Optimised nuclear medicine method for tumour marking and sentinel node detection in occult primary breast lesions

Does failed mapping predict sentinel lymph node metastasis in cN0 breast cancer?

Aims: The clinical significance of nonvisualized sentinel lymph nodes (non-vSLNs) is unknown. The authors sought to determine the incidence of non-vSLNs on lymphoscintigraphy, the identification rate during surgery, factors associated with non-vSLNs and related axillary management. Patients & methods: A total of 30,508 consecutive SLN procedures performed at a single institution from 2000 to 2017 were retrospectively studied. Associations between clinicopathological factors and the identification of SLNs during surgery were assessed. Results: Non-vSLN occurred in 525 of the procedures (1.7%). In 73.3%, at least one SLN was identified intraoperatively. Nodal involvement was only significantly associated with SLN nonidentification (p < 0.001). Conclusion: Patients with non-vSLN had an increased risk for SLN metastasis. The detection rate during surgery was consistent, reducing the amount of unnecessary axillary dissection.

[Identification of sentinel lymph node: Comparison between SNOLL and routine isotopic procedure]

INTRODUCTION

Axillary staging remains the most accurate predictive factor for recurrence risk and survival in patients with invasive breast carcinoma. Sentinel Node Occult Lesion Localization (SNOLL) allows with a single intra-lesion injection both localization of impalpable breast lesion and sentinel node biopsy. Our aim was to compare the efficacy of SNOLL and standard radio isotopic method for sentinel node localization by lymphoscintigraphy.

METHODS

This retrospective study enrolled 100 patients treated for breast carcinoma with indication of sentinel node biopsy between may 2017 and January 2019 in breast surgery unit of Montpellier university hospital.

RESULTS

SNOLL and standard radio isotopic method were realized in respectively 65 and 35 patients. Failure rates of sentinel node localization were respectively 34% and 11% by lymphoscintigraphy (P=0.02), 17% and 9% intraoperatively and 11% et 6% using radioisotope combined with colorimetric method.

DISCUSSION

Failure rate of sentinel node localization is higher using SNOLL. This rate is reduced by additional radioisope migration in the time between isotope injection and surgery and by the use of combined method. SNOLL should therefore be combined with colorimetric method. These results must be confirmed in a larger study.

Is SNOLL a good localization technique in early breast cancer treatment? A single center's experience

Aim

The aim of this study was to evaluate the method and present one center's experience in applying the SNOLL technique to patients with non-palpable suspicious breast lesions.

Materials and methods

371 patients with suspected malignant lesions or diagnosed non-palpable breast cancer were subjected to a preoperative SNOLL procedure. The day before the surgery, they were administered two radiotracers to localize the tumor in the breast and the sentinel node. The following day, with the help of a handheld gamma probe the breast conserving surgery was performed.

Results

All 371 patients (100%) had their suspected occult breast lesions resected. Histo-pathological examination revealed cancer in 339 patients all these patients had their sentinel nodes examined. The intraoperative tests showed the sentinel node to be metastatic in 35 patients, who were then given a simultaneous axillary lymphadenectomy. Another 7 patients were diagnosed with positive lymph nodes in the final pathology and had to undergo a second operation. Reoperations compelled by positive surgical margins were performed in 26 cases.

Conclusions

SNOLL as a good technique of intraoperative localization, enables to remove a nonpalpable breast cancer together with sentinel lymph node in a single surgical procedure. It seems to be a optional method to be used in patients treated with breast conserving therapy.

Multicentric breast cancer with heterogeneous histopathology: a multidisciplinary review

Multiple synchronous (multifocal or multicentric) ipsilateral breast cancers with heterogeneous histopathology are a rare clinical occurrence, however, their incidence is increasing due to the use of MRI for breast cancer screening and staging. Some studies have demonstrated poorer clinical outcomes for this pattern of breast cancer, but there is no evidence to guide clinical practice. In this multidisciplinary review, we reflect on pathology and molecular characteristics, imaging findings, surgical management including conservation and reconstructive options and approach to the axilla, and the role of chemotherapy and radiotherapy. Multidisciplinary discussions appear decisive in planning an appropriate surgical choice and defining the correct systemic treatment tailored to each clinical condition.

Radio-guided and clip-guided preoperative localization for malignant microcalcifications offer similar performances in breast-conserving surgery

Obtaining a tailored breast resection is challenging in microcalcifications detected on screening mammography, and an accurate localization is required. The aim of this study was to compare the efficacy of radio-guided localization (ROLL) versus ultrasound localization of a titanium clip with collagen (TCC) in terms of clear margins, re-intervention rates, excess of resected breast tissue, and operative times in pure malignant microcalcifications detected on screening mammography. Two hundred and twenty-one consecutive patients with malignant microcalcifications detected on screening mammography from a tertiary breast unit were reviewed: 177 patients were localized by TCC and 44 patients by stereotactic ROLL. A propensity score-matched analysis was performed, followed by a logistic regression model, to avoid selection bias. Adequacy of resection was expressed as the calculated resection ratio considering lesion size. No differences were found in clear margins with ROLL versus TCC (77.3% vs 81.8%, adjusted OR 2, P = 0.27). Re-operation rates were similar, being 11.3% with ROLL and 7.4% with TCC (P = 0.627). Mean resection volume was 46.2 cm³ with ROLL versus 54.2 cm³ with TCC (P = 0.222). Adjusted mean calculated resection ratio was 1.8 with ROLL and 2.1 with TCC (P = 0.38). Surgery time was longer with TCC compared to ROLL (69.6 vs 52.7 minutes, P < 0.0001). ROLL and TCC are equally effective to excise malignant microcalcifications with clear margins, providing similar re-intervention rates and resection volumes.

Use of the ROLL technique for lumpectomy in non-palpable breast lesions

OBJECTIVE

To evaluate the efficiency of radioguided occult lesion localising in non-palpable breast lesions (NPBL) compared to the surgical wire technique.

METHOD

A prospective study was conducted on 161 women with NPBL, of whom 80 marked with the wire (group 1), whereas 81 women were marked with an intratumour injection of ^99mTc-nanocoloid (group 2). The NPBL were located by ultrasound or stereotactic guidance. The lumpectomies were performed following the wire direction in group 1, and with the aid of a gamma-probe in group 2. Surgical margins were then checked, determining the need of extension if the margin was less than 5mm in the intra-surgical study, and less than 2mm in the deferred study. Data were collected on the mean number detected by surgery, surgical margins, number of extensions, presence of residual tumour in the extension, second surgeries, lumpectomy volume, as well as total resected volume, volume/tumour ratio, and complications.

RESULTS

No significant differences were observed between the two groups in the mean number detected, surgical margins, number of extensions, presence of residual tumour in the extension, second surgeries, lumpectomy volume, total resected volume, volume/tumour ratio or complications. The multivariate analysis showed the determining factors of the resected volume were the radiological guidance technique, as well as the surgeon.

CONCLUSIONS

The radioguided occult lesion localising technique helps in the detection and resection of NPBL with the same efficiency as the surgical wire, and adds the possibility of sentinel node detection in the same surgery. The determining factors of the resected volume were the radiological guidance technique and the surgeon.

The clinical utility of combining pre-operative axillary ultrasonography and fine needle aspiration cytology with radionuclide guided sentinel lymph node biopsy in breast cancer patients with palpable axillary lymph nodes

PURPOSE

Clinically palpable lymph nodes (CPLN) are usually considered a contraindication to sentinel lymph node biopsy (SLNB) but one third of these patients are node negative. The aim of the present study is to evaluate the clinical usefulness of combining SLNB and preoperative axillary ultrasonography (AUS) with FNAC in patients with clinically palpable but indeterminate axillary lymph nodes.

MATERIALS AND METHODS

Fifty three patients with primary breast cancer and CPLN (mean age, 51.6 years; median age 51 years; age range, 28-73 years) were included in the study. All patients underwent AUS and fine needle aspiration (FNAC) followed by SLNB in FNAC negative patients (Group A). Patients with proven metastasis subsequently had axillary lymph node dissection (ALND) (Group B). Standard SLN scintigraphy was performed 2-4h before surgery by injecting Tc-99m labeled nano-colloid intra-dermally in the periareolar region.

RESULTS

Nodal metastases were documented at FNAC in 26 (49%) of the 53 patients with subsequent ALND (Group B). All 27 patients (51%) with negative FNAC results (Group A) underwent SLNB, which revealed metastasis in 6 (11%) patients. The remaining 21 (40%) patients were tumor negative and all these patients remain disease free during the follow-up period of 12-36 months with NPV of 100%. SLN was identified in all patients (100% success rate). Preoperative AUS sensitivity was 78%, specificity 76%, PPV 83%, NPV 69% and accuracy 77% (p=0.001). In comparison, ultrasound guided FNAC sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 81%, 100%, 100%, 78%, 89% respectively (p=0.001).

CONCLUSIONS

The inaccuracy of clinical assessment allows widening of indication of SLNB. Preoperative ultrasonography and guided FNAC can help in selecting the patients suitable for ALND or SLNB. Patients who are FNAC positive can proceed to ALND whilst FNAC negative samples can undergo SLNB. This combination strategy may be helpful in avoiding unnecessary ALND.

A modified sentinel node and occult lesion localization (SNOLL) technique in non-palpable breast cancer: a pilot study

Background

The spread of mammographic screening programs has allowed an increasing amount of early breast cancer diagnosis. A modern approach to non-palpable breast lesions requires an accurate intraoperative localization, in order to achieve a complete surgical resection. In addiction, the assessment of lymph node status is mandatory as it represents a major prognostic factor in these patients. The aim of this study is to evaluate the reliability of a modified technical approach using a single nanocolloidal radiotracer to localize both sentinel node and breast occult lesion.

Methods

Twenty-five patients with a single non-palpable breast lesions and clinically negative axilla were enrolled. In the same day of surgery, patients underwent intratumoral and peritumoral administration of ^99mTc-labeled nanocolloid tracer under sonographic guidance. A lymphoscintigraphy was performed to localize the sentinel lymph node and its cutaneous projection was marked on the skin in order to guide the surgeon to an optimal incision. During surgery an hand-held gamma-detection probe was used to select the best surgical access route and to guide localization of both occult breast lesion and sentinel lymph node. After specimen excision, the surgical field was checked with the gamma-probe to verify the absence of residual sources of significant radioactivity, thereby ensuring a radical treatment in a single surgical session and minimizing normal tissue excision.

Results

Both targeted breast lesion and sentinel lymph node were localized and removed at the first attempt in every patients and histopathological diagnosis of malignancy was confirmed in 25/26 samples. Non-palpable lesions were included within the surgical margins in all patients and in all samples surgical margins were free from neoplastic infiltration thus avoiding any further reintervention. Only two patients showed metastatic involvement of sentinel lymph node.

Conclusions

The modified sentinel node and occult lesion localization (SNOLL) technique performed with a single injection of nanocolloidal radiotracer has shown an excellent intraoperative identification rate of both non-palpable lesion and sentinel lymph node. This procedure offers, as opposed to standard techniques, an accurate, simple and reliable approach to the management of non-palpable breast cancer.

Meta-analysis of superficial versus deep injection of radioactive tracer and blue dye for lymphatic mapping and detection of sentinel lymph nodes in breast cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in early breast cancer. Currently, no consensus exists on the optimal site of injection of the radioactive tracer or blue dye.

METHODS

A systematic review and meta-analysis of studies comparing superficial and deep injections of radioactive tracer or blue dye for lymphatic mapping and SLNB was performed. The axillary and extra-axillary sentinel lymph node (SLN) identification rates obtained by lymphoscintigraphy and intraoperative SLNB were evaluated. Pooled odds ratios (ORs) and 95 per cent c.i. were estimated using fixed-effect analyses, or random-effects analyses if there was statistically significant heterogeneity (P < 0·050).

RESULTS

Thirteen studies were included in the meta-analysis. There was no significant difference between superficial and deep injections of radioactive tracer for axillary SLN identification on lymphoscintigraphy (OR 1·59, 95 per cent c.i. 0·79 to 3·17), during surgery (OR 1·27, 0·60 to 2·68) and for SLN identification using blue dye (OR 1·40, 0·83 to 2·35). The rate of extra-axillary SLN identification was significantly greater when deep rather than superficial injection was used (OR 3·00, 1·92 to 4·67). The discordance rate between superficial and deep injections ranged from 4 to 73 per cent for axillary and from 0 to 61 per cent for internal mammary node mapping.

CONCLUSION

Both superficial and deep injections of radioactive tracer and blue dye are effective for axillary SLN identification. Clinical consequences of discordance rates between the two injection techniques are unclear. Deep injections are associated with significantly greater extra-axillary SLN identification; however, this may not have a significant impact on clinical management.

Radioguided localisation of impalpable breast lesions using 99m-Technetium macroaggregated albumin: Lessons learnt during introduction of a new technique to guide preoperative localisation

Introduction

Preoperative wire-guided localisation (WGL) of impalpable breast lesions is widely used but can be technically difficult. Risks include wire migration, inaccurate placement, and inadequate surgical margins. Research shows that radioguided occult lesion localisation (ROLL) is quicker, easier, and can improve surgical and cosmetic outcomes. An audited introduction of ROLL was conducted to validate the technique as a feasible alternative to WGL.

Methods

Fifty patients with single impalpable lesions and biopsy proven malignancy or indeterminate histology underwent WGL followed by intralesional radiopharmaceutical injection of 99m-Technetium macroaggregated albumin. Postprocedural mammography was performed to demonstrate wire position, and scintigraphy to evaluate radiopharmaceutical migration. Lymphoscintigraphy and intraoperative sentinel node biopsy were performed if indicated, followed by lesion localisation and excision using a gamma probe. Specimen imaging was performed, with immediate reexcision for visibly inadequate margins.

Results

Accurate localisation was achieved in 86% of patients with ROLL compared to 72% with WGL. All lesions were successfully removed, with clear margins in 71.8% of malignant lesions. Reexcision and intraoperative sentinel node localisation rates were equivalent to preaudit figures for WGL. ROLL was easy to perform and problems were infrequent. Inaccurate radiopharmaceutical placement necessitating WGL occurred in four patients. Minor radiopharmaceutical migration was common, but precluded using ROLL in only two cases.

Conclusions

ROLL is effective, simple, inexpensive, and easily learnt; however, preoperative confirmation of correct radiopharmaceutical placement using mammography and the gamma probe is important to help ensure successful lesion removal. Insertion of a backup hookwire is recommended during the initial introduction of ROLL.

[Place of hand-held gamma-cameras in breast cancer]

Non-palpable breast cancers are more and more frequent. Their surgical management requires the excision of the tumor and sentinel lymph node (SLN) needing a technical preoperative organization combining preoperative identification of the tumor by wire guide and injection of a radioactive tracer for the identification of SLN. The implementation of this minimally invasive surgery is sometimes paradoxically complicated due to the presurgical organization requiring several medical teams. It is for this reason that hand-held gamma-cameras have been developed, used either preoperatively or during surgery to replace lymphoscintigraphy but also as a help to excision of the tumor after radioisotope injection. The objective of this study was to evaluate the interest of the main hand-held gamma-cameras used in breast cancer.

Polydimethylsiloxane: a new contrast material for localization of occult breast lesions

Background

The radioguided localization of occult breast lesions (ROLL) technique often utilizes iodinated radiographic contrast to assure that the local injection of ^99mTc-MAA corresponds to the location of the lesion under investigation. However, for this application, this contrast has several shortcomings. The objective of this study was to evaluate the safety, effectiveness and technical feasibility of the use of polydimethylsiloxane (PDMS) as radiological contrast and tissue marker in ROLL.

Materials and methods.

The safety assessment was performed by the acute toxicity study in Wistar rats (n = 50). The radiological analysis of breast tissue (n = 32) from patients undergoing reductive mammoplasty was used to verify the effectiveness of PDMS as contrast media. The technical feasibility was evaluated through the scintigraphic and histologic analysis.

Results

We found no toxic effects of PDMS for this use during the observational period. It has been demonstrated in human breast tissue that the average diameter of the tissue marked by PDMS was lower than when marked by the contrast medium (p <0.001). PDMS did not interfere with the scintigraphic uptake (p = 0.528) and there was no injury in histological processing of samples.

Conclusions

This study demonstrated not only the superiority of PDMS as radiological contrast in relation to the iodinated contrast, but also the technical feasibility for the same applicability in the ROLL.

Preliminary experience in sentinel node and occult lesion localization (SNOLL) technique-One center study

AIM

The aim of this study was to present one center experience in applying the SNOLL technique to patients with suspected occult breast lesions.

BACKGROUND

In the last years, the widespread use of mammographic screening programs resulted in an increasing number of women with nonpalpable suspicious breast lesions requiring further examination. The new method called sentinel node and occult lesion localization (SNOLL) enables the intraoperative detection of nonpalpable breast tumors and sentinel node biopsy in one surgical procedure.

MATERIALS AND METHODS

46 patients with suspected malignant lesions or diagnosed non-palpable breast cancer were subjected to a pre-operative SNOLL procedure. The day before the surgery, they were administered two radiotracers: one to localize the tumor and the other to localize the sentinel node. During the surgery, the breast tumor and the sentinel node, which in most cases had been examined intraoperatively, were detected with a handheld gamma probe and resected under its control.

RESULTS

All 46 (100%) patients had their occult breast lesions resected. Histopathologic examination revealed cancer in 40 patients: in situ in 2 cases, invasive in 38 cases. All these patients had their sentinel nodes examined. In one case only, the sentinel node could not be located with a gamma probe. Intraoperative tests showed the sentinel node to be metastatic in 5 patients, who were then given a simultaneous axillary lymphadenectomy. In addition, the final histopathologic examination revealed metastasis to the sentinel node in one patient, who had to be reoperated.

CONCLUSION

SNOLL is a modern technique that enables a precise intraoperative localization of non-palpable suspected malignant breast lesions in combination with a sentinel node biopsy. Extended application of intraoperative management leads to significant decrease in the number of reoperations performed in patients with early bread cancer.

Diagnostic and therapeutic imaging for cancer: therapeutic considerations and future directions

As cancer treatment cost soar and the mantra for "personalized medicine" grows louder, we will increasingly be searching for solutions to these diametrically opposed forces. In this review we highlight several exciting novel imaging strategies including MRI, CT, PET SPECT, sentinel node, and ultrasound imaging that hold great promise for improving outcomes through detection of lymph node involvement. We provide clinical data that demonstrate how these evolving strategies have the potential to transform treatment paradigms.

[PET/CT-guided salvage surgery protocol. Results with ROLL Technique and PET probe]

OBJECTIVE

To assess the value of intraoperatory radioguided probe detection to guide surgical resection of malignant lesions previously detected by (18)F-FDG PET-CT.

MATERIAL

Twelve consecutive patients with suspected tumor recurrence detected by (18)F-FDG PET-CT considered resectable were enrolled in the study. Ultrasound guided fine needle aspiration (FNA) before surgery was performed in 6 patients and CT guided biopsy was performed in 1 patient. In 5 patients with accessible lesions, a radioguided occult lesion localization (ROLL) technique was performed after injection of (99m)Tc-colloid (1.7-2.4 mCi) inside the lesion under ultrasound or CT guidance, pre-operatively. Radioguided surgical detection was then carried out 19-24 hours afterwards using the gamma probe. In 7 patients with non-accessible needle lesions or multiple lesions, 9.5-10.5 mCi of (18)F-FDG were injected 3-5 hours before radioguided surgery using a PET-dedicated probe (Gamma locator DXI-GF&E).

RESULTS

ROLL technique: All lesions injected with nanocolloid were resected (6 lesions in 5 patients, 1 patient with 2 lesions), and recurrence was histologically confirmed. PET probe: Fourteen out of 16 hypermetabolic lesions detected on the PET-CT were resected. One cervical and one mediastinal lymph node in different patients could not be excised. Histological recurrence was confirmed in 12 out of 14 lesions. In one patient, the 2 lymph nodes excised were inflammatory.

CONCLUSIONS

(18)F-FDG PET-CT can be key in deciding surgical approach and appropriate radioguided protocol. When lesions are solitary and easily accessible, ROLL technique seems the method of choice. PET probe is more adequate for less accessible lesions.

Systematic review of radioguided surgery for non-palpable breast cancer

BACKGROUND

This systematic review examines whether radioguided localization surgery (RGL) (radioguided occult lesion localization - ROLL and radioguided seed localization - RSL) for non-palpable breast cancer lesions produces lower positive margin rates than standard wire-guided localization surgery.

METHODS

We performed a comprehensive literature review to identify clinical studies using either ROLL or RSL. Included studies examined invasive or in situ BC and reported pathologically assessed margin status or specimen volume/weight. Two reviewers independently assessed study eligibility and quality and abstracted relevant data on patient and surgical outcomes. Quantitative data analyses were performed.

RESULTS

Fifty-two clinical studies on ROLL (n = 46) and RSL (n = 6) were identified. Twenty-seven met our inclusion criteria: 12 studies compared RGL to WGL and 15 studies were single cohorts using RGL. Ten studies were included in the quantitative analyses. Data for margin status and re-operation rates from 4 randomized controlled trials (RCT; n = 238) and 6 cohort studies were combined giving a combined odds ratio (OR) of 0.367 and 95% confidence interval (CI): 0.277 to 0.487 (p < 0.001) for margins status and OR 0.347, 95% CI: 0.250 to 0.481 (p < 0.001) for re-operation rates.

CONCLUSIONS

The results of this systematic review of RGL versus WGL demonstrate that RGL technique produces lower positive margins rates and fewer re-operations. While this review is limited by the small size and quality of RCTs, the odds ratios suggest that RGL may be a superior technique to guide surgical resection of non-palpable breast cancers. These results should be confirmed by larger, multi-centered RCTs.

Radio-guided ultrasound lymph node localization: feasibility of a new technique for localizing and excising nonpalpable lymph nodes ultrasound suspicious for melanoma metastases

Identification of lymph nodes suspicious for metastases is crucial in melanoma patients during the follow-up. We propose a procedure called radio-guided ultrasound lymph node localization (RULL) for melanoma patients with ultrasound (US) suspicious, not palpable, lymph nodes. The aim of this study was to evaluate the feasibility of this technique, and to assess the efficacy of this new method. RULL was applied in 12 consecutive melanoma patients with non-palpable lymph nodes found suspicious for metastases during US follow-up. Macro-aggregates of human serum albumin labelled with diluted technetium-99m were injected into the suspected lymph node under US guidance and followed by a scintigraphy. The surgical treatment was carried out with the support of hand-held gamma-probe used for sentinel node biopsy. The tracer was correctly positioned in all 12 patients. Pathological examination revealed seven patients with metastatic lymph nodes, four with no metastatic lymph node, one patient with Hodgkin disease. No surgical complications were described. In conclusion, RULL may integrate the standard ultrasound-guided fine-needle aspiration to improve the diagnostic accuracy on US suspicious nodes and might replace the more logistically complicated wire identification or less accurate cutaneous marker identification of these nodes. Sensibility and specificity of this approach should be defined through a large multicentric study.

Axillary lymph node drainage pathways from intradermal and intraparenchymal breast planes

BACKGROUND

To compare functional anatomy of breast peri-areolar and peri-tumoral lymphatic drainage basins.

METHODS

Fifteen breast cancer patients received simultaneous peri-areolar (intradermal) and peri-tumoral (intraparenchymal) injections of human polyclonal immunoglobulin (HIG) labeled with (99m)Tc and (111)In 2 to 4 h before axillary lymph node clearance surgery. Resected nodes (range 5-20; median 16) were individually counted for (99m)Tc and (111)In in a well-counter and ranked according to activity content (echelon). Activity in distal nodes was negligible so extraction efficiency (E) of HIG in the first echelon node was calculated as counts divided by total counts in the chain.

RESULTS

Five- to 10-fold more activity was recovered after intradermal injection. The injection planes identified the same first echelon node in 10 patients (group 1) but different in five (group 2). In group 1, intradermal E correlated with intra-parenchymal E (r = 0.82; P < 0.01). E of intradermal first echelon nodes in group 2 was 51 (SD 13)%, similar to intradermal E in group 1 (58 [23]%). E of intraparenchymal first echelon nodes in group 2, however, was 28 (6)%, lower than intraparenchymal E in group 1 (54 [20]%; P < 0.02).

CONCLUSIONS

Lymph nodes extract approximately 50% of HIG. Extracted HIG does not cascade to distal nodes, validating HIG for sentinel node lymphoscintigraphy. HIG injected intradermally at the areola drains via a single route to the axilla. In two-thirds of patients, peri-tumoral HIG follows a similar route, but in one-third of patients drainage from the parenchymal plane is more complex, with more than one route to the axilla.

[Radioguided breast surgery. Evolution of the use of minimal-invasive technologies and current situation]

The increase in the detection of occult lesions has led to the development of new localisation methods using radiopharmaceutical products. The use of these products allows us to perform a "thrifty" (less-aggressive) surgical excision and, to simultaneously carry out the biopsy of the sentinel node in cases of breast cancer. On making a search for the most up to date references on this particular topic, we found many articles on radioguided surgery by many leading international work groups. These articles clearly show the advantages of the radioguided surgery method, its effectiveness and attractiveness to surgeons who are very much involved in the search for excellence in their daily work. We also contribute our experience as a functional group, with 413 interventions on occult lesions performed using the radioguided method (ROLL). In 229 cases out of these 413, we found a malignancy (75%); in all these 229 cases it was possible to perform the intervention simultaneously with the biopsy of the sentinel node (SNOLL), during the same surgical act. However the interest created by the new procedure, it is essential to keep a critical but innovative and reflexive mind on this issue, in order to accurately analyze the results obtained by each group. We must remember that these types of methods involve several clinical specialties and, therefore, each one will have to contribute with the highest efficiency.

[US-guided localization of non-palpable breast cancer and sentinel node using 99mTechnetium-albumin colloid]

OBJECTIVE

Surgery on non-palpable breast lesions is becoming increasingly common and new techniques for preoperative lesion localization have appeared. Radio-guided occult lesion localization (ROLL) enables malignant or probably malignant non-palpable breast lesions to be located and biopsy of the sentinel node to be performed (SNOLL: sentinel node and occult lesion localization).

MATERIAL AND METHODS

Included were 118 patients with malignant or probably malignant non-palpable breast lesions visible on ultrasonography in whom radio-guided lesion resection and sentinel node biopsy were indicated. 99mTechnetium-albumin colloid was injected into the periphery of the lesion under ultrasonographic guidance and all patients underwent preoperative scintigraphy.

RESULTS

From November 2001 to December 2004, 118 patients were included. All patients underwent conservative surgery, with the non-palpable lesion being located in all cases (100% lesion detection rate). The histological diagnoses were: 81 invasive ductal carcinomas (68.64%), 7 infiltrating lobular carcinomas (5.93%), 5 mixed-type carcinomas (4.24%), 17 carcinomas in situ (14.40%), and 8 other invasive carcinomas (6.78%). The sentinel node was detected in 98.41%.

DISCUSSION AND CONCLUSIONS

Radio-guided ROLL surgery on non-palpable lesions located under ultrasonographic guidance is a simple, fast technique that enables the lesion to be safely excised. Both ROLL and SNOLL can be carried out in the same intervention with a single ultrasound-guided injection of 99mTechnetium-albumin colloid with satisfactory results.

Accuracy of sonographic localisation and specimen ultrasound performed by surgeons in impalpable screen-detected breast lesions

The National Breast Screening Programme had dramatically impacted surgical practice. Up to 50% of all newly diagnosed cancers are now impalpable creating increased demand for image-guided localisation. Wire-guided localisation (WGL) is the current gold standard, but USS-guided localisation by radiologists is a well-documented and effective technique. Increasing numbers of surgeons are proficient in using ultrasound and may be as accurate as radiologists in localising lesions intra-operatively. Of 68 patients with screen-detected impalpable lesions referred to one surgeon in our unit between January 2005 and February 2006, 32 had mass lesions, which were well seen on ultrasound and underwent intra-operative USS-guided localisation performed by a surgeon. All lesions were correctly identified and 87.5% (n=28) were fully excised. Those lesions not fully excised were lobular cancers. Intra-operative sonographic localisation performed by surgeons is an accurate and effective technique. It may produce less patient anxiety and discomfort than WGL and allow more effective and efficient use of resources and theatre time.

Occult Breast Lesion Localization plus Sentinel Node Biopsy (SNOLL): Experience with 959 Patients at the European Institute of Oncology

BACKGROUND

Non-palpable breast lesions are diagnosed frequently posing the problem of localization and removal. When such lesions are malignant, axillary node status must be determined. We report our experience using radio-guided occult lesion localization (ROLL) for locating and removing non-palpable breast lesions together with sentinel node biopsy (SNB) to assess axillary status. We call the technique SNOLL.

METHODS

From March 1997 to April 2004, 1046 consecutive patients presented suspicious non-palpable breast lesions and were programmed for conservative surgery and SNB. In 87 patients intraoperative histological examination revealed a benign lesion and SNB was not performed. The remaining 959 patients, with cytologically or histologically proven cancer, underwent SNOLL with immobile radiotracer injected under mammographic or ultrasound (US) guidance into the lesion, and subsequent injection of mobile tracer subdermally to localize the sentinel node (SN). Patients then underwent breast surgery and SNB.

RESULTS

Breast lesions were localized by ROLL in 99.6% of cases and were removed radically with negative margins in 91.9% of cases. Sentinel nodes were detected in all but one case. Intraoperative or definitive histological examination revealed 776 invasive/microinvasive carcinomas and 182 with in situ disease. Sentinel nodes were positive in 154 (19.8%) of 776 invasive/microinvasive cancers and in two with ductal intraepithelial neoplasia (1.1%).

CONCLUSIONS

In SNOLL the injection procedures are performed separately, but both lesion and SNs are removed together; axillary dissection is performed if the SN is positive, thus definitive treatment of malignant non-palpable lesions occurs in a single surgical session.

'Radioguided occult lesion localisation' (ROLL) for non-palpable breast lesions: a review of the relevant literature

BACKGROUND

'Radioguided occult lesion localisation' (ROLL) is a possible alternative to the commonly used 'wire-guided localisation' (WGL) of non-palpable breast lesions. Intratumoural injection of a radiotracer identifies both the primary tumour and the sentinel lymph nodes for intraoperative gamma probe guided dissection.

METHOD

A broad literature search was conducted, using the Pubmed, Embase and The Cochrane Library databases. Five clinically controlled trials and one randomised controlled trial, all of modest size, were selected which describe both ROLL and WGL. Four articles were found that describe the combined use of the ROLL technique with the sentinel node procedure.

RESULTS

In the ROLL group between 69% and 84% of the lesions were radically excised, compared with 44-60% of the lesions in the WGL group. The studies that combined ROLL and the sentinel node procedure mentioned even higher percentages of radically excised specimens ranging from 90% to 95% and an identification rate of sentinel nodes up to 100%. One randomised controlled trial mentioned that the ROLL procedure had a faster localisation time, was easier to perform, was less painful and gave a better cosmetic result than WGL.

CONCLUSION

ROLL seems a promising technique, which appears to be more radical than WGL. Localisation tends to be more accurate and faster, the excision procedure is more elegant and simple to perform, and the cosmetic result seems to be better. Further research is necessary to establish the exact role of ROLL in the management of non-palpable breast lesions.

The evolution of the conservative approach to breast cancer

The profound revolution that surgical treatment of breast cancer has undergone during the past 30 years has led to the progressive reduction of the extent of surgery, with less mutilation. As a consequence, quality of life has improved and women are now more motivated to follow screening programs for early diagnosis of the disease. Since conservative surgery is as effective as radical surgery, research is now focused on reducing radiotherapy. Overall, survival after breast cancer is not affected by reducing the extent of surgery, which, together with less invasive diagnostic procedures, has a good effect on patients' quality of life. For this reason in our Institute we are now evaluating the feasibility of a reduction of the radiation field and the sensibility and sensitivity of new diagnostic approaches for axillary staging.