Update on Preoperative Breast Localization

Timing of radiofrequency identification tag placement: can early placement save time and patient experience?

PURPOSE

Radiofrequency identification tag localization (TL) is a method of localizing nonpalpable breast cancers and high-risk lesions that can be performed prior to the day of surgery (DOS). We evaluated if placement of TL prior to DOS would affect patients' length of stay (LOS) and improve surgical on-time starts.

METHODS

A retrospective review of excisional biopsies and lumpectomies with TL was performed. Associations between timing of TL (DOS vs. prior), time in radiology, surgical case delay, LOS on DOS, and total LOS were assessed.

RESULTS

439 patients underwent TL for nonpalpable breast cancer or high-risk lesions between July 2018 and July 2021 at our institutions. 158 TL procedures were performed on the DOS and 281 TL procedures were performed a median of 3 days prior to the DOS (range 1-28). All intended targets were removed. The median total LOS (time in radiology and surgery) was 336 min and 434 min for the early placement group and DOS group, respectively (p < 0.001). The median length of time in radiology was 47 min for the early placement group and 54 min for the DOS group (p < 0.001). Cases were significantly more likely to be delayed (p = 0.002) and could not be first-start cases if TL was performed on DOS. Vasovagal events during TL and narcotic use in the post-operative setting were rare across both groups.

CONCLUSIONS

TL prior to DOS was associated with a decrease in total LOS (p < 0.001) and case delay (p = 0.002), as well as an increase in first-start cases. These findings suggest the potential superiority of TL prior to DOS.

Recognizing patient-related artefacts in MRI of the breasts: principles, imaging appearance, and solutions to minimize them

Breast MRI has emerged as an increasingly important tool in evaluating breast pathologies including detection and assessment of cancers, evaluation of implant integrity and as a problem-solving tool for inconclusive conventional breast imaging findings. MRI artefacts encountered during image interpretation may create diagnostic dilemmas. Many of these artefacts are patient-related and can be avoidable. Identification of these artefacts can be challenging in daily practice in particular to trainees or inexperienced radiologists. This article illustrates the principles and imaging appearance of the common patient-related artefacts in breast MRI, with discussion on how to minimize them. They include positioning-related artefacts, inhomogeneous fat suppression, susceptibility artefacts including those associated with the newly emerged non-radioactive wireless localization devices and superparamagnetic lymphatic tracer, as well as motion artefacts. Familiarization with these 4 major types of artefacts by radiologists is crucial in troubleshooting and achieving accurate image interpretation.

Innovations in the localization techniques for non-palpable breast lesions: Make invisible visible

Non-palpable breast cancer lesions pose a challenge for surgeons to resect cancer lesions. Making 'invisible' lesions 'visible' is the main strategy. Currently, multiple preoperative localization techniques have been applied in clinical. Among them, wire-guided localization (WGL) is the most common procedure due to its convenience and low cost. However, its limitations including discomfort, wire migration and the coupling of localization and operation procedures cause troubles for surgeons and patients. The desire for localization methods improvement, accompanied by the advance of emerging science and technology, leads to the development of a series of locating approaches for breast non-palpable lesions, aiming to improve locating accuracy while reducing adverse events. These emerging methods have undergone improvements from steel wire to functional particles, from radioactivity to non-radioactive, which help doctors and patients choose a more appropriate scheme. This review outlines the principles, procedures, advantages and disadvantages of these locating methods, and highlights the latest progress and related clinical data on innovative locating approaches. Finally, we briefly discuss the current challenges and future opportunities for the clinical application of these localization approaches.

Radar reflectors for marking of target lymph nodes in initially node-positive patients receiving neoadjuvant chemotherapy for breast cancer-a subgroup analysis of the prospective AXSANA (EUBