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Bjelica D, Colakovic N, Opric S, Zdravkovic D, Loboda B, Petricevic S, Gojgic M, Zecic O, Skuric Z, Zecic K, Ivanovic N. Non-Invasive 3D Breast Tumor Localization: A Viable Alternative to Invasive Tumor Marking. Cancers (Basel) 2024; 16:2564. [PMID: 39061203 PMCID: PMC11274474 DOI: 10.3390/cancers16142564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 07/08/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Background: We present a detailed description and the preliminary results of our original technique for non-invasive three-dimensional tumor localization in the breast, which was created as an alternative to standard invasive tumor marking before neoadjuvant systemic therapy (NAST), aiming to enable adequate surgery after complete tumor regression. Methods: A detailed description of the technique is provided in the main text. The technique's feasibility and precision were assessed in a single-arm, prospective study based on the histological parameters of the adequacy and rationality of the excision of completely regressed tumor beds. Results: Out of 94 recruited patients, 15 (16%) were deemed unsuitable, mainly due to the tumors' inadequate ultrasound visibility. Among the 79 processed patients, 31 (39%) had complete clinical regression after NAST and were operated on using our technique. The histological parameters of surgical precision (signs of tumor regression: 24/31; microscopic cancer residues: 7/31) were verified in all excised specimens (100% precision). There were no positive margins in seven cases with microscopic residues, indicating our technique's capacity to enable oncologically safe post-NAST surgery. Conclusions: The proposed technique is feasible and satisfactorily accurate in determining the location of regressed tumors, thus representing an alternative to invasive tumor marking, especially in surgical centers lacking trained staff and equipment for invasive marking. The technique's limitations are mainly related to the inadequate ultrasound visibility of the tumor.
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Affiliation(s)
- Dragana Bjelica
- Department of Radiology, University Hospital Medical Center “Bežanijska kosa”, Zorza Matea bb, 11070 Belgrade, Serbia;
| | - Natasa Colakovic
- Department of Surgical Oncology, University Hospital Medical Center “Bežanijska kosa”, Zorza Matea bb, 11070 Belgrade, Serbia (N.I.)
- Faculty of Medicine, University of Belgrade, Dr. Subotica 8, 11000 Belgrade, Serbia
| | - Svetlana Opric
- Department of Pathology, University Hospital Medical Center “Bežanijska kosa”, Zorza Matea bb, 11070 Belgrade, Serbia
- Faculty of Dentistry Pancevo, Zarka Zrenjanina 179, 26000 Pancevo, Serbia
| | - Darko Zdravkovic
- Department of Surgical Oncology, University Hospital Medical Center “Bežanijska kosa”, Zorza Matea bb, 11070 Belgrade, Serbia (N.I.)
- Faculty of Medicine, University of Belgrade, Dr. Subotica 8, 11000 Belgrade, Serbia
| | - Barbara Loboda
- Department of Surgical Oncology, University Hospital Medical Center “Bežanijska kosa”, Zorza Matea bb, 11070 Belgrade, Serbia (N.I.)
| | - Simona Petricevic
- Department of Surgical Oncology, University Hospital Medical Center “Bežanijska kosa”, Zorza Matea bb, 11070 Belgrade, Serbia (N.I.)
- Faculty of Medicine, University of Belgrade, Dr. Subotica 8, 11000 Belgrade, Serbia
| | - Milan Gojgic
- Department of Surgical Oncology, University Hospital Medical Center “Bežanijska kosa”, Zorza Matea bb, 11070 Belgrade, Serbia (N.I.)
| | - Ognjen Zecic
- Department of General Surgery, University Hospital Medical Center “Bežanijska kosa”, Zorza Matea bb, 11070 Belgrade, Serbia
| | - Zlatko Skuric
- Department of Surgical Oncology, University Hospital Medical Center “Bežanijska kosa”, Zorza Matea bb, 11070 Belgrade, Serbia (N.I.)
| | - Katarina Zecic
- Clinic for Gynecology and Obstetrics, Clinical Center of Serbia, Visegradska 26, 11000 Belgrade, Serbia
| | - Nebojsa Ivanovic
- Department of Surgical Oncology, University Hospital Medical Center “Bežanijska kosa”, Zorza Matea bb, 11070 Belgrade, Serbia (N.I.)
- Faculty of Medicine, University of Belgrade, Dr. Subotica 8, 11000 Belgrade, Serbia
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Boeer B, Obermoser J, Marx M, Schönfisch B, Grube M, Röhm C, Helms G, Fugunt R, Hartkopf AD, Brucker SY, Hahn M. Ultrasound-guided breast-conserving surgery compared to conventional breast-conserving surgery. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024. [PMID: 38901438 DOI: 10.1055/a-2290-1543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
PURPOSE The goal of breast-conserving surgery is to achieve negative tumor margins, since insufficient marginal distance is associated with more local and distant recurrences. This study investigates whether IOUS (intraoperative ultrasound) can reduce the re-resection rate compared to standard breast surgery, regardless of tumor biology and focality. MATERIALS AND METHODS The present study is a monocentric, prospective, randomized, and non-blinded parallel group study conducted between 7/2015 and 2/2018. Patients with sonographically visible breast cancer were randomized into two study arms: 1) breast-conserving surgery with IOUS; 2) conventional arm. RESULTS 364 patients were included in the study and underwent surgery. Tumor biology, size, and focality were equally distributed in both groups (p = 0.497). The study arms did not differ significantly in the proportion of preoperative wire markings (p= 0.084), specimen weight (p = 0.225), surgery duration (p = 0.849), and the proportion of shavings taken intraoperatively (p = 0.903). Positive margins were present in 16.6% of the cases in the IOUS arm and in 20.8% in the conventional arm (p = 0.347). Re-operation was necessary after intraoperative shavings in 14.4% of cases in the US arm and in 21.3% in the conventional arm (p = 0.100). CONCLUSION Although the present study showed a clear difference in the rate of positive tumor margins with IOUS compared to conventional breast surgery without IOUS, this was not statistically significant in contrast to the current literature. This could be due to the high expertise of the breast surgeons, the precise wire marking, or the fact that the IOUS technique was not standardized.
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Affiliation(s)
- Bettina Boeer
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Jennifer Obermoser
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Mario Marx
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
- ELBLANDKLINIKUM Radebeul, Radebeul, Germany
| | - Birgitt Schönfisch
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Marcel Grube
- Diakonie-Klinikum Schwäbisch Hall, Schwäbisch Hall, Germany
| | - Carmen Röhm
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Gisela Helms
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Regina Fugunt
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Andreas D Hartkopf
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Sara Y Brucker
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Markus Hahn
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
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Ferrucci M, Milardi F, Passeri D, Mpungu LF, Francavilla A, Cagol M, Saibene T, Michieletto S, Toffanin M, Del Bianco P, Grossi U, Marchet A. Intraoperative Ultrasound-Guided Conserving Surgery for Breast Cancer: No More Time for Blind Surgery. Ann Surg Oncol 2023; 30:6201-6214. [PMID: 37606837 DOI: 10.1245/s10434-023-13900-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/23/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Breast-conserving surgery (BCS) still remains a blind surgery despite all available tumor localization methods. Intraoperative ultrasound (IOUS) allows real-time visualization during all resection phases. METHODS This was a prospective observational cohort study conducted at the Veneto Institute of Oncology between January 2021 and June 2022. Patients with ductal carcinoma in situ, T1-2 invasive cancer, or post-neoadjuvant tumors, suitable for BCS, were recruited. All breast cancer lesion types were included, i.e. solid palpable, solid non-palpable, non-solid non-palpable, and post-neoadjuvant treatment residual lesions. Eligible participants were randomly assigned to either IOUS or traditional surgery (TS) in a 1:1 ratio. The main outcomes were surgical margin involvement, reoperation rate, closest margin width, main specimen and cavity shaving margin volumes, excess healthy tissue removal, and calculated resection ratio (CRR). RESULTS Overall, 160 patients were enrolled: 80 patients were allocated to the TS group and 80 to the IOUS group. IOUS significantly reduced specimen volumes (16.8 cm3 [10.5-28.9] vs. 24.3 cm3 [15.0-41.3]; p = 0.015), with wider closest resection margin width (2.0 mm [1.0-4.0] vs. 1.0 mm [0.5-2.0] after TS; p < 0.001). Tumor volume to specimen volume ratio was significantly higher after IOUS (4.7% [2.5-9.1] vs. 2.9% [0.8-5.2]; p < 0.001). IOUS yielded significantly better CRR (84.5% [46-120.8] vs. 114% [81.8-193.2] after TS; p < 0.001), lower involved margin rate (2.5 vs. 15%; p = 0.009) and reduced re-excision rate (2.5 vs. 12.5%; p = 0.032). CONCLUSIONS IOUS allows real-time resection margin visualization and continuous control during BCS. It showed clear superiority over TS in both oncological and surgical outcomes for all breast cancer lesion types. These results disfavor the paradigm of blind breast surgery.
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Affiliation(s)
- Massimo Ferrucci
- Breast Surgery Unit, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy.
| | - Francesco Milardi
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Daniele Passeri
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Andrea Francavilla
- Unit of Biostatistics, Epidemiology and Public Health, Department of CardiacThoracic Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Matteo Cagol
- Breast Surgery Unit, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
| | - Tania Saibene
- Breast Surgery Unit, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
| | - Silvia Michieletto
- Breast Surgery Unit, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
| | - Mariacristina Toffanin
- Breast Surgery Unit, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
| | - Paola Del Bianco
- Clinical Trials and Biostatistics, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
| | - Ugo Grossi
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Alberto Marchet
- Breast Surgery Unit, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
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4
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Vartanian A, Papas PV, Guarecuco Castillo JE, Sistare M, Masri MM. Ultrasound Guided Intraoperative Wire Localization Under General Anesthesia in Breast-Conserving Surgery. Cureus 2023; 15:e41662. [PMID: 37565099 PMCID: PMC10412144 DOI: 10.7759/cureus.41662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/12/2023] Open
Abstract
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.
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Affiliation(s)
- Artin Vartanian
- General Surgery, St. George's University School of Medicine, St. George's, GRD
| | - Paraskevi V Papas
- General Surgery, St. George's University School of Medicine, St. George's, GRD
| | | | - Michael Sistare
- General Surgery, Larkin Community Hospital, South Miami, USA
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5
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Togawa R, Hederer J, Ragazzi M, Bruckner T, Fastner S, Gomez C, Hennigs A, Nees J, Pfob A, Riedel F, Schäfgen B, Stieber A, Lux MP, Heil J, Golatta M. Imaging of lumpectomy surface with large field-of-view confocal laser scanning microscopy 'Histolog® scanner' for breast margin assessment in comparison with conventional specimen radiography. Breast 2023; 68:194-200. [PMID: 36842192 PMCID: PMC9988675 DOI: 10.1016/j.breast.2023.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/05/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
PURPOSE The Histolog® Scanner (SamanTree Medical SA, Lausanne, Switzerland) is a large field-of-view confocal laser scanning microscope designed to allow intraoperative margin assessment by the production of histological images ready for assessment in the operating room. We evaluated the feasibility and the performance of the Histolog® Scanner (HS) to correctly identify infiltrated margins in clinical practice of lumpectomy specimens. It was extrapolated if the utilization of the HS has the potential to reduce infiltrated margins and therefore reduce re-operation rates in patients undergoing breast conserving surgery (BCS) due to a primarily diagnosed breast cancer including ductal carcinoma in situ. METHODS This is a single-center, prospective, non-interventional, diagnostic pilot study including 50 consecutive patients receiving BCS. The complete surface of the specimen was scanned using the HS intraoperatively. The surgery and the intraoperative margin assessment of the specimen was performed according to the clinical routine consisting of conventional specimen radiography as well as the clinical impression of the surgeon. Three surgeons and an experienced pathologist assessed the scans produced by the HS for cancer cells on the surface. The potential of the HS to correctly identify involved margins was compared to the results of the conventional specimen radiography alone as well as the clinical routine. The histopathological report served as the gold standard. RESULTS 50 specimens corresponding to 300 surfaces were scanned by the HS. The mean sensitivity of the surgeons to identify involved margins with the HS was 37.5% ± 5.6%, the specificity was 75.2% ± 13.0%. The assessment of resection margins by the pathologist resulted in a sensitivity of 37.5% and a specificity of 81.0%, while the local clinical routine resulted in a sensitivity of 37.5% and a specificity of 78.2%. CONCLUSION Acquisition of high-resolution histological images using the HS was feasible in clinical practice. Sensitivity and specificity were comparable to clinical routine. With more specific training and experience on image interpretation and acquisition, the HS may have the potential to enable more accuracy in the margin assessment of BCS specimens.
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Affiliation(s)
- Riku Togawa
- Breast Unit, Department of Obstetrics and Gynecology, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Johanna Hederer
- Breast Unit, Department of Obstetrics and Gynecology, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Moira Ragazzi
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Thomas Bruckner
- Institute of Medical Biometry (IMBI), Heidelberg University, 69120, Heidelberg, Germany
| | - Sarah Fastner
- Breast Unit, Sankt Elisabeth Hospital, 69121, Heidelberg, Germany
| | - Christina Gomez
- Breast Unit, Department of Obstetrics and Gynecology, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - André Hennigs
- Breast Unit, Department of Obstetrics and Gynecology, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Juliane Nees
- Breast Unit, Department of Obstetrics and Gynecology, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - André Pfob
- Breast Unit, Department of Obstetrics and Gynecology, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Fabian Riedel
- Breast Unit, Department of Obstetrics and Gynecology, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Benedikt Schäfgen
- Breast Unit, Department of Obstetrics and Gynecology, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Anne Stieber
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Michael P Lux
- Department of Gynecology and Obstetrics, Frauenklinik St. Louise Paderborn, St. Josefs-Krankenhaus, 33098, Salzkotten, Germany
| | - Jörg Heil
- Breast Unit, Department of Obstetrics and Gynecology, Heidelberg University Hospital, 69120, Heidelberg, Germany; Breast Unit, Sankt Elisabeth Hospital, 69121, Heidelberg, Germany
| | - Michael Golatta
- Breast Unit, Department of Obstetrics and Gynecology, Heidelberg University Hospital, 69120, Heidelberg, Germany; Breast Unit, Sankt Elisabeth Hospital, 69121, Heidelberg, Germany.
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Banys-Paluchowski M, Kühn T, Masannat Y, Rubio I, de Boniface J, Ditsch N, Karadeniz Cakmak G, Karakatsanis A, Dave R, Hahn M, Potter S, Kothari A, Gentilini OD, Gulluoglu BM, Lux MP, Smidt M, Weber WP, Aktas Sezen B, Krawczyk N, Hartmann S, Di Micco R, Nietz S, Malherbe F, Cabioglu N, Canturk NZ, Gasparri ML, Murawa D, Harvey J. Localization Techniques for Non-Palpable Breast Lesions: Current Status, Knowledge Gaps, and Rationale for the MELODY Study (EUBREAST-4/iBRA-NET, NCT 05559411). Cancers (Basel) 2023; 15:cancers15041173. [PMID: 36831516 PMCID: PMC9954476 DOI: 10.3390/cancers15041173] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Surgical excision of a non-palpable breast lesion requires a localization step. Among available techniques, wire-guided localization (WGL) is most commonly used. Other techniques (radioactive, magnetic, radar or radiofrequency-based, and intraoperative ultrasound) have been developed in the last two decades with the aim of improving outcomes and logistics. METHODS We performed a systematic review on localization techniques for non-palpable breast cancer. RESULTS For most techniques, oncological outcomes such as lesion identification and clear margin rate seem either comparable with or better than for WGL, but evidence is limited to small cohort studies for some of the devices. Intraoperative ultrasound is associated with significantly higher negative margin rates in meta-analyses of randomized clinical trials (RCTs). Radioactive techniques were studied in several RCTs and are non-inferior to WGL. Smaller studies show higher patient preference towards wire-free localization, but little is known about surgeons' and radiologists' attitudes towards these techniques. CONCLUSIONS Large studies with an additional focus on patient, surgeon, and radiologist preference are necessary. This review aims to present the rationale for the MELODY (NCT05559411) study and to enable standardization of outcome measures for future studies.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lübeck, 23538 Lübeck, Germany
- Correspondence:
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Die Filderklinik, 70794 Filderstadt, Germany
| | - Yazan Masannat
- Aberdeen Breast Unit, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK
| | - Isabel Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, 28027 Madrid, Spain
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 17177 Stockholm, Sweden
- Department of Surgery, Capio St. Göran’s Hospital, 11219 Stockholm, Sweden
| | - Nina Ditsch
- Breast Cancer Center, University Hospital Augsburg, 86156 Augsburg, Germany
| | - Güldeniz Karadeniz Cakmak
- Breast and Endocrine Unit, General Surgery Department, Zonguldak BEUN The School of Medicine, Kozlu/Zonguldak 67600, Turkey
| | - Andreas Karakatsanis
- Department for Surgical Sciences, Faculty of Pharmacy and Medicine, Uppsala University, 75236 Uppsala, Sweden
- Section for Breast Surgery, Department of Surgery, Uppsala University Hospital, 75236 Uppsala, Sweden
| | - Rajiv Dave
- Nightingale & Genesis Breast Cancer Prevention Centre, Manchester University NHS Foundation Trust, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Markus Hahn
- Department for Women’s Health, University of Tübingen, 72076 Tübingen, Germany
| | - Shelley Potter
- Bristol Medical School (THS), Bristol Population Health Science Institute, Bristol BS8 1QU, UK
| | - Ashutosh Kothari
- Guy’s & St Thomas NHS Foundation Trust, Kings College, London SE1 9RT, UK
| | - Oreste Davide Gentilini
- Department of Breast Surgery, San Raffaele University and Research Hospital, 20132 Milan, Italy
| | - Bahadir M. Gulluoglu
- Department of Surgery, Breast Surgery Unit, Marmara University School of Medicine and SENATURK Turkish Academy of Senology, Istanbul 34854, Turkey
| | - Michael Patrick Lux
- Department of Gynecology and Obstetrics, St. Louise Frauen-und Kinderklinik, 33098 Paderborn, Germany
| | - Marjolein Smidt
- Department of Surgical Oncology, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands
| | - Walter Paul Weber
- Division of Breast Surgery, Department of Surgery, Basel University Hospital, 4031 Basel, Switzerland
| | - Bilge Aktas Sezen
- European Breast Cancer Research Association of Surgical Trialists (EUBREAST), 73730 Esslingen, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Steffi Hartmann
- Department of Gynecology and Obstetrics, University Hospital Rostock, 18059 Rostock, Germany
| | - Rosa Di Micco
- Department of Breast Surgery, San Raffaele University and Research Hospital, 20132 Milan, Italy
| | - Sarah Nietz
- Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Francois Malherbe
- Breast and Endocrine Surgery Unit, Groote Schuur Hospital, University of Cape Town, Cape Town 7935, South Africa
| | - Neslihan Cabioglu
- Istanbul Faculty of Medicine, Department of General Surgery, Istanbul University, Istanbul 34093, Turkey
| | - Nuh Zafer Canturk
- Department of General Surgery, Kocaeli University School of Medicine, Kocaeli 41001, Turkey
| | - Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ospedale Regionale di Lugano EOC, 6900 Lugano, Switzerland
- Centro di Senologia della Svizzera Italiana (CSSI), Ente Ospedaliero Cantonale, Via Pietro Capelli 1, 6900 Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Via Giuseppe Buffi 13, 6900 Lugano, Switzerland
| | - Dawid Murawa
- General Surgery and Surgical Oncology Department, Collegium Medicum, University in Zielona Gora, 65-417 Zielona Góra, Poland
| | - James Harvey
- Nightingale & Genesis Breast Cancer Prevention Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester M13 9PL, UK
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7
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Fosko NK, Gribkova Y, Krupa K, Bs KJ, Moore D, Chen C, Potdevin L, Kumar S, Eladoumikdachi F, Kowzun MJ. The Use of Intraoperative Ultrasound During Breast Conserving Surgery. Clin Breast Cancer 2023; 23:54-59. [PMID: 36319507 DOI: 10.1016/j.clbc.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/07/2022] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Nicole K Fosko
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Kelly Krupa
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Kavita Jain Bs
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Dirk Moore
- Rutgers School of Public Health, New Brunswick, New Jersey
| | - Chunxia Chen
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Lindsay Potdevin
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Shicha Kumar
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | | | - Maria J Kowzun
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
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8
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Banys-Paluchowski M, Rubio IT, Karadeniz Cakmak G, Esgueva A, Krawczyk N, Paluchowski P, Gruber I, Marx M, Brucker SY, Bündgen N, Kühn T, Rody A, Hanker L, Hahn M. Intraoperative Ultrasound-Guided Excision of Non-Palpable and Palpable Breast Cancer: Systematic Review and Meta-Analysis. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:367-379. [PMID: 35760079 DOI: 10.1055/a-1821-8559] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Wire-guided localization (WGL) is the most frequently used localization technique in non-palpable breast cancer (BC). However, low negative margin rates, patient discomfort, and the possibility of wire dislocation have been discussed as potential disadvantages, and re-operation due to positive margins may increase relapse risk. Intraoperative ultrasound (IOUS)-guided excision allows direct visualization of the lesion and the resection volume and reduces positive margins in palpable and non-palpable tumors. We performed a systematic review on IOUS in breast cancer and 2 meta-analyses of randomized clinical trials (RCTs). In non-palpable BC, 3 RCTs have shown higher negative margin rates in the IOUS arm compared to WGL. Meta-analysis confirmed a significant difference between IOUS and WGL in terms of positive margins favoring IOUS (risk ratio 4.34, p < 0.0001, I2 = 0%). 41 cohort studies including 3291 patients were identified, of which most reported higher negative margin and lower re-operation rates if IOUS was used. In palpable BC, IOUS was compared to palpation-guided excision in 3 RCTs. Meta-analysis showed significantly higher rates of positive margins in the palpation arm (risk ratio 2.84, p = 0.0047, I2 = 0%). In 13 cohort studies including 942 patients with palpable BC, negative margin rates were higher if IOUS was used, and tissue volumes were higher in palpation-guided cohorts in most studies. IOUS is a safe noninvasive technique for the localization of sonographically visible tumors that significantly improves margin rates in palpable and non-palpable BC. Surgeons should be encouraged to acquire ultrasound skills and participate in breast ultrasound training.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
- Medical Faculty, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Isabel T Rubio
- Breast Surgical Unit, Clinica Universidad de Navarra, Madrid, Spain
| | - Güldeniz Karadeniz Cakmak
- General Surgery Department, Breast and Endocrine Unit, Zonguldak BEUN The School of Medicine, Kozlu/Zonguldak, Turkey
| | - Antonio Esgueva
- Breast Surgical Unit, Clinica Universidad de Navarra, Madrid, Spain
| | - Natalia Krawczyk
- Department of Obstetrics and Gynecology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Peter Paluchowski
- Department of Gynecology and Obstetrics, Regio Klinikum Pinneberg, Pinneberg, Germany
| | - Ines Gruber
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Mario Marx
- Department of Plastic, Reconstructive and Breast Surgery, Elblandklinikum Radebeul, Radebeul, Germany
| | - Sara Y Brucker
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Nana Bündgen
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
| | - Achim Rody
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Lars Hanker
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Markus Hahn
- Department for Women's Health, University of Tübingen, Tübingen, Germany
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9
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Davey MG, O'Donnell JPM, Boland MR, Ryan ÉJ, Walsh SR, Kerin MJ, Lowery AJ. Optimal localization strategies for non-palpable breast cancers –A network meta-analysis of randomized controlled trials. Breast 2022; 62:103-113. [PMID: 35151049 PMCID: PMC8844725 DOI: 10.1016/j.breast.2022.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 01/31/2022] [Accepted: 02/06/2022] [Indexed: 12/04/2022] Open
Abstract
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. Ultrasound-guided (USGL) and anchor-guided (AGL) localization had optimal outcomes. These methods significantly lowered margin positivity (odds ratio: 0.192 & 0.229). However, small sample sizes in trials evaluating USGL and AGL limit these results. Operation duration, complications, or specimen data were comparable for all methods.
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Affiliation(s)
- Matthew G Davey
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Galway, H91 YR71, Ireland.
| | - John P M O'Donnell
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Galway, H91 YR71, Ireland
| | - Michael R Boland
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Galway, H91 YR71, Ireland
| | - Éanna J Ryan
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Galway, H91 YR71, Ireland
| | - Stewart R Walsh
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Galway, H91 YR71, Ireland
| | - Michael J Kerin
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Galway, H91 YR71, Ireland
| | - Aoife J Lowery
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Galway, H91 YR71, Ireland
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10
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Semillas radiactivas y no radiactivas como método de localización quirúrgica de las lesiones mamarias no palpables. Rev Esp Med Nucl Imagen Mol 2022. [DOI: 10.1016/j.remn.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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11
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Cebrecos I, Sánchez-Izquierdo N, Ganau S, Mensión E, Perissinotti A, Úbeda B, Bargalló X, Alonso I, Vidal-Sicartb S. Radioactive and non-radioactive seeds as surgical localization method of non-palpable breast lesions. Rev Esp Med Nucl Imagen Mol 2022; 41:100-107. [DOI: 10.1016/j.remnie.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 11/21/2021] [Indexed: 11/28/2022]
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12
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Hadar T, Koretz M, Nawass M, Allweis TM. Innovative Standards in Surgery of the Breast after Neoadjuvant Systemic Therapy. Breast Care (Basel) 2021; 16:590-597. [PMID: 35087362 PMCID: PMC8739938 DOI: 10.1159/000520051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/29/2021] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND The goal of neoadjuvant systemic therapy (NST) in breast cancer is to downstage tumors and downgrade treatment. Indications are constantly evolving. These changes raise practical questions for planning of surgery after NST. SUMMARY In this review we discuss current evolving aspects of surgery of the breast after NST. Breast-conserving surgery (BCS) eligibility increases after NST - both neoadjuvant chemotherapy (NAC) and neoadjuvant endocrine therapy. Adequate margin width in NST and upfront surgery are similar - "no tumor on ink" for invasive cancer. Oncoplastic breast surgery after NST is feasible - both for BCS and mastectomy with reconstruction. There is increasing interest in the possibility of omitting surgery in patients with a complete response to NAC. Several trials are being conducted in aim of achieving acceptable prediction of pathological complete response, by combination of imaging and percutaneous biopsy of the tumor bed, as well as assessing the safety of such an approach. KEY MESSAGES Surgery of the breast after NST should be determined not only according to biologic and anatomic parameters at diagnosis, but is dynamic, and must be tailored according to the response to therapy. The omission of surgery in exceptional responders after NAC is being explored.
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Affiliation(s)
- Tal Hadar
- Department of Breast Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Michael Koretz
- Department of Breast Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mahmood Nawass
- Department of Breast Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Tanir M. Allweis
- Department of Breast Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
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13
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Does Tumor Marking Before Neoadjuvant Chemotherapy Helps Achieve Better Outcomes in Patients Undergoing Breast Conservative Surgery? A Systematic Review. Indian J Surg Oncol 2021; 12:624-631. [PMID: 34658593 DOI: 10.1007/s13193-021-01393-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022] Open
Abstract
Patients with breast cancer are increasingly being offered breast conserving surgery (BCS) following neoadjuvant chemotherapy (NACT). We aimed to conduct a systematic review to assess the advantage of tumor marking in patients undergoing BCS after NACT. After registering the protocol for a systematic review with PROSPERO, a systematic search was conducted through September 30, 2020, for all studies involving patients undergoing BCS post NACT after tumor marking. Margin status on final histology was the primary outcome. Oxford Centre for Evidence Based Medicine (OCEBM) levels were used to assess internal validity. A total of 636 records from Medline/PubMed, 1381 from Embase, and 1422 from Cochrane library were extracted. After screening, 15 articles (1520 patients) were included for data synthesis. For marking, 6 studies used metallic markers and 5 used 125I-radioactive seeds (RSL) followed by skin tattoo and radio-guided occult lesion localization using 99mTc (ROLL) in one study each. Most studies used a single marker at the center except for two (143 patients), who practiced the bracketing technique. Incidence of unsatisfactory margins (positive/close) ranged from 5 to 23.5%. After excluding patients with complete pathological response, the "adjusted unsatisfactory margin" rate was found to be 19.3% (10.4-33%). Overall 20.6 recurrences (locoregional/distant) were reported per 1000 patient-years follow-up. Overall survival (OS) was only reported by one study as 96.6% and 84.7% in patients with and without marker placement (p = .01). Re-excision and secondary mastectomy rates (reported by nine studies) were 7.3% and 5.7% respectively. There is limited evidence that tumor marking before neoadjuvant chemotherapy improves the rate of unsatisfactory margins or survival outcomes in a patient undergoing BCS after NACT.
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14
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Richey WL, Heiselman JS, Luo M, Meszoely IM, Miga MI. Impact of deformation on a supine-positioned image-guided breast surgery approach. Int J Comput Assist Radiol Surg 2021; 16:2055-2066. [PMID: 34382176 DOI: 10.1007/s11548-021-02452-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 07/06/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To reduce reoperation rates for image-guided breast-conserving surgery, the enhanced sensitivity of magnetic resonance (MR) supine imaging may be leveraged. However, accurate tissue correspondence between images and their physical counterpart in the surgical presentation is challenging due to breast deformations (e.g., from patient/arm position changes, and operating room table rotation differences). In this study, standard rigid registration methods are employed and tissue deformation is characterized. METHODS On n = 10 healthy breasts, surface displacements were measured by comparing intraoperative fiducial locations as the arm was moved from conventional MR scanning positions (arm-down and arm-up) to the laterally extended surgical configuration. Supine MR images in the arm-down and arm-up positions were registered to mock intraoperative presentations. RESULTS Breast displacements from a supine MR imaging configuration to a mock surgical presentation were 28.9 ± 9.2 mm with shifts occurring primarily in the inferior/superior direction. With respect to supine MR to surgical alignment, the average fiducial, target, and maximum target registration errors were 9.0 ± 1.7 mm, 9.3 ± 1.7 mm, and 20.0 ± 7.6 mm, respectively. Even when maintaining similar arm positions in the MR image and mock surgery, the respective averages were 6.0 ± 1.0 mm, 6.5 ± 1.1 mm, and 12.5 ± 2.8 mm. CONCLUSION From supine MR positioning to surgical presentation, the breast undergoes large displacements (9.9-70.1 mm). The data also suggest that significant nonrigid deformations (9.3 ± 1.7 mm with 20.0 mm average maximum) exist that need to be considered in image guidance and modeling applications.
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Affiliation(s)
- Winona L Richey
- Department of Biomedical Engineering, Vanderbilt University, 1225 Stevenson Center Ln, Nashville, 37235, USA.
- Vanderbilt Institute for Surgery and Engineering, 1161 21st Ave. S, Nashville, 37204, USA.
- Vanderbilt University, 1225 Stevenson Center Ln, Stevenson Center 5824, Nashville, TN, 37240, USA.
| | - Jon S Heiselman
- Department of Biomedical Engineering, Vanderbilt University, 1225 Stevenson Center Ln, Nashville, 37235, USA
- Vanderbilt Institute for Surgery and Engineering, 1161 21st Ave. S, Nashville, 37204, USA
| | - Ma Luo
- Department of Biomedical Engineering, Vanderbilt University, 1225 Stevenson Center Ln, Nashville, 37235, USA
- Vanderbilt Institute for Surgery and Engineering, 1161 21st Ave. S, Nashville, 37204, USA
| | - Ingrid M Meszoely
- Vanderbilt Institute for Surgery and Engineering, 1161 21st Ave. S, Nashville, 37204, USA
- Division of Surgical Oncology, Vanderbilt University Medical Center, 719 Thompson Ln Suite 22100, Nashville, 37232, USA
| | - Michael I Miga
- Department of Biomedical Engineering, Vanderbilt University, 1225 Stevenson Center Ln, Nashville, 37235, USA
- Vanderbilt Institute for Surgery and Engineering, 1161 21st Ave. S, Nashville, 37204, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave. S, Nashville, 37232, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA
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15
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Gulcelik MA, Dogan L. Unplanned breast-conserving surgery after systemic therapy in locally advanced breast cancer: The results of level II oncoplastic techniques. Int J Clin Pract 2021; 75:e14268. [PMID: 33891352 DOI: 10.1111/ijcp.14268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/19/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In patients with breast cancer for whom neoadjuvant chemotherapy (NAC) is planned, it is recommended to mark the primary tumour before treatment (planned surgery). However, surgeons may have to perform breast-conserving surgery on patients whose tumours are not marked (unplanned surgery). This study focused on the results obtained with planned and unplanned level II oncoplastic surgery (OPS) techniques applied to patients after NAC. METHODS Patient groups who underwent planned, unplanned OPS and mastectomy after NAC were compared. Surgical margin status, re-operation and re-excision requirements, ipsilateral breast tumour recurrence (IBTR) and axillary recurrence rates recorded. Long-term local recurrence-free survival (LRFS), disease-free survival and overall survival were evaluated. RESULTS There was no significant difference between the planned and unplanned OPS groups in terms of surgical margin status, re-excision requirement, and mastectomy rates. During an average follow-up period of 43 months, 5.3% and 4% of the patients in the planned OPS group developed IBTR and axillary recurrence, respectively, whereas these rates were 6.6% and 5.3% in the unplanned OPS group. In the mastectomy group, the rates of IBTR and axillary recurrence were found to be 4.1% and 3.8%, respectively. There was no significant difference between the three groups in terms of IBTR (P: .06) and axillary recurrence (P: .08) rates. CONCLUSION Breast conserving surgery can be applied using level II OPS techniques with the post-NAC radiological examination and marking even if primary tumour marking is not done in the pre-NAC period.
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Affiliation(s)
- Mehmet A Gulcelik
- Department of Surgical Oncology, Gulhane Medical School, University of Health Sciences, Ankara, Turkey
| | - Lutfi Dogan
- Department of Surgical Oncology, University of Health Sciences AY Ankara Oncology Training and Research Hospital, Ankara, Turkey
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16
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Wu ZY, Kim GB, Lee S, Choi SH, Kim N, Ko B. Case Report: A 3D-Printed Surgical Guide for Breast-Conserving Surgery After Neoadjuvant Chemotherapy. Front Oncol 2021; 11:633302. [PMID: 33842340 PMCID: PMC8027348 DOI: 10.3389/fonc.2021.633302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background A challenging problem for patients undergoing breast-conserving surgery after neoadjuvant chemotherapy (NACT) is the accuracy of preoperative tumor localization. After chemotherapy, the original tumor is likely to shrink or scatter dramatically or even show complete remission. For breast-conserving surgery, the development of a guidance device to accurately estimate the resection area is imperative. Case Presentation We produced a three-dimensional (3D)-printed breast surgical guide (BSG) based on prone and supine magnetic resonance imaging (MRI). This device was tested on a patient who underwent breast-conserving surgery after NACT. Both ultrasonography and MRI revealed that the tumor shrank substantially after NACT. Identifying the target tumor area using pre-NACT MRI was feasible, and the tumor was safely removed with clear resection margins. Conclusion The BSG has several advantages over conventional methods for tumor localization after NACT. In particular, the BSG provided precise quantitative MRI information about the tumor area.
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Affiliation(s)
- Zhen-Yu Wu
- Department of Breast Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.,Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.,Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, South Korea
| | - Guk Bae Kim
- Research Department, Anymedi Inc., Seoul, South Korea
| | - Sangwook Lee
- Research Department, Anymedi Inc., Seoul, South Korea
| | | | - Namkug Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - BeomSeok Ko
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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17
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Magnetic resonance-guided ROLL/SNOLL in breast cancer patients treated with neoadjuvant chemotherapy. Rev Esp Med Nucl Imagen Mol 2021. [DOI: 10.1016/j.remnie.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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18
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Lee HS, Kim HJ, Chung IY, Kim J, Lee SB, Lee JW, Son BH, Ahn SH, Kim HH, Seo JB, Ahn JH, Gong G, Lee S, Kim N, Ko BS. Usefulness of 3D-surgical guides in breast conserving surgery after neoadjuvant treatment. Sci Rep 2021; 11:3376. [PMID: 33564029 PMCID: PMC7873218 DOI: 10.1038/s41598-021-83114-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 01/28/2021] [Indexed: 01/23/2023] Open
Abstract
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).
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Affiliation(s)
- Han Shin Lee
- Department of Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Hee Jeong Kim
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Il Yong Chung
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jisun Kim
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sae Byul Lee
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jong Won Lee
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Byung Ho Son
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sei Hyun Ahn
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hak Hee Kim
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Joon Beom Seo
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jin Hee Ahn
- Department of Oncology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gyungyub Gong
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sangwook Lee
- Department of Convergence Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Namkug Kim
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea. .,Department of Convergence Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Beom Seok Ko
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
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19
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Wu ZY, Kim GB, Choi S, Lee S, Kim N, Ko B. Breast-Conserving Surgery after Neoadjuvant Chemotherapy Using a Three-Dimensional-Printed Surgical Guide Based on Supine Magnetic Resonance Imaging: A Case Report. J Breast Cancer 2021; 24:235-240. [PMID: 33818018 PMCID: PMC8090799 DOI: 10.4048/jbc.2021.24.e8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/01/2021] [Accepted: 01/04/2021] [Indexed: 11/30/2022] Open
Abstract
Tumor localization in patients receiving neoadjuvant chemotherapy (NACT) is challenging because substantial therapeutic remission of the original tumor after NACT is often noted. Currently, there is no guidance device that allows for an accurate estimation of the resection range in breast-conserving surgery after NACT. To increase the accuracy of tumor resection, we used a 3-dimensional-printed breast surgical guide based on magnetic resonance imaging (MRI) in the supine position for a breast cancer patient who underwent breast-conserving surgery after NACT. Using this device, the breast tumor with apparent therapeutic changes after NACT on imaging was successfully removed with clear resection margins by identifying the original tumor site in the affected breast. Irrespective of whether the residual tumor area after NACT is well defined, it is possible to confirm and target the tumor area on pre-NACT MRI using this device.
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Affiliation(s)
- Zhen Yu Wu
- Department of Breast Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.,Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | | | | | | | - Namkug Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - BeomSeok Ko
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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20
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Norman C, Lafaurie G, Uhercik M, Kasem A, Sinha P. Novel wire-free techniques for localization of impalpable breast lesions-A review of current options. Breast J 2020; 27:141-148. [PMID: 33368757 DOI: 10.1111/tbj.14146] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/24/2020] [Accepted: 12/01/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Carol Norman
- Kings College Hospital NHS Foundation Trust, Princess Royal University Hospital, Bromley, UK.,Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Guillaume Lafaurie
- Kings College Hospital NHS Foundation Trust, Princess Royal University Hospital, Bromley, UK.,Lewisham & Greenwich NHS Trust, Queen Elizabeth Hospital, Woolwich, UK
| | - Michal Uhercik
- Kings College Hospital NHS Foundation Trust, Princess Royal University Hospital, Bromley, UK
| | - Abdul Kasem
- Kings College Hospital NHS Foundation Trust, Princess Royal University Hospital, Bromley, UK
| | - Prakash Sinha
- Kings College Hospital NHS Foundation Trust, Princess Royal University Hospital, Bromley, UK
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21
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Hu X, Li S, Jiang Y, Wei W, Ji Y, Li Q, Jiang Z. Intraoperative ultrasound-guided lumpectomy versus wire-guided excision for nonpalpable breast cancer. J Int Med Res 2020; 48:300060519896707. [PMID: 31937169 PMCID: PMC7113704 DOI: 10.1177/0300060519896707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective This study was designed to compare the margin clearance and re-excision rates of ultrasound (US)- and wire-guided excision in a large number of patients with nonpalpable breast cancer. Methods In total, 520 women who were histologically diagnosed with nonpalpable breast cancer were recruited in this study. All nonpalpable lesions were visible by US. The patients were randomly divided into two groups: those who underwent wire-guided breast-conserving surgery (BCS) and those who underwent US-guided BCS. Re-excision rates and positive surgical margins were recorded. Results A total of 262 patients underwent US-guided excision and 258 patients underwent wire-guided excision. No differences were found in tumor or patient characteristics. The positive margin rate was 4.6% in the US-guided group and 19.4% in the wire-guided group with a significant difference. Age, menopausal status, excision volume, histological grade, and tumor type significantly influenced the positive surgical margin rate. The intraoperative re-excision rate was significantly lower in the US-guided group than wire-guided group (11.1% vs. 24.0%, respectively). Conclusions US-guided BCS seems to be more effective than wire-guided BCS for treatment of nonpalpable breast cancers in terms of the margin clearance and re-excision rates. Patients can avoid the discomfort caused by preoperative wire placement.
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Affiliation(s)
- Xin Hu
- Department of Pain Management, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Si Li
- Department of Breast Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yi Jiang
- Department of Breast Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wei Wei
- Department of Breast Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yinan Ji
- Department of Breast Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Qiuyun Li
- Department of Breast Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Zongbin Jiang
- Department of Pain Management, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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22
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MRI guided ROLL/SNOLL in breast cancer patients treated with neoadjuvant chemotherapy. Rev Esp Med Nucl Imagen Mol 2020; 40:91-99. [PMID: 33191151 DOI: 10.1016/j.remn.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/17/2020] [Accepted: 09/17/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE To describe the results of MRI (magnetic resonance image) guided ROLL (radioguided occult lesion localization) and SNOLL (sentinel node occult lesion localization) in the localization of residual disease after neoadjuvant chemotherapy for breast cancer, as well as assessing the surgical results obtained and disease free survival. METHODS Prospective observational analysis of 132 patients with 136 tumors, treated with neoadjuvant chemotherapy at our hospital between 2011-2017. Residual disease was located presurgically with MRI guided ROLL/SNOLL technique. We analyzed technical aspects of localization, and variables corresponding to surgical procedures and events occurred during follow-up. RESULTS The median tumor size was of 20.5mm (interquartilic range [IQR]: 14-28). The majority (96.3%) were invasive ductal carcinomas. Sentinel lymph node detection rate was 98.9%. Complete pathological response (CPR) in the breast was achieved in 58.1% of cases. The rate of affected margins in 89 cases operated by conservative surgery was 2.2%. With a median follow-up of 50 months (IQR: 37-61) we found a 7.4% rate of relapses. Of these, seven were loco-regional and three at distant sites. The estimated mean of disease-free survival time was 83.2 months (Confidence Interval [CI] 95%: 79.6-86.6). CONCLUSIONS MRI guided ROLL/SNOLL is a great tool for breast cancer residual disease localization following neoadjuvant chemotherapy. In addition, this technique attains good loco-regional control of the diseases and has excellent surgical results.
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23
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Miyoshi T, Yamaguchi S, Fujimoto H, Yoshioka S, Shiobara M, Wakatsuki K, Suda K, Miyazawa K, Aida T, Watanabe Y, Otsuka M. A new method to optimize resection area using a radiation treatment planning system and deformable image registration for breast-conserving surgery after neoadjuvant chemotherapy. Eur J Surg Oncol 2020; 47:789-795. [PMID: 33051115 DOI: 10.1016/j.ejso.2020.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND We devised a breast-conserving surgery (BCS) utilizing a new image-processing and projection technique using a radiation treatment planning system (RTPS) and deformable image registration (DIR) for patients with breast cancer after neoadjuvant chemotherapy (NAC). RTPSs and DIR are commonly used in planning radiation treatment. The purpose of this pilot study was to evaluate the feasibility of our procedure. PATIENTS AND METHODS Twenty-six patients diagnosed with breast cancer underwent NAC and BCS between November 2014 and May 2020. Multidetector-row computed tomography was performed in the same position used for surgery before and after NAC. In the DIR, CT before NAC was fused to CT after NAC. The RTPS simulated the design of tumor excision, and excision area was projected onto the breast skin utilizing an irradiation device. RESULTS In 26 patients with breast cancer after NAC, BCS was performed using the processing and projection technique of the RTPS with DIR. Only 1 of 26 patients showed carcinoma present in the surgical margins, and subsequently developed ipsilateral breast tumor recurrence. Mean excised volume was 33.5 cm3 (range, 12.8-62.8 cm3), and percent breast volume excised was 6.8% (range, 2.5-15.7%). CONCLUSIONS This pilot study confirmed the simplicity and utility of our procedure for minimally invasive BCS in patients with breast cancer after NAC. We will keep evaluating the safety and efficacy of our procedure in more patients.
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Affiliation(s)
| | | | - Hiroshi Fujimoto
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | | | | | - Kazuo Wakatsuki
- Department of Surgery, Kaihin Municipal Hospital, Chiba, Japan
| | - Kosuke Suda
- Department of Surgery, Kaihin Municipal Hospital, Chiba, Japan
| | - Kotaro Miyazawa
- Department of Surgery, Kaihin Municipal Hospital, Chiba, Japan
| | - Toshiaki Aida
- Department of Surgery, Kaihin Municipal Hospital, Chiba, Japan
| | | | - Masayuki Otsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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24
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Esgueva A, Siso C, Espinosa-Bravo M, Sobrido C, Miranda I, Salazar JP, Rubio IT. Leveraging the increased rates of pathologic complete response after neoadjuvant treatment in breast cancer to de-escalate surgical treatments. J Surg Oncol 2020; 123:71-79. [PMID: 33002230 DOI: 10.1002/jso.26236] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/05/2020] [Accepted: 09/14/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Breast conservative surgery (BCS) and sentinel lymph node biopsy (SLNB) after neoadjuvant treatment (NAT) is safe and effective for selected patients. This aim of this study is to evaluate the impact of anatomic site of response on outcomes and to assess the real population who may benefit from nonsurgical approaches after NAT. MATERIAL AND METHODS From a prospectively maintained database, patients with T1-4 N0-2 breast cancer undergoing NAT were identified. Clinicopathological and survival rates were compared in relation to response and anatomic site of response. RESULTS Six hundred and forty-six patients were included in the study. Pathologic complete response (pCR) was an independent factor for BCS and SLN. HER2 positive and TN tumors with cN0 achieving a breast pCR remain ypN0 (p = .002). Residual axillary disease was associated with breast residual tumor (p = .05) and subtype (p = .001). With a median follow up of 35.25 months, patients with any pCR had improved survival when compared with partial response, but not significant differences between pCR, axillary pCR, or breast pCR. CONCLUSION Achieving a pCR increases BCS and SLN. In selected subgroups, sparing any axillary surgery after NAT maybe feasible. In cN+ patients, any pCR was associated with survival, but not the anatomic site of response.
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Affiliation(s)
- Antonio Esgueva
- Department of Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
| | - Christian Siso
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Martin Espinosa-Bravo
- Department of Breast Surgical Oncology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Carolina Sobrido
- Breast Imaging Unit, Department of Radiology, Clinica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
| | - Ignacio Miranda
- Breast Imaging Unit, Department of Radiology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Juan P Salazar
- Breast Imaging Unit, Department of Radiology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Isabel T Rubio
- Department of Breast Surgical Oncology, Clinica Universidad de Navarra, Universidad de Navarra, Madrid, Spain
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Tasdöven I, Karadeniz Çakmak G, Emre AU, Engin H, Bahadır B, Bakkal HB, Güllüoğlu MB. Intraoperative ultrasonography-guided surgery: An effective modality for breast conservation after neo-adjuvant chemotherapy. Breast J 2020; 26:1680-1687. [PMID: 33443786 DOI: 10.1111/tbj.13992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/05/2020] [Accepted: 07/10/2020] [Indexed: 11/28/2022]
Abstract
Margin status is one of the significant prognostic factors for recurrence in breast-conserving surgery (BCS). The issue that merits consideration for oncologic safety and cost-effectiveness about the modalities to assure clear margins at initial surgical intervention remains controversial after neo-adjuvant chemotherapy (NAC). The presented study aimed to assess the impact of intraoperative ultrasound (IOUS)-guided surgery on accurate localization of tumor site, adequacy of excision with clear margins, and healthy tissue sacrifice in BCS after NAC. Patients who had IOUS-guided BCS ater NAC were reviewed. No patient had preoperative localization with wire or radiotracer. Intraoperative real-time sonographic localization, sonographic margin assessment during resection, macroscopic and sonographic examination of specimen, and cavity shavings (CS) were done as the standard procedure. No frozen assessment was performed. One hundred ninety-four patients were included, in which 42.5% had pCR. IOUS-guided surgery accomplished successful localization of the targeted lesions in all patients. Per protocol, all inked margins on CS specimens were reported to be tumor-free in permanent histopathology. No re-excision or mastectomy was required. For a setting without CS, the negative predictive value (NPV) of IOUS rate was 96%. IOUS was found to over and underestimate tumor response to NAC both in 2% of patients. IOUS-guided surgery seems to be an efficient modality to perform adequate BCS after NAC with no additional localization method. Especially, when CS is integrated as a standard to BCS, IOUS seems to provide safe surgery for patients with no false negativity and a high rate of NPV.
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Affiliation(s)
- Ilhan Tasdöven
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Güldeniz Karadeniz Çakmak
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Ali Ugur Emre
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Hüseyin Engin
- Department of Oncology, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Burak Bahadır
- Department of Pathology, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Hakan Bekir Bakkal
- Department of Radiation Oncology, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
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Konen J, Murphy S, Berkman A, Ahern TP, Sowden M. Intraoperative Ultrasound Guidance With an Ultrasound-Visible Clip: A Practical and Cost-effective Option for Breast Cancer Localization. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:911-917. [PMID: 31737930 DOI: 10.1002/jum.15172] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/14/2019] [Accepted: 10/27/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES In partial mastectomy (PM) or lumpectomy, ultrasound (US) localization avoids discomfort and additional procedures associated with wire localization. The purpose of this study was to evaluate the association between ultrasound-visible clip (UVC) use at the time of biopsy and US use during resection, hypothesizing that UVCs facilitate US localization and reduce costs compared with traditional radiopaque clips or no clip placement. METHODS The study population consisted of adult female patients with breast cancer undergoing PM or lumpectomy at our institution between 2014 and 2016. The core biopsy clip type and localization method during PM were characterized as wire localization versus US localization, and associations were estimated with multivariable regression models. For the cost evaluation, breast biopsy data were obtained from the Department of Radiology. RESULTS Among 674 patients, 490 had data on localization and the clip type. Ultrasound-visible clip placement at biopsy increased US use during resection by 13% (95% confidence interval, 6%-21%). There was no difference in the total specimen weight with US versus wire localization. The cost savings for using UVCs for the 2209 patients who underwent breast biopsy from 2014 to 2016 was $36,000. CONCLUSIONS This study demonstrates that US localization for PM is feasible at a single institution and cost-effective when facilitated by UVCs. Placement of a UVC at the time of biopsy is recommended, as it is cost-effective and avoids the discomfort and inconvenience of wire localization.
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Affiliation(s)
- John Konen
- Department of Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Serena Murphy
- Department of Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Amy Berkman
- Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Thomas P Ahern
- Division of Surgical Research, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Michelle Sowden
- Department of Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
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Efficacy of intraoperative specimen radiography as margin assessment tool in breast conserving surgery. Breast Cancer Res Treat 2019; 179:425-433. [PMID: 31654190 DOI: 10.1007/s10549-019-05476-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/12/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To explore the ability of intraoperative specimen radiography (SR) to correctly identify positive margins in patients receiving breast conserving surgery (BCS). To assess whether the reoperation rate can be reduced by using this method. METHODS This retrospective study included 470 consecutive cases receiving BCS due to a primarily diagnosed breast cancer. SR was carried out in two planes, assessing the specimen regarding the presence of the lesion and its relation to all margins. If indicated, re-excision of selective orientations was advised. Under consideration of gross inspection and the SR-findings, it was up to the surgeon whether to perform re-resections. The recommendations for re-excision were, separately for each orientation, compared to the histopathological results, serving as gold standard. RESULTS Intraoperative SR was performed in 470 cases, thus 2820 margins were assessed. Of those, 2510 (89.0%) were negative and 310 (11.0%) positive. SR identified 2179 (77.3%) margins correctly as negative, whereas 331 (11.7%) clear margins were misjudged as positive. Of 310 infiltrated margins, SR identified 114 (4.0%) correctly, whereas 196 (7.0%) infiltrated margins were missed. This resulted in a sensitivity/specificity of 36.8%/86.8% and PPV/NPV of 25.6%/91.8%. Through targeted re-resections positive margins could be reduced by 31.0% [310 to 214 (7.6%)]. On case level, the rate of secondary procedures could be reduced by 37.0% [from 162 to 102 (21.7%)]. CONCLUSIONS SR is a helpful tool to identify infiltrated margins and to reduce the rate of secondary surgeries by recommending targeted re-excisions of according orientations in order to obtain a final negative margin status.
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28
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Chang S, Brooke M, Cureton E, Yeh A, Chen R, Mazzetti-Barros N, Rahbari R, Butler S, Hill N, Shim V. Rapid Implementation of Intraoperative Ultrasonography to Reduce Wire Localization in The Permanente Medical Group. Perm J 2019; 23:18-073. [PMID: 31314730 DOI: 10.7812/tpp/18-073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Preoperative wire localization (WL), the most common localization technique for nonpalpable breast lesions, has drawbacks including scheduling constraints, cost, and patient discomfort. OBJECTIVE To reduce WL use in our health care system, we investigated using hydrogel clips to facilitate intraoperative ultrasonography-guided lumpectomies. DESIGN We retrospectively reviewed electronic medical records of patients with nonpalpable, ultrasound-visible breast lesions who underwent lumpectomy by 7 surgeons at 4 pilot sites in Kaiser Permanente Northern California between January 2015 and October 2015. Hydrogel clips, used for several years before the study period, were placed routinely during core-needle biopsy in all patients with nonpalpable, ultrasound-visible breast lesions. MAIN OUTCOME MEASURES Localization method, lesion size, margin positivity, and receipt of neoadjuvant therapy. RESULTS One hundred forty-three patients underwent hydrogel clip placement and lumpectomy by pilot-site surgeons. Localization consisted of intraoperative ultrasonography alone, preoperative skin marking, or WL. Of the 143 patients, 71.3% did not need WL (60.8% ultrasonography alone and 10.5% skin marking). The non-WL and WL groups had similarly sized lesions, and the positive margin rate was 7.2% overall, with no significant difference between the non-WL and WL groups (5.9% vs 11.5%, p = 0.33). Of the 12 patients who underwent neoadjuvant chemotherapy, 8 (67%) did not require WL. CONCLUSION A multifacility protocol using intraoperative ultrasonography to visualize hydrogel clips was implemented, which decreased WL procedures and produced no significant difference in margin positivity between the WL and non-WL groups. This technique can be a cost-effective alternative to WL in patients who are candidates for hydrogel clip placement.
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Affiliation(s)
- Sharon Chang
- Department of Surgery, Fremont Medical Center, CA
| | - Magdalene Brooke
- Department of Surgery, University of California, San Francisco East Bay.,Department of Surgery, Oakland Medical Center, CA
| | | | - Alice Yeh
- Department of Surgery, South San Francisco Medical Center, CA
| | - Rhona Chen
- Department of Surgery, South San Francisco Medical Center, CA
| | | | - Reza Rahbari
- Department of Surgery, Fresno Medical Center, CA
| | - Sherry Butler
- Department of Surgery, South San Francisco Medical Center, CA
| | - Nicole Hill
- Department of Surgery, Fresno Medical Center, CA
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Gerrard AD, Shrotri A. Surgeon-led Intraoperative Ultrasound Localization for Nonpalpable Breast Cancers: Results of 5 Years of Practice. Clin Breast Cancer 2019; 19:e748-e752. [PMID: 31208875 DOI: 10.1016/j.clbc.2019.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/05/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND The uptake of breast screening has led to a rise in the number of nonpalpable breast cancer diagnoses. Breast conserving therapy (BCT) is the treatment of choice for early breast cancer, and this requires localization of the lesion. Commonly detection is achieved by wire-guided localization in the radiology department. This technique has complications and requires utilization of a radiologist. Intraoperative ultrasound (IOUS) has been shown to be a safe alternative, but there is little data on its use. The aim of this study is to report the use of surgeon-led IOUS over the past 5 years, assessing the ability to detect lesions and the re-excision rate for involved margins. PATIENTS AND METHODS A retrospective observational study was performed on consecutive patients undergoing IOUS-marked BCT between 2014 and 2018. The technique is described, and patients' records were reviewed to assess the histologic specimen reports and need for subsequent re-excision. RESULTS Ninety-five IOUS BCT operations were performed. Every cancer was identified by IOUS and removed. Fourteen margins were positive and required re-excision. Of these, only 2 contained residual tumor. CONCLUSION This is the first data from the United Kingdom for IOUS skin marking without wire localization. IOUS is a safe method of localization in BCT. It offers advantages both to the patient and the unit as it reduces pressure on the radiology department.
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Affiliation(s)
- Adam D Gerrard
- Breast Department, Aintree University Hospital NHS Foundation Trust, Liverpool, England
| | - Anu Shrotri
- Breast Department, Aintree University Hospital NHS Foundation Trust, Liverpool, England.
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30
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Colomer R, Saura C, Sánchez-Rovira P, Pascual T, Rubio IT, Burgués O, Marcos L, Rodríguez CA, Martín M, Lluch A. Neoadjuvant Management of Early Breast Cancer: A Clinical and Investigational Position Statement. Oncologist 2019; 24:603-611. [PMID: 30710068 PMCID: PMC6516119 DOI: 10.1634/theoncologist.2018-0228] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 11/20/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Neoadjuvant treatment is increasingly one of the preferred therapeutic options for early breast cancer and may have some unique outcomes, such as identifying predictive and prognostic factors of response or increasing the knowledge of individual tumor biology. DESIGN A panel of experts from different specialties reviewed published clinical studies on the neoadjuvant management of breast cancer. Recommendations were made that emphasized the clinical multidisciplinary management and the investigational leverage in early breast cancer. RESULTS Neoadjuvant therapy has equivalent efficacy to adjuvant therapy, and it has some additional benefits that include increasing breast conservation, assessing tumor response, establishing prognosis based on the pathological response, and providing a "second opportunity" for nonresponding patients. Achieving pathological complete remission because of neoadjuvant therapy has been correlated with long-term clinical benefit, particularly in HER2-positive and triple-negative breast cancer. In addition, the neoadjuvant setting is a powerful model for the development of new drugs and the identification of prognostic markers. Finally, neoadjuvant therapy has proven to be cost-effective by reducing nondrug costs, avoiding radical surgery, and reducing hospital stays when compared with other treatment approaches. CONCLUSION Neoadjuvant therapy has clinical benefits in early breast cancer and provides in vivo information of individual breast cancer biology while allowing the investigation of new treatment approaches. Access to neoadjuvant therapy should be an option available to all patients with breast cancer through multidisciplinary tumor management. IMPLICATIONS FOR PRACTICE Neoadjuvant treatment should be strongly considered as a therapeutic option for localized breast cancer and is a powerful tool for understanding breast cancer biology and investigating new treatment approaches.
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Affiliation(s)
- Ramon Colomer
- Department of Medical Oncology, Hospital Universitario La Princesa, Madrid, Spain
| | - Cristina Saura
- Department of Medical Oncology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Tomás Pascual
- Department of Medical Oncology, Hospital Clínic, Barcelona, Spain
- Translational Genomic and Targeted Therapeutics in Solid Tumors, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Isabel T Rubio
- Department of Breast Surgical Oncology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Octavio Burgués
- Pathology Department, Hospital Clínico Universitario, Valencia, Spain
| | - Lourdes Marcos
- Department of Radiology, Hospital Universitario La Princesa, Madrid, Spain
| | - César A Rodríguez
- Department of Medical Oncology, Hospital Clínico Universitario de Salamanca-IBSAL, Salamanca, Spain
| | - Miguel Martín
- Department of Medical Oncology, Hospital Universitario Gregorio Marañon, Madrid, Spain
| | - Ana Lluch
- Department of Medical Oncology and Hematology, Hospital Clínico Universitario, University of Valencia-INCLIVA Health Research Institute, CIBERONC, Valencia, Spain
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Esgueva A, Rodríguez-Revuelto R, Espinosa-Bravo M, Salazar JP, Rubio IT. Learning curves in intraoperative ultrasound guided surgery in breast cancer based on complete breast cancer excision and no need for second surgeries. Eur J Surg Oncol 2019; 45:578-583. [DOI: 10.1016/j.ejso.2019.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/11/2018] [Accepted: 01/11/2019] [Indexed: 01/05/2023] Open
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Value of intra-operative ultrasound in localization of palpable or non-palpable breast tumors during breast conserving surgery. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2018. [DOI: 10.1016/j.ejrnm.2018.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Rubio IT. ASO Author Reflections: Moving Forward De-escalation of Axillary Surgery After Neoadjuvant Treatment in Breast Cancer. Ann Surg Oncol 2018; 25:638-639. [PMID: 30284130 DOI: 10.1245/s10434-018-6849-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Isabel T Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain. .,Universidad de Navarra, Madrid, Spain.
