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Langman EL, Johnson KS, Dinome ML. Retained Biopsy Site Markers After Breast Lesion Surgical Resection: Associations With Residual Malignancy. AJR Am J Roentgenol 2024; 222:e2329670. [PMID: 37646391 DOI: 10.2214/ajr.23.29670] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND. Biopsy site markers (BSMs) placed during image-guided core needle biopsy (CNB) are typically targeted for surgical excision, along with the breast imaging abnormality. Retained BSMs raise concern of incomplete resection of the breast abnormality. OBJECTIVE. The purpose of our study was to assess the frequency of residual malignancy in patients with retained BSMs identified on the initial mammography performed after breast lesion surgical excision. METHODS. This retrospective study included 30 patients (median age, 59 years) who underwent surgical resection between August 2015 and April 2022 of a borderline, high-risk, or malignant breast lesion after CNB and technically adequate preoperative image-guided localization, in whom the initial postoperative mammography report described a retained nonmigrated BSM. EMR data were extracted. The index pathology from CNB and initial surgical resection was classified as malignant or nonmalignant. The presence of residual malignancy after initial surgical resection required pathologic confirmation from subsequent tissue sampling; the absence of residual malignancy required 2 years of benign imaging follow-up. RESULTS. Thirteen specimen radiographs were interpreted intraoperatively by a surgeon with later radiologist interpretation, and 17 underwent real-time radiologist interpretation. Eighteen patients had malignant index pathology from the initially resected lesion. The frequency of residual malignancy on subsequent follow-up after initial surgical resection was higher in patients with malignant than nonmalignant index pathology (39% [7/18] vs 0% [0/12], respectively; p = .02). Among patients with malignant index pathology, the frequency of residual malignancy was higher in those without, than with, malignancy in the initial surgical specimen (80% [4/5] vs 23% [3/13]; p = .047). Also in these patients, the frequency of a positive interpretation of the initial postoperative mammography (BI-RADS category 4 or 6) was not significantly different between those with and without residual malignancy (57% [4/7] vs 55% [6/11]; p > .99). CONCLUSION. Patients with retained BSMs associated with malignant index lesions are at substantial risk of having residual malignancy. Initial postoperative mammography is not sufficient for excluding residual malignancy. CLINICAL IMPACT. Retained BSMs associated with index malignancy should be considered suspicious for residual malignancy. In this scenario, timely additional tissue sampling targeting the retained BSM is warranted, given the greater-than-2% chance of malignancy. Active surveillance is a reasonable management strategy in patients with retained BSMs from nonmalignant index lesions.
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Affiliation(s)
- Eun L Langman
- Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710
| | - Karen S Johnson
- Department of Radiology, Duke University Medical Center, 2301 Erwin Rd, Box 3808, Durham, NC 27710
| | - Maggie L Dinome
- Department of Surgery, Duke University School of Medicine, Durham, NC
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Arudra SKC, Garvey LC, Hagemann IS. In-laboratory breast specimen radiography reduces tissue block utilization and improves turnaround time of pathologic examination. BMC Med Imaging 2021; 21:59. [PMID: 33757455 PMCID: PMC7988919 DOI: 10.1186/s12880-021-00589-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 03/17/2021] [Indexed: 11/20/2022] Open
Abstract
Background This study was performed to determine whether in-laboratory specimen radiography reduces turnaround time or block utilization in surgical pathology.
Methods Specimens processed during a 48-day trial of an in-lab cabinet radiography device (Faxitron) were compared to a control group of specimens imaged in the mammography suite during a prior 1-year period, and to a second group of specimens not undergoing imaging of any type. Results Cases imaged in the mammography suite had longer turnaround time than cases not requiring imaging (by 1.15 days for core biopsies, and 1.73 days for mastectomies; p < 0.0001). In contrast, cases imaged in-lab had turnaround time that was no longer than unimaged cases (p > 0.05 for core biopsies, lumpectomies and mastectomies). Mastectomies imaged in-lab required submission of fewer blocks than controls not undergoing any imaging (mean reduction of 10.6 blocks). Conclusions Availability of in-lab radiography resulted in clinically meaningful improvements in turnaround time and economically meaningful reductions in block utilization.
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Affiliation(s)
- Sri Krishna Chaitanya Arudra
- Department of Pathology and Immunology, Washington University School of Medicine, 425 S. Euclid Ave., Campus Box 8118, St. Louis, MO, 63110, USA
| | - Laura C Garvey
- Department of Pathology and Immunology, Washington University School of Medicine, 425 S. Euclid Ave., Campus Box 8118, St. Louis, MO, 63110, USA
| | - Ian S Hagemann
- Department of Pathology and Immunology, Washington University School of Medicine, 425 S. Euclid Ave., Campus Box 8118, St. Louis, MO, 63110, USA.
