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Asmai R, Huy T, Baker JL, Yang HH, Thompson CK, Kapoor NS. Does surgeon-performed intraoperative wire localization allow for lower margin positivity rates compared to radiologist-performed preoperative localization in early breast cancer? Am J Surg 2024:115986. [PMID: 39327165 DOI: 10.1016/j.amjsurg.2024.115986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Revised: 09/15/2024] [Accepted: 09/20/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND This study compares positive margin rates in breast conserving surgery (BCS) for early breast cancer using two localization techniques: surgeon-performed intraoperative ultrasound-guided wire localization (IOWL) versus radiologist-performed preoperative wire localization (POWL). METHODS Patients with unifocal breast cancer undergoing BCS with follow-up at a single institution were retrospectively identified. Factors associated with positive margins were identified. RESULTS 177 patients underwent IOWL (N = 85) or POWL (N = 92). There was a significantly lower rate of positive margins for IOWL vs. POWL (7.1 % vs. 23.9 %, p = 0.002) and a corresponding lower rate of re-excision for IOWL vs. POWL (5.9 % vs. 18.5 %, p = 0.011). Presence of DCIS was associated with positive margins (p = 0.015). After adjusting for presence of DCIS, tumor size, and volume of tissue removed, the positive margin rate was significantly lower in the IOWL group compared to the POWL group (aOR 0.34, 95 % CI 0.13-0.93). CONCLUSIONS In this study, adjusted analysis favored IOWL in achieving negative tumor margins. Prospective studies are needed to further explore the impact of IOWL on quality, cost-effectiveness, and patient experience.
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Affiliation(s)
- Reeta Asmai
- University of California Los Angeles, David Geffen School of Medicine, Department of Surgery, United States
| | - Tess Huy
- University of California Los Angeles, David Geffen School of Medicine, Department of Surgery, United States
| | - Jennifer L Baker
- University of California Los Angeles, David Geffen School of Medicine, Department of Surgery, United States
| | - Hong-Ho Yang
- University of California Los Angeles, David Geffen School of Medicine, Department of Surgery, United States
| | - Carlie K Thompson
- University of California Los Angeles, David Geffen School of Medicine, Department of Surgery, United States
| | - Nimmi S Kapoor
- University of California Los Angeles, David Geffen School of Medicine, Department of Surgery, United States.
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Belonenko GA, Aksyonov AA, Sukhina NA, Aksyonova EG. The Use of Pneumocystography for Navigation of Stereotaxic Core-needle Biopsy in Complex Breast Cysts: Case Report. Kurume Med J 2024; 69:265-269. [PMID: 38233178 DOI: 10.2739/kurumemedj.ms6934011] [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] [Indexed: 01/19/2024]
Abstract
Complex breast cysts (CBC) are characterized by a high (up to 31.0%) oncological potential and the need for a biopsy. In some clinical situations, navigating a biopsy using mammography (MG), ultrasound (US), endoscopy, and magnetic resonance imaging (MRI) may be difficult. The first case of stereotaxic core-needle biopsy (sCNB) under pneumocystography (PCG) guide is presented.
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Affiliation(s)
- G A Belonenko
- Department of Surgery, Faculty of Postgraduate Education, Donetsk National Medical University
| | - A A Aksyonov
- Department of Minimally Invasive Interventions of the National Cancer Institute
| | - N A Sukhina
- Department of Radiology, Faculty of Postgraduate Education, Donetsk National Medical University
| | - E G Aksyonova
- Department of Fundamental Medicine ESC "Institute of Biology and Medicine" T. Shevchenko National University
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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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Belonenko G, Sukhina N, Aksyonov A, Aksyonova E. Stereotaxic Core-Needle Biopsy in Assessing Intraductal Pathologic Findings at Ductography. Eur J Breast Health 2022; 18:279-285. [DOI: 10.4274/ejbh.galenos.2022.2022-3-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/12/2022] [Indexed: 12/01/2022]
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Athanasiou C, Mallidis E, Tuffaha H. Comparative effectiveness of different localization techniques for non-palpable breast cancer. A systematic review and network meta-analysis. Eur J Surg Oncol 2021; 48:53-59. [PMID: 34656392 DOI: 10.1016/j.ejso.2021.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/25/2021] [Accepted: 10/01/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Several localization techniques are in use for localization of non palpable breast cancer but data on comparative effectiveness of these techniques are sparse. Our aim was to provide the first comparative effectiveness data on the topic. METHODS PubMed, Ovid, Scopus and Cochrane library were searched for randomized controlled trials. Pairwise meta-analysis was performed when more than 2 studies reported on the same head-to-head comparison. Network meta-analysis was performed in Stata. RESULTS Eighteen studies with 3112 patients were identified. A star shaped network was formed for every outcome as all studies had as common comparator the wire localization technique (WGL). Ultrasound guided surgery (UGS) had decreased positive margin both in the pairwise [OR = 0.19(0.11, 0.35); P < 0.01] and network meta-analysis OR = 0.19 (0.11,0.60). There was also a statistically significant reduction in re-operation rate [OR = 0.19 (0.11, 0.36); P < 0.01] and operative time [MD = -4.24(-7.85,-0.63); P = 0.02] as compared to WGL in pairwise meta-analysis. Re-operation rate and operative time did not hold there statistical significance in network meta-analysis. On network meta-analysis UGS had a statistically significant reduction in positive margin as compared to radio-guided occult lesion localization (ROLL) OR = 0.19 (0.11,0.6) and radioactive seed localization (RSL) OR = 0.26(0.13, 0.52). UGS had a 54.6% of being the best technique for positive margin. All techniques were equivalent for successful excision, localization complications, operative time and overall complications. CONCLUSIONS UGS has potential benefits in reduction of positive surgical margin, the rest of the techniques seem to have equivalent efficacy. Further randomized trials are required to verify these results.
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Affiliation(s)
| | | | - Hussein Tuffaha
- East Suffolk and North Essex Foundation Trust, Ipswich, United Kingdom.
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Chakedis JM, Tang A, Kuehner GE, Vuong B, Lyon LL, Romero LA, Raber BM, Mortenson MM, Shim VC, Datrice-Hill NM, McEvoy JR, Arasu VA, Wisner DJ, Chang SB. Implementation of Intraoperative Ultrasound Localization for Breast-Conserving Surgery in a Large, Integrated Health Care System is Feasible and Effective. Ann Surg Oncol 2021; 28:5648-5656. [PMID: 34448055 PMCID: PMC8418593 DOI: 10.1245/s10434-021-10454-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/25/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Intraoperative ultrasound (IUS) localization for breast cancer is a noninvasive localization technique. In 2015, an IUS program for breast-conserving surgery (BCS) was initiated in a large, integrated health care system. This study evaluated the clinical results of IUS implementation. METHODS The study identified breast cancer patients with BCS from 1 January to 31 October 2015 and from 1 January to 31 October 2019. Clinicopathologic characteristics were collected, and localization types were categorized. Clinical outcomes were analyzed, including localization use, surgeon adoption of IUS, day-of-surgery intervals, and re-excision rates. Multivariate logistic regression analysis was performed to evaluate predictors of re-excision. RESULTS The number of BCS procedures increased 23%, from 1815 procedures in 2015 to 2226 procedures in 2019. The IUS rate increased from 4% of lumpectomies (n = 79) in 2015 to 28% of lumpectomies (n = 632) in 2019 (p < 0.001). Surgeons using IUS increased from 6% (5 of 88 surgeons) in 2015 to 70% (42 of 60 surgeons) in 2019. In 2019, 76% of IUS surgeons performed at least 25% of lumpectomies with IUS. The mean time from admission to incision was shorter with IUS or seed localization than with wire localization (202 min with IUS, 201 with seed localization, 262 with wire localization in 2019; p < 0.001). The IUS re-excision rates were lower than for other localization techniques (13.6%, vs 19.6% for seed localization and 24.7% for wire localization in 2019; p = 0.006), and IUS predicted lower re-excision rates in a multivariable model (odds ratio [OR], 0.59). CONCLUSIONS In a high-volume integrated health system, IUS was adopted for BCS by a majority of surgeons. The use of IUS decreased the time from admission to incision compared with wire localization, and decreased re-excision rates compared with other localization techniques.
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Affiliation(s)
- Jeffery M Chakedis
- Department of General Surgery and Radiology, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Annie Tang
- Department of Surgery, University of California San Francisco, East Bay-Highland Hospital, Oakland, CA, USA
| | - Gillian E Kuehner
- Department of General Surgery and Radiology, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Brooke Vuong
- Department of General Surgery and Radiology, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Liisa L Lyon
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | - Lucinda A Romero
- Department of General Surgery and Radiology, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Benjamin M Raber
- Department of General Surgery and Radiology, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Melinda M Mortenson
- Department of General Surgery and Radiology, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Veronica C Shim
- Department of General Surgery and Radiology, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Nicole M Datrice-Hill
- Department of General Surgery and Radiology, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Jennifer R McEvoy
- Department of General Surgery and Radiology, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Vignesh A Arasu
- Department of General Surgery and Radiology, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Dorota J Wisner
- Department of General Surgery and Radiology, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Sharon B Chang
- Department of General Surgery and Radiology, The Permanente Medical Group (TPMG), Oakland, CA, USA. .,Department of Surgery, Kaiser Permanente Fremont Medical Center, Fremont, CA, USA.
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Layeequr Rahman R, Puckett Y, Habrawi Z, Crawford S. A decade of intraoperative ultrasound guided breast conservation for margin negative resection - Radioactive, and magnetic, and Infrared Oh My…. Am J Surg 2020; 220:1410-1416. [PMID: 32958157 DOI: 10.1016/j.amjsurg.2020.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/11/2020] [Accepted: 09/03/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND The oncologic goal of margin-negative breast conservation requires adequate localization of tumor. Intraoperative ultrasound remains most feasible but under-utilized method to localize the tumor and assess margins. METHODS A prospectively maintained breast cancer database over a decade was queried for margin status in breast cancer patients undergoing breast conservation. Techniques of tumor localization, margin re-excision and closest margins were analyzed. Rate of conversion to mastectomy was determined. RESULTS Of the 945 breast cancer patients treated at a university-based Breast Center of Excellence between January 1, 2009 and December 31, 2018, 149(15.8%) had ductal carcinoma in situ; 712(75.3%) had invasive ductal carcinoma, and 63(6.7%) had invasive lobular carcinoma. Clinical stage distribution was: T1 = 372(39.4%); T2 = 257(27.2%); T3 = 87(9.2%). Five hundred and eighty three (61.7%) patients underwent breast conservation. The median (25th -75th centile) closest margin was 6(2.5, 10.0) mm. Thirty five (6.0%) patients underwent margin re-excision, of which 9(25%) were converted to mastectomy. Tumor localization was achieved with ultrasound in 521(89.4%) patients and with wire localization in 62(10.6%) patients. The median (25th-75th centile) closest margin with wire localization was 5.0(2.0, 8.5) mm versus 5.0 (2.0, 8.0) mm with ultrasound guidance [p = 0.6635]. The re-excision rate with wire localization was 14.5% versus 4.9% with ultrasound guidance [p = 0.0073]. The unadjusted Odds Ratio (95% CI) for margin revision in wire localized group compared with ultrasound was 3.2 (7.14, 1.42) [p = 0.0045]; multivariate adjusted OR (95%) was 4(9.09, 1.7) [p = 0.0013]. CONCLUSIONS Ultrasound guidance for localization of breast cancer remains the most effective option for margin negative breast conservation.
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Affiliation(s)
- Rakhshanda Layeequr Rahman
- Texas Tech University Health Sciences Center, Department of Surgery, MS 8312, 3601 Fourth Street Lubbock, Texas, 79430, USA.
| | - Yana Puckett
- Texas Tech University Health Sciences Center, Department of Surgery, MS 8312, 3601 Fourth Street Lubbock, Texas, 79430, USA.
| | - Zaina Habrawi
- Texas Tech University Health Sciences Center, Department of Surgery, MS 8312, 3601 Fourth Street Lubbock, Texas, 79430, USA.
| | - Sybil Crawford
- University of Massachusetts, Medical School Division of Preventive and Behavioral Medicine, Department of Medicine, 55 Lake Avenue North, Shaw Building Room 228, Worcester, Massachusetts, 01655, USA.
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Lindenberg M, van Beek A, Retèl V, van Duijnhoven F, van Harten W. Early budget impact analysis on magnetic seed localization for non-palpable breast cancer surgery. PLoS One 2020; 15:e0232690. [PMID: 32401779 PMCID: PMC7219736 DOI: 10.1371/journal.pone.0232690] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/19/2020] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Current localization techniques used in breast conserving surgery for non-palpable tumors show several disadvantages. Magnetic Seed Localization (MSL) is an innovative localization technique aiming to overcome these disadvantages. This study evaluated the expected budget impact of adopting MSL compared to standard of care. METHODS Standard of care with Wire-Guided Localization (WGL) and Radioactive Seed Localization (RSL) use was compared with a future situation gradually adopting MSL next to RSL or WGL from a Dutch national perspective over 5 years (2017-2022). The intervention costs for WGL, RSL and MSL and the implementation costs for RSL and MSL were evaluated using activity-based costing in eight Dutch hospitals. Based on available list prices the price of the magnetic seed was ranged €100-€500. RESULTS The intervention costs for WGL, RSL and MSL were respectively: €2,617, €2,834 and €2,662 per patient and implementation costs were €2,974 and €26,826 for MSL and RSL respectively. For standard of care the budget impact increased from €14.7m to €16.9m. Inclusion of MSL with a seed price of €100 showed a budget impact of €16.7m. Above a price of €178 the budget impact increased for adoption of MSL, rising to €17.6m when priced at €500. CONCLUSION MSL could be a cost-efficient localization technique in resecting non-palpable tumors in the Netherlands. The online calculation model can inform adoption decisions internationally. When determining retail price of the magnetic seed, cost-effectiveness should be considered.
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Affiliation(s)
- Melanie Lindenberg
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Health Technology and Services research, University of Twente, Enschede, The Netherlands
| | - Anne van Beek
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Valesca Retèl
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Health Technology and Services research, University of Twente, Enschede, The Netherlands
| | - Frederieke van Duijnhoven
- Division of Surgical Oncology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Wim van Harten
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Health Technology and Services research, University of Twente, Enschede, The Netherlands
- * E-mail:
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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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