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Intraoperative ultrasound in breast cancer surgery-from localization of non-palpable tumors to objectively measurable excision. World J Surg Oncol 2018; 16:184. [PMID: 30205823 PMCID: PMC6134720 DOI: 10.1186/s12957-018-1488-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 09/05/2018] [Indexed: 01/08/2023] Open
Abstract
Background The utilization of intraoperative ultrasound (IOUS) in breast cancer surgery is a relatively new concept in surgical oncology. Over the last few decades, the field of breast cancer surgery has been striving for a more rational approach, directing its efforts towards removing the tumor entirely yet sparing tissue and structures not infiltrated by tumor cells. Further progress in objectivity and optimization of breast cancer excision is possible if we make the tumor and surrounding tissue visible and measurable in real time, during the course of the operation; IOUS seems to be the optimal solution to this complex requirement. IOUS was introduced into clinical practice as a device for visualization of non-palpable tumors, and compared to wire-guided localization (WGL), IOUS was always at least a viable, or much better alternative, in terms of both precision in identification and resection and for patients’ and surgeons’ comfort. In recent years, intraoperative ultrasound has been used in the surgery of palpable tumors to optimize resection procedures and overcome the disadvantages of classic palpation guided surgery. Objective The aim of this review is to show the role of IOUS in contemporary breast cancer surgery and its changes over time. Methods A PubMed database comprehensive search was conducted to identify all relevant articles according to assigned key words. Conclusion Over time, the use of IOUS has been transformed from being the means of localizing non-palpable lesions to an instrument yielding a reduced number of positive resection margins, with a smaller volume of healthy breast tissue excided around tumor, by making the excision of the tumor optimal and objectively measurable.
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Cordoba O, Carrillo-Guivernau L, Reyero-Fernández C. Surgical Management of Breast Cancer Treated with Neoadjuvant Therapy. Breast Care (Basel) 2018; 13:238-243. [PMID: 30319325 PMCID: PMC6167713 DOI: 10.1159/000491760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Neoadjuvant therapy (NAT) allows downstaging in some cases of breast cancer. By consequence, it may enable a more conservative surgical approach or make surgery possible in cases ineligible for surgery before NAT. In this article, we review the evidence and management recommendations for optimal surgical treatment in this setting.
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Affiliation(s)
- Octavi Cordoba
- Obstetrics and Gynecology Department, Hospital Universitari Son Espases, Palma, Spain
| | - Lourdes Carrillo-Guivernau
- Breast Cancer Unit, Obstetrics and Gynecology Department, Hospital Universitari Son Espases, Palma, Spain
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Siso C, de Torres J, Esgueva-Colmenarejo A, Espinosa-Bravo M, Rus N, Cordoba O, Rodriguez R, Peg V, Rubio IT. Intraoperative Ultrasound-Guided Excision of Axillary Clip in Patients with Node-Positive Breast Cancer Treated with Neoadjuvant Therapy (ILINA Trial). Ann Surg Oncol 2018; 25:784-791. [DOI: 10.1245/s10434-017-6270-z] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Richey WL, Luo M, Goodale SE, Clements LW, Meszoely IM, Miga MI. A system for automatic monitoring of surgical instruments and dynamic, non-rigid surface deformations in breast cancer surgery. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2018; 10576:105761H. [PMID: 31130766 PMCID: PMC6530568 DOI: 10.1117/12.2295221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
When negative tumor margins are achieved at the time of resection, breast conserving therapy (lumpectomy followed with radiation therapy) offers patients improved cosmetic outcomes and quality of life with equivalent survival outcomes to mastectomy. However, high reoperation rates ranging 10-59% continue to challenge adoption and suggest that improved intraoperative tumor localization is a pressing need. We propose to couple an optical tracker and stereo camera system for automated monitoring of surgical instruments and non-rigid breast surface deformations. A bracket was designed to rigidly pair an optical tracker with a stereo camera, optimizing overlap volume. Utilizing both devices allowed for precise instrument tracking of multiple objects with reliable, workflow friendly tracking of dynamic breast movements. Computer vision techniques were employed to automatically track fiducials, requiring one-time initialization with bounding boxes in stereo camera images. Point based rigid registration was performed between fiducial locations triangulated from stereo camera images and fiducial locations recorded with an optically tracked stylus. We measured fiducial registration error (FRE) and target registration error (TRE) with two different stereo camera devices using a phantom breast with five fiducials. Average FREs of 2.7 ± 0.4 mm and 2.4 ± 0.6 mm with each stereo-camera device demonstrate considerable promise for this approach in monitoring the surgical field. Automated tracking was shown to reduce error when compared to manually selected fiducial locations in stereo camera image-based localization. The proposed instrumentation framework demonstrated potential for the continuous measurement of surgical instruments in relation to the dynamic deformations of a breast during lumpectomy.
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Affiliation(s)
- Winona L Richey
- Vanderbilt University, Department of Biomedical Engineering, Nashville, TN USA
| | - Ma Luo
- Vanderbilt University, Department of Biomedical Engineering, Nashville, TN USA
| | - Sarah E Goodale
- Vanderbilt University, Department of Biomedical Engineering, Nashville, TN USA
| | - Logan W Clements
- Vanderbilt University, Department of Biomedical Engineering, Nashville, TN USA
| | - Ingrid M Meszoely
- Vanderbilt University Medical Center, Division of Surgical Oncology, Nashville, TN USA
| | - Michael I Miga
- Vanderbilt University, Department of Biomedical Engineering, Nashville, TN USA
- Vanderbilt University Department of Radiology and Radiological Sciences, Nashville, TN USA
- Vanderbilt Institute for Surgery and Engineering, Nashville, TN USA
- Vanderbilt University Medical Center, Department of Neurological Surgery, Nashville, TN USA
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Breast-conserving surgery following neoadjuvant therapy-a systematic review on surgical outcomes. Breast Cancer Res Treat 2017; 168:1-12. [PMID: 29214416 PMCID: PMC5847047 DOI: 10.1007/s10549-017-4598-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/07/2017] [Indexed: 01/14/2023]
Abstract
Purpose Neoadjuvant chemotherapy (NACT) is increasingly used in breast cancer treatment. One of the main goals of NACT is to reduce the extent of local surgery of the breast and axilla. The aim of this study was to determine surgical outcomes for patients receiving breast-conserving therapy (BCT) after NACT, including margin status plus secondary surgeries, excision volumes, and cosmetic outcomes. Methods A systematic review was performed in accordance with PRISMA principles. Pubmed, MEDLINE, Embase, and the Cochrane Library were searched for studies investigating the results of BCT following NACT. The main study outcomes were margin status, additional local therapies, excision volumes, and cosmetic outcomes. Non-comparative studies on NACT were also included. Exclusion criteria were studies with less than 25 patients, and studies excluding secondary mastectomy patients. Findings Of the 1219 studies screened, 26 studies were deemed eligible for analysis, including data from 5379 patients treated with NACT and 10,110 patients treated without NACT. Included studies showed wide ranges of tumor-involved margins (2–39.8%), secondary surgeries (0–45.4%), and excision volumes (43.2–268 cm3) or specimen weight (26.4–233 g) after NACT. Most studies were retrospective, with a high heterogeneity and a high risk of bias. Cosmetic outcomes after NACT were reported in two single-center cohort studies. Both studies showed acceptable cosmetic outcomes. Interpretation There is currently insufficient evidence to suggest that NACT improves surgical outcomes of BCT. It is imperative that clinical trials include patient outcome measures in order to allow monitoring and meaningful comparison of treatment outcomes in breast cancer.
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Arko D, Čas Sikošek N, Kozar N, Sobočan M, Takač I. The value of ultrasound-guided surgery for breast cancer. Eur J Obstet Gynecol Reprod Biol 2017; 216:198-203. [DOI: 10.1016/j.ejogrb.2017.07.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 12/16/2022]
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Karadeniz Cakmak G, Emre AU, Tascilar O, Bahadir B, Ozkan S. Surgeon performed continuous intraoperative ultrasound guidance decreases re-excisions and mastectomy rates in breast cancer. Breast 2017; 33:23-28. [DOI: 10.1016/j.breast.2017.02.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/11/2016] [Accepted: 02/22/2017] [Indexed: 01/14/2023] Open
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Gunn J, McLaughlin S. Current Trends in Localization Techniques for Non-palpable Breast Lesions: Making the Invisible Visible. CURRENT BREAST CANCER REPORTS 2017. [DOI: 10.1007/s12609-017-0244-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Espinosa-Bravo M, Rubio IT. Intraoperative ultrasound guided breast surgery: paving the way for personalized surgery. Gland Surg 2016; 5:366-8. [PMID: 27294242 DOI: 10.21037/gs.2016.03.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Martin Espinosa-Bravo
- Breast Surgical Oncology, Breast Cancer Center, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Isabel T Rubio
- Breast Surgical Oncology, Breast Cancer Center, Hospital Universitario Vall d'Hebron, Barcelona, Spain
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Rubio I, Ahmed M, Kovacs T, Marco V. Margins in breast conserving surgery: A practice-changing process. Eur J Surg Oncol 2016; 42:631-40. [DOI: 10.1016/j.ejso.2016.01.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 01/18/2016] [Indexed: 11/17/2022] Open
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