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Menes TS, Golan O, Weiser R, Tvito Green R. ASO Author Reflections: Facing the Challenge of the Missing Clip in Breast Lumpectomy Specimens. Ann Surg Oncol 2021; 28:4981-4982. [PMID: 33683523 DOI: 10.1245/s10434-021-09801-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 12/24/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Tehillah S Menes
- Department of Surgery, Sheba Medical Center, Tel Hashomer, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Orit Golan
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Roi Weiser
- Department of Surgery, The University of Texas Medical Branch at Galveston, Galveston, TX, USA.,Surgery Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ravit Tvito Green
- Surgery Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Green RT, Weiser R, Golan O, Menes TS. In Search of the Lost Clip: Outcome of Women After Needle-Guided Lumpectomy of a Marking Clip. Ann Surg Oncol 2021; 28:4974-4980. [PMID: 33677760 DOI: 10.1245/s10434-021-09800-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/10/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Needle localization of a marking clip is required to guide accurate removal of many breast lesions. When the clip is not visualized on specimen radiography, concerns regarding the completeness of cancer removal and long-term outcomes arise. Using a large cohort of women undergoing breast conservation, we examined the magnitude of the problem and the outcome of women with a missing clip. METHODS We conducted a case-control study including all women undergoing mammographic wire-guided localization between 2013 and 2018 with a specimen radiograph showing a missing clip. The control group included women with successful removal of the clip(s). Data included demographics, cancer and treatment characteristics, and outcome. The groups were compared in regard to margin status, repeat surgery, and recurrence rates. RESULTS The research group included 43 women [5% of the cohort; 95% confidence interval (CI) 3.9-7.2] with a missing clip. Positive margins were comparable (7, 17% of cases; 29, 15% of 196 cases in the control group; p = 0.96). Eleven women (33%) had a residual clip visualized on post-operative mammography; in four cases, a percutaneous biopsy of the clip was successful, all with no residual tumor. There was no significant difference in re-excision rates (14% vs. 8%, p = 0.23) or in local or distant recurrence. CONCLUSIONS In the majority of women with a missing clip, the clip is not visualized on post-operative mammography. Those with a residual clip can be managed with percutaneous biopsy as long as the lesion was removed with clear margins, with comparable outcomes as women in whom the clip is visualized on specimen radiograph.
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Affiliation(s)
- Ravit Tvito Green
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Roi Weiser
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Orit Golan
- The Breast Imaging Unit, Tel Aviv Soursaky Medical Center, Tel Aviv, Israel
| | - Tehillah S Menes
- Department of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. .,Department of Surgery C and Surgical Oncology, Meirav Comprehensive Breast Health Center, Chaim Sheba Medical Center, Ramat Gan, Israel.
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Reprint of: Breast tissue markers: Why? What's out there? How do I choose? Clin Imaging 2019; 55:196-212. [DOI: 10.1016/j.clinimag.2019.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/20/2018] [Accepted: 07/04/2018] [Indexed: 11/21/2022]
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Breast tissue markers: Why? What's out there? How do I choose? Clin Imaging 2018; 52:123-136. [DOI: 10.1016/j.clinimag.2018.07.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/20/2018] [Accepted: 07/04/2018] [Indexed: 11/17/2022]
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Mango VL, Wynn RT, Feldman S, Friedlander L, Desperito E, Patel SN, Gomberawalla A, Ha R. Beyond Wires and Seeds: Reflector-guided Breast Lesion Localization and Excision. Radiology 2017; 284:365-371. [PMID: 28430555 DOI: 10.1148/radiol.2017161661] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To evaluate outcomes of Savi Scout (Cianna Medical, Aliso Viejo, Calif) reflector-guided localization and excision of breast lesions by analyzing reflector placement, localization, and removal, along with target excision and rates of repeat excision (referred to as re-excision). Materials and Methods A single-institution retrospective review of 100 women who underwent breast lesion localization and excision by using the Savi Scout surgical guidance system from June 2015 to May 2016 was performed. By using image guidance 0-8 days before surgery, 123 nonradioactive, infrared-activated, electromagnetic wave reflectors were percutaneously inserted adjacent to or within 111 breast targets. Twenty patients had two or three reflectors placed for bracketing or for localizing multiple lesions, and when ipsilateral, they were placed as close as 2.6 cm apart. Target and