Intraoperative ultrasound in conservative surgery for non-palpable breast cancer after neoadjuvant chemotherapy

The Use of Intraoperative Ultrasound During Breast Conserving Surgery

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intraoperative Ultrasound-Guided Excision of Non-Palpable and Palpable Breast Cancer: Systematic Review and Meta-Analysis

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.

Does Tumor Marking Before Neoadjuvant Chemotherapy Helps Achieve Better Outcomes in Patients Undergoing Breast Conservative Surgery? A Systematic Review

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.

Unplanned breast-conserving surgery after systemic therapy in locally advanced breast cancer: The results of level II oncoplastic techniques

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.

Novel Multimodal, Multiscale Imaging System with Augmented Reality

A novel multimodal, multiscale imaging system with augmented reality capability were developed and characterized. The system offers 3D color reflectance imaging, 3D fluorescence imaging, and augmented reality in real time. Multiscale fluorescence imaging was enabled by developing and integrating an in vivo fiber-optic microscope. Real-time ultrasound-fluorescence multimodal imaging used optically tracked fiducial markers for registration. Tomographical data are also incorporated using optically tracked fiducial markers for registration. Furthermore, we characterized system performance and registration accuracy in a benchtop setting. The multiscale fluorescence imaging facilitated assessing the functional status of tissues, extending the minimal resolution of fluorescence imaging to ~17.5 µm. The system achieved a mean of Target Registration error of less than 2 mm for registering fluorescence images to ultrasound images and MRI-based 3D model, which is within clinically acceptable range. The low latency and high frame rate of the prototype system has shown the promise of applying the reported techniques in clinically relevant settings in the future.

Outcomes of intraoperative versus preoperative ultrasound-guided wire localization of nonpalpable breast lesions

Background: Nonpalpable breast lesions require localization, the gold standard for which is preoperative ultrasound-guided wire localization (PUGWL). Our unit also employs intraoperative ultrasound-guided wire localization (IUGWL). Here we evaluate PUGWL and IUGWL outcomes between 2014 and 2018. Primary outcomes were reoperation rates, complication rates and average specimen weights. Trainee feedback and cost analysis assessed IUGWL viability. Methods: Prospectively recorded data were collected. 511 patients were included (241 PUGWL and 270 IUGWL). Results: Reoperation rates: PUGWL 17.7% versus IUGWL 13.9% (p = 0.28) . Complication rates: PUGWL 5.8% versus IUGWL 6.6% (p = 0.72) . Average specimen weight: PUGWL 34.2 g versus IUGWL 24.3 g (p < 0.0001) . Trainees needed 15 supervised cases to be IUGWL competent. Performing IUGWL saves £289 per localization. Conclusion: IUGWL outcomes are comparable to those of PUGWL. IUGWL is cost-effective, patient-friendly and easy to learn and replicate. IUGWL merits wider dissemination and further planned research.

Usefulness of 3D-surgical guides in breast conserving surgery after neoadjuvant treatment

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).

A new method to optimize resection area using a radiation treatment planning system and deformable image registration for breast-conserving surgery after neoadjuvant chemotherapy

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.

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

BACKGROUND/AIM

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Clip and wire localization of locally advanced malignant breast masses in patients undergoing neoadjuvant chemotherapy and breast conservation therapy

Background

In locally advanced breast cancers, the use of preoperative systemic therapy has been shown to induce tumor response and to improve the local control rate after subsequent surgery and radiation therapy. The purpose of the study is to evaluate the accuracy of localization of breast malignant masses in patients who received neoadjuvant chemotherapy and will undergo conservative breast surgery by using clip and wire marker.

Results

Clip placement was done in 20/20 cases (100%). There was no mammographic evidence of clip migration or complication related to the clip insertion. Wire localization of tumor bed marked by radiopaque clip 1-day preoperative was done in 18/20 patient (90%), the other 2 patients, the masses were clinically palpable (10%). Accurate localization by wire was positive in 18/18 cases. Clip and wire retrieval were positive in all cases.

Conclusion

Clip markers can be used for tumor localization in breast cancer patients undergoing neoadjuvant chemotherapy without migration. Clips are tolerated and safe for the patient, easily visualized on imaging, do not interfere with treatment response, and are cost-effective. Also, serves as a guide for post-neoadjuvant chemotherapy localization when the tumor is not palpable.

Surgeon-led Intraoperative Ultrasound Localization for Nonpalpable Breast Cancers: Results of 5 Years of Practice

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.

Paradigm shift in the local treatment of breast cancer: mastectomy to breast conservation surgery

There have been fundamental changes in the approach to breast cancer management over the last century but the primary objective of achieving oncological safety remains unchanged. This evolution is highlighted with a summary of the key evidences in support of the oncological safety of breast conserving surgery (BCS) in early breast cancer (EBC) management. We will also discuss the increasingly pivotal role that neoadjuvant chemotherapy (NACT) may play, in the local treatment of EBC and locally advanced breast cancer (LABC) and the long-term surgical and oncological outcomes.

Surgical Management of Breast Cancer Treated with Neoadjuvant Therapy

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.

Hygroscopic sonographically detectable clips form characteristic breast and lymph node pseudocysts

The use of hygroscopic sonographically detectable clips (HSDCs) has dramatically increased during the last years, especially in breast cancer patients who undergo neoadjuvant chemotherapy. The aims of this study are to define the appearance of HSDC sites in histopathological specimens, and to enable pathologists to recognize these sites and differentiate them from other lesions. We examined 124 breast cancer specimens in which the application of HSDCs was documented, 88 breast tissues and 36 lymph nodes, and analyzed the appearance of the clip site in these tissues. The clip site was clearly detected histologically in 79/88 (90%) of the breast specimens and in 29/36 (81%) of lymph node specimens. In most of the specimens, the HSDC site had a specific characteristic appearance of a pseudocyst, lined by layers of epithelioid histiocytes, sometimes with pseudopapillary formation, and with minimal or no fibrosis. This was the appearance in 69 of the breast specimens and in 23 of the lymph node specimens. In other specimens, scarring, scattered foamy macrophages and abundant siderophages were the predominant findings, as usually found in sites of other clips. As non-palpable breast lesions become more frequent, clips play a major role in the treatment of breast cancer, making them an important component of the communication among radiologists, surgeons, pathologists, and oncologists. HSDCs in tissues have a characteristic appearance with an epithelioid component. Pathologists should be able to recognize this finding, differentiate it from other breast lesions and include it in the pathology report.

Breast-conserving surgery following neoadjuvant therapy-a systematic review on surgical outcomes

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.

Detectability of Hygroscopic Clips Used in Breast Cancer Surgery

Sonographically detectable clips were introduced over the last decade. We retrospectively studied the rate and duration of sonographically detectable clip detectability in patients with breast cancer who had sonographically detectable clips inserted over a 2-year period. Nine of 26 patients had neoadjuvant chemotherapy, with all clips remaining detectable 140 to 187 days after insertion. Six of the 9 had intraoperative sonographic localization, with 1 reoperation (17%). Eleven additional patients with nonpalpable tumors and sonographically detectable clips had intraoperative sonographic localization with 1 reoperation (9%). In 1 patient, a sonographically detectable clip enabled intraoperative identification of a suspicious lymph node. There were no complications or clip migration. Sonographically detectable clips are helpful in breast cancer surgery with and without neoadjuvant chemotherapy, remaining detectable for many months and often averting preoperative localization and scheduling difficulties.