drawbacks, including a low signal-to-noise ratio, artifacts, and the need for experience with the acquirement and interpretation of images. A possible solution might be computer-aided ultrasound evaluation. In this study, we have developed new ensemble approaches for automated breast tumor segmentation. The ensemble approaches to predict positive and close margins (distance from tumor to margin ≤ 2.0 mm) in the ultrasound images were based on 8 pre-trained deep neural networks. The best optimum ensemble approach for segmentation attained a median Dice score of 0.88 on our data set. Furthermore, utilizing the segmentation results we were able to achieve a sensitivity of 96% and a specificity of 76% for predicting a close margin when compared to histology results. The promising results demonstrate the capability of AI-based ultrasound imaging as an intraoperative surgical margin assessment tool during breast-conserving surgery.

Technique of intraoperative ultrasound-guided excision of impalpable breast lesions

The introduction of breast screening programs has led to the increased detection of occult breast lesions requiring diagnostic surgical biopsy or breast-conserving surgery for early-stage breast cancer. Excision of impalpable breast lesions can be challenging. Whilst a variety of techniques have now been described including the use of adjuncts such as hook wires, radioactive seeds, magnetic seeds or radiofrequency devices, many of these modalities are expensive and can be logistically problematic. The technique of surgeon-performed ultrasound-guided excision is a straightforward technique which is safe, cost-efficient and avoids a painful preoperative procedure for patients such as hook wire localisation. Whilst the use of intraoperative ultrasound-guided excision of breast lesions has been widely reported, the actual technique itself has been less well described.

The Use of Intraoperative Ultrasound During Breast Conserving Surgery

OBJECTIVES

The purpose of this study is to evaluate the utilization of intraoperative ultrasound (IOUS) for tumor localization in breast-conserving surgery and to examine its impact on margin positivity and re-excision rates. Additionally, the study seeks to identify factors contributing to surgeon utilization of IOUS.

METHODS

A retrospective chart review was conducted of patients with preoperative diagnosis of breast cancer undergoing breast-conserving surgery by breast surgeons at multiple centers within a single healthcare system. Characteristics such as lesion size, palpability, histology, receptor status, and use of neoadjuvant chemotherapy were recorded. Re-excision rates were determined based on localization technique and surgeons' status of breast ultrasound certification.

RESULTS

A total of 671 cases were performed, with 322 meeting study inclusion. 57 cases utilized IOUS, 250 utilized preoperative wire-guided localization (WGL), 10 used both methods and 5 cases used neither method. There was no significant difference in re-excision rates between IOUS and WGL or among the four surgeons. Ultrasound-certified surgeons were more likely to utilize IOUS, and re-excision rates trended higher for WGL, which may be clinically significant.

CONCLUSION

Increasing familiarity with and utilization of IOUS during breast-conserving surgery may be clinically advantageous over traditional localization techniques. Ultrasound certification may lead to increased use of IOUS among surgeons.

Application of near-infrared fluorescence imaging in the accurate assessment of surgical margins during breast-conserving surgery

Objective

To evaluate the feasibility and accuracy of near-infrared fluorescence imaging technology for assessing margins during breast-conserving surgery for breast cancer.

Methods

Forty-three breast cancer patients who received surgical treatment at Yijishan Hospital of Wannan Medical College were selected. Before the operation, the patients were administered with an indocyanine green injection of 0.5 mg/kg intravenously 2 h before operation. During and after the operation, all patients underwent surgical margin monitoring with the near-infrared fluorescence imaging system for fluorescence imaging and acquisition of images and quantitative fluorescence intensity. During the operation, the patients’ tissue specimens were collected on the upper, lower, inner, outer, apical, and basal sides of the fluorescence boundary of the isolated lesions for pathological examination.

Results

Fluorescence was detected in the primary tumor in all patients. The average fluorescence intensities of tumor tissue, peritumoral tissue, and normal tissue were 219.41 ± 32.81, 143.35 ± 17.37, and 105.77 ± 17.79 arbitrary units, respectively (P < 0.05, t test). The signal-to-background ratio of tumor to peritumor tissue and normal tissue was 1.54 ± 0.20 and 2.14 ± 0.60, respectively (P < 0.05, t test). Abnormal indocyanine green fluorescence was detected in 11.6% patients (5/43), including 3 patients with residual infiltrating carcinoma and 2 patients with adenosis with ductal dilatation.

Conclusion

This study confirms the high sensitivity and specificity of near-infrared fluorescence imaging technology for breast-conserving surgery margin assessment. Near-infrared fluorescence imaging technology can be used as an intraoperative diagnosis and treatment tool to accurately determine the surgical margin and is of important guiding value in breast-conserving surgery for breast cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02827-4.

Rate of effect of surgical margins after breast conserving surgery and estimation of direct costs

OBJECTIVE

Assessment of the reoperation rate in patients with positive resection margins after initial breast-conserving surgery for breast cancer and estimation of the cost to the hospital.

METHOD

146 patients with diagnosis of invasive breast cancer were included, who were initially intervened with conservative surgery by the Gynecology and Obstetrics Service of Hospital Universitario de Tarragona Juan XXIII (HUTJ23) during the years 2018 and 2019. We calculated the rate of involvement of the surgical margins of the resection piece after initial conservative surgery, establishing in which cases it was necessary to carry out a second resection, estimating the added direct costs of the second surgical procedure, and comparing them with the costs established by the Catalan Health Service according to the level of the hospital and the Diagnosis-Related Groups (DRG) established by the National Health System.

RESULTS

The rate of positive margins after initial conservative surgery was 20.55% and 19.17% patients underwent reoperation, generating a total expense of € 129,696.89, € 82,654.34 in conservative surgeries (€ 3757.01 on average per patient) and € 47,042.55 in mastectomies (€ 6720.36 on average per patient).

CONCLUSIONS

Margin involvement after breast-conserving surgery is synonymous for reoperation, this involves a series of direct costs. It is advisable to control the factors related to affected margins to minimize their impact.

Breast Cancer—How Can Imaging Help?

Breast cancer is the most common malignant disease among women, causing death and suffering worldwide. It is known that, for the improvement of the survival rate and the psychological impact it has on patients, early detection is crucial. For this to happen, the imaging techniques should be used at their full potential. We selected and examined 44 articles that had as subject the use of a specific imaging method in breast cancer management (mammography, ultrasound, MRI, ultrasound-guided biopsy, PET-CT). After analyzing their data, we summarized and concluded which are the best ways to use each one of the mentioned techniques for a good outcome. We created a simplified algorithm with easy steps that can be followed by radiologists when facing this type of neoplasia.

Ultrasound Image Features under Deep Learning in Breast Conservation Surgery for Breast Cancer

This study was to analyze the effect of the combined application of deep learning technology and ultrasound imaging on the effect of breast-conserving surgery for breast cancer. A deep label distribution learning (LDL) model was designed, and the semiautomatic segmentation algorithm based on the region growing and active contour technology (RA) and the segmentation model based on optimized nearest neighbors (ON) were introduced for comparison. The designed algorithm was applied to the breast-conserving surgery of breast cancer patients. According to the difference in intraoperative guidance methods, 102 female patients with early breast cancer were divided into three groups: 34 cases in W1 group (ultrasound guidance based on deep learning segmentation model), 34 cases in W2 group (ultrasound guidance), and 34 cases in W3 group (palpation guidance). The results revealed that the tumor area segmented by the LDL algorithm constructed in this study was closer to the real tumor area; the segmentation accuracy (AC), Jaccard, and true-positive (TP) values of the LDL algorithm were obviously greater than those of the RA and ON algorithms, while the false-positive (FP) value was significantly lower in contrast to the RA and ON algorithms, showing statistically observable differences (P < 0.05); the actual resection volume of the patients in the W1 group was the closest to the ideal resection volume, which was much smaller in contrast to that of the patients in the W2 and W3 groups, showing statistical differences (P < 0.05); the positive margins of the patients in the W1 group were statistically lower than those in the W2 and W3 groups (P < 0.05). In addition, 1 patient in the W1 group was not satisfied with the cosmetic effect, 3 patients in the W2 group were not satisfied with the cosmetic effect, and 9 patients in the W3 group were not satisfied with the cosmetic effect. Finally, it was found that the ultrasound image based on the deep LDL model effectively improved the AC of tumor resection and negative margins, reduced the probability of normal tissue being removed, and improved the postoperative cosmetic effect of breast.

Rate of effect of surgical margins after breast conserving surgery and estimation of direct costs

OBJECTIVE

Assessment of the reoperation rate in patients with positive resection margins after initial breast-conserving surgery for breast cancer and estimation of the cost to the hospital.

METHOD

146 patients with diagnosis of invasive breast cancer were included, who were initially intervened with conservative surgery by the Gynecology and Obstetrics Service of Hospital Universitario de Tarragona Juan XXIII (HUTJ23) during the years 2018 and 2019. We calculated the rate of involvement of the surgical margins of the resection piece after initial conservative surgery, establishing in which cases it was necessary to carry out a second resection, estimating the added direct costs of the second surgical procedure, and comparing them with the costs established by the Catalan Health Service according to the level of the hospital and the Diagnosis-Related Groups (DRG) established by the National Health System.

RESULTS

The rate of positive margins after initial conservative surgery was 20.55% and 19.17% patients underwent reoperation, generating a total expense of € 129.696,89, € 82.654,34 in conservative surgeries (€ 3.757,01 on average per patient) and € 47.042,55 in mastectomies (€ 6.720,36 on average per patient).

CONCLUSIONS

Margin involvement after breast-conserving surgery is synonymous for reoperation, this involves a series of direct costs. It is advisable to control the factors related to affected margins to minimize their impact.

Review of Variables Associated With Positive Surgical Margins Using Scout Reflector Localizations for Breast Conservation Therapy

OBJECTIVE

To evaluate factors contributing to positive surgical margins associated with reflector guidance for patients undergoing breast conserving therapy for malignancy.

MATERIALS AND METHODS

A retrospective IRB-approved review of our institutional database was performed for malignant breast lesions preoperatively localized from January 1, 2018 to December 31, 2020. The following data was recorded using electronic medical records: lesion type and grade, lesion location, reflector and wire placement modality, use of intraoperative ultrasound, margin status, patient age, family history, BMI, and final pathology. Statistical analysis was performed with univariate summary statistics and logistic regression. P < .05 was significant.

RESULTS

A total of 606 image-guided pre-surgical localizations were performed for lumpectomies of breast malignancies. A total of 352 of 606 (58%) wire localizations and 254 of 606 (42%) SCOUT reflector localizations were performed. Sixty out of 352 (17%) of wire-localized patients had positive surgical margins, whereas forty-eight out of 254 (19%) of reflector-localized patients had positive surgical margins. (OR = 1.12, P value: .59). For reflector guided cases, the use of intraoperative ultrasound (IOUS) was associated with decreased positive margin status (OR = 0 .28, 95% CI = [0.14, 0.58]) while in situ disease was associated with increased positive margin status (OR = 1.99, 95% CI = [1.05, 3.75]). No association between modality used for localization (mammography vs. ultrasound) and positive margin status was observed (OR = 0.63, 95% CI = [0.33, 1.19]). No association between positive margins and age, family history, tumor location and BMI was observed.

CONCLUSION

For reflector guided surgeries, the use of IOUS was associated with decreased positive margins, by contrast the presence of ductal carcinoma in situ was associated with increased positive margins. There was no statistically significant difference in surgical outcomes for reflector-guided localization compared to wire localizations of the breast.

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.

Novel wire-free techniques for localization of impalpable breast lesions-A review of current options

Localization methods for breast lesions including cancers have changed and advanced since their inception. Currently, the most widely used technique in the United Kingdom is the image-guided hook wire localizer developed in the 1970s. It remains as the gold standard for localization of impalpable breast tumors. Besides its advantages, there are some disadvantages associated with this technique. In recent years, novel wire-free techniques (eg, Magseed^® , SCOUT^® , and LOCalizer™) have been developed to not only localize impalpable breast lesions but also negate the disadvantages of wire localization. This article reviews the variety of techniques from their origins to the most recent advancements that are used to localize breast lesions. The future is heading toward non-wire technology and wire localization may then be reserved for special cases.

A decade of intraoperative ultrasound guided breast conservation for margin negative resection - Radioactive, and magnetic, and Infrared Oh My…

BACKGROUND

The oncologic goal of margin-negative breast conservation requires adequate localization of tumor. Intraoperative ultrasound remains most feasible but under-utilized method to localize the tumor and assess margins.

METHODS

A prospectively maintained breast cancer database over a decade was queried for margin status in breast cancer patients undergoing breast conservation. Techniques of tumor localization, margin re-excision and closest margins were analyzed. Rate of conversion to mastectomy was determined.

RESULTS

Of the 945 breast cancer patients treated at a university-based Breast Center of Excellence between January 1, 2009 and December 31, 2018, 149(15.8%) had ductal carcinoma in situ; 712(75.3%) had invasive ductal carcinoma, and 63(6.7%) had invasive lobular carcinoma. Clinical stage distribution was: T1 = 372(39.4%); T2 = 257(27.2%); T3 = 87(9.2%). Five hundred and eighty three (61.7%) patients underwent breast conservation. The median (25th -75th centile) closest margin was 6(2.5, 10.0) mm. Thirty five (6.0%) patients underwent margin re-excision, of which 9(25%) were converted to mastectomy. Tumor localization was achieved with ultrasound in 521(89.4%) patients and with wire localization in 62(10.6%) patients. The median (25th-75th centile) closest margin with wire localization was 5.0(2.0, 8.5) mm versus 5.0 (2.0, 8.0) mm with ultrasound guidance [p = 0.6635]. The re-excision rate with wire localization was 14.5% versus 4.9% with ultrasound guidance [p = 0.0073]. The unadjusted Odds Ratio (95% CI) for margin revision in wire localized group compared with ultrasound was 3.2 (7.14, 1.42) [p = 0.0045]; multivariate adjusted OR (95%) was 4(9.09, 1.7) [p = 0.0013].

CONCLUSIONS

Ultrasound guidance for localization of breast cancer remains the most effective option for margin negative breast conservation.

First Reported Use of the Faxitron LOCalizer™ Radiofrequency Identification (RFID) System in Europe - A Feasibility Trial, Surgical Guide and Review for Non-palpable Breast Lesions

BACKGROUND/AIM

The problem of adequately marking any given lesion within a breast surgical site is commonly solved by introducing a titanium clip. However, clip dislocation and/or stereotactic hook-wire dislocation are common problems. An ideal solution would be a clip that can be easily found without the use of stereotactic intervention. This work reviews the available data on radiofrequency identification devices (RFID) in breast surgery, reports initial experience data in Europe and discusses surgical pitfalls, advantages and disadvantages.

PATIENTS AND METHODS

This study represents a single center, consecutively recruited, initiation trial with subsequent surgeon questionnaire for the first institution in Europe to report Faxitron LOCalizer™ chip data. Four patients with non-palpable tumors were marked with the system and were correlated via mammography, pre- and intra-operative ultrasound and pathology. Data were then compared to available literature and a literature review was added.

RESULTS

The four patients marked with this RFID system, displayed a 100% success location rate at a 0% complication rate. Surgeons evaluated the new system as being safe to use and only slightly more difficult to place compared to a standard clip. A significant improvement in ultrasound localization and intraoperative localization was also reported for the LOCalizer™ system when compared to a standard titanium clip.

CONCLUSION

This trial added a small number of consecutively recruited patients to an existing number of available data, resulting in a total of 121 evaluated and reviewed Faxitron LOCalizer™ marked non-palpable in-breast lesions worldwide.

Real-time electromagnetic navigation for breast-conserving surgery using NaviKnife technology: A matched case-control study

Breast-conserving surgery (BCS) is a mainstay in breast cancer treatment. For nonpalpable breast cancers, current strategies have limited accuracy, contributing to high positive margin rates. We developed NaviKnife, a surgical navigation system based on real-time electromagnetic (EM) tracking. The goal of this study was to confirm the feasibility of intraoperative EM navigation in patients with nonpalpable breast cancer and to assess the potential value of surgical navigation. We recruited 40 patients with ultrasound visible, single, nonpalpable lesions, undergoing BCS. Feasibility was assessed by equipment functionality and sterility, acceptable duration of the operation, and surgeon feedback. Secondary outcomes included specimen volume, positive margin rate, and reoperation outcomes. Study patients were compared to a control group by a matched case-control analysis. There was no equipment failure or breach of sterility. The median operative time was 66 (44-119) minutes with NaviKnife vs 65 (34-158) minutes for the control (P = .64). NaviKnife contouring time was 3.2 (1.6-9) minutes. Surgeons rated navigation as easy to setup, easy to use, and useful in guiding nonpalpable tumor excision. The mean specimen volume was 95.4 ± 73.5 cm³ with NaviKnife and 140.7 ± 100.3 cm³ for the control (P = .01). The positive margin rate was 22.5% with NaviKnife and 28.7% for the control (P = .52). The re-excision specimen contained residual disease in 14.3% for NaviKnife and 50% for the control (P = .28). Our results demonstrate that real-time EM navigation is feasible in the operating room for BCS. Excisions performed with navigation result in the removal of less breast tissue without compromising postive margin rates.

Intraoperative sonography for nonpalpable breast lesions: Additional indications for a consolidate technique

This prospective study evaluated the intraoperative ultrasound scan (IUSS) for nonpalpable breast lesions' detection. A total of 108 consecutive female patients underwent surgery using IUSS: Frozen sections demonstrated clear margins in 95.5% of neoplastic patients. Only four (4.5%) patients underwent local re-excision in the same operation. IUSS demonstrated to be quick, accurate, useful, effective, and safe for the intraoperative management of neoplastic nonpalpable breast lesions when performed by a surgeon who has undergone US training, particularly for people in whom alternative approaches can show some limitations due to contraindications or because of scheduling constraints, costs, and patient discomfort.

Stepwise En Bloc Resection of Breast Implant-Associated Anaplastic Large Cell Lymphoma with Oncologic Considerations

Guidelines published by the National Comprehensive Cancer Network state that standard of care treatment for the majority of patients with breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is surgical resection. This cancer is generally indolent, and if confined to the capsule, curative treatment is usually surgery alone. An en bloc resection involves a total capsulectomy, explantation, complete excision of associated masses, and excision of any involved lymph node(s). Patients with surgical control of disease have favorable long-term overall and event-free survival. Oncologic principles should be applied when resecting BIA-ALCL, and a complete oncologic resection is essential to cure patients of the disease. Incomplete resections, partial capsulectomies, and positive margins are all associated with high rates of disease recurrence and have potential for progression of the disease. Routine sentinel lymph node biopsy is unnecessary and full axillary lymph node dissection is rarely indicated except in cases of proven involvement of multiple nodes. Lymphoma oncology consultation and disease staging by imaging is performed prior to surgery. Importantly, en bloc resection is indicated only for an established diagnosis of BIA-ALCL, and is not recommended for merely suspicious or prophylactic surgeries. The purpose of this article was to demonstrate a stepwise approach to surgical ablation of BIA-ALCL with an emphasis on oncologic considerations critical to disease prognosis.