reflector were localized intraoperatively by one of two breast surgeons who used a handpiece that emitted infrared light and electromagnetic waves. Radiographs of the specimen and pathologic analysis helped verify target and reflector removal. Target to reflector distance was measured on the mammogram and radiograph of the specimen, and reflector depth was measured on the mammogram. Pathologic analysis was reviewed. Re-excision rates and complications were recorded. By using statistics software, descriptive statistics were generated with 95% confidence intervals (CIs) calculated. Results By using sonographic (40 of 123; 32.5%; 95% CI: 24.9%, 41.2%) or mammographic (83 of 123; 67.5%; 95% CI: 58.8% 75.1%) guidance, 123 (100%; 95% CI: 96.4%, 100%) reflectors were placed. Mean mammographic target to reflector distance was 0.3 cm. All 123 (100%; 95% CI: 96.4%, 100%) targets and reflectors were excised. Pathologic analysis yielded 54 of 110 malignancies (49.1%; 95% CI: 39.9%, 58.3%; average, 1.0 cm; range, 0.1-5 cm), 32 high-risk lesions (29.1%; 95% CI: 21.4%, 38.2%), and 24 benign lesions (21.8%; 95% CI: 115.1%, 30.4%). Four of 54 malignant cases (7.4%; 95% CI: 2.4%, 18.1%) demonstrated margins positive for cancer that required re-excision. Five of 110 radiographs of the specimen (4.5%; 95% CI: 1.7%, 10.4%) demonstrated increased distance between the target and reflector distance of greater than 1.0 cm (range, 1.1-2.6 cm) compared with postprocedure mammogram the day of placement, three of five were associated with hematomas, two of five migrated without identifiable cause. No related postoperative complications were identified. Conclusion Savi Scout is an accurate, reliable method to localize and excise breast lesions with acceptable margin positivity and re-excision rates. Bracketing is possible with reflectors as close as 2.6 cm. Savi Scout overcomes many limitations of other localization methods, which warrants further study. © RSNA, 2017.
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Affiliation(s)
- Victoria L Mango
- From the Department of Radiology, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, 10th Floor, New York, NY 10032
| | - Ralph T Wynn
- From the Department of Radiology, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, 10th Floor, New York, NY 10032
| | - Sheldon Feldman
- From the Department of Radiology, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, 10th Floor, New York, NY 10032
| | - Lauren Friedlander
- From the Department of Radiology, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, 10th Floor, New York, NY 10032
| | - Elise Desperito
- From the Department of Radiology, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, 10th Floor, New York, NY 10032
| | - Sejal N Patel
- From the Department of Radiology, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, 10th Floor, New York, NY 10032
| | - Ameer Gomberawalla
- From the Department of Radiology, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, 10th Floor, New York, NY 10032
| | - Richard Ha
- From the Department of Radiology, Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Ave, 10th Floor, New York, NY 10032
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Amso NN, Shayeb AG. Intraoperative imaging. Best Pract Res Clin Obstet Gynaecol 2013; 27:323-38. [PMID: 23587767 DOI: 10.1016/j.bpobgyn.2013.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 02/20/2013] [Indexed: 11/24/2022]
Abstract
Intraoperative image is a rapidly expanding field encompassing many applications that use a multitude of technologies. Some of the these applications have been in use for many years and are firmly embedded in, and indispensable to, clinical practice (e.g. the use of X-ray to locate foreign bodies during surgery or oocyte retrieval under ultrasound guidance. In others, the application may have been in use in one discipline but not yet fully explored in another. Examples include the use of intraoperative ultrasound with or without contrast enhancement for the detection of hepatic metastases not identified preoperatively, and the effect of such additional information on the ultimate operative procedure. Intraoperative identification of sentinel lymph nodes has been explored in many specialties to a varying extent, with the aim of fine tuning and avoiding unnecessary surgery. In both these instances, we do not know the long-term effect of these interventions on patient survival or quality of life. In this chapter, we will explore the available evidence on these applications and current advances in the new technology in general, with a specific focus on gynaecology.
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Affiliation(s)
- Nazar N Amso
- Cardiff University, School of Medicine, Heath Park, Cardiff CF14 4XW, UK.
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A plea for the biopsy marker: how, why and why not clipping after breast biopsy? Breast Cancer Res Treat 2011; 132:881-93. [DOI: 10.1007/s10549-011-1847-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 10/19/2011] [Indexed: 10/16/2022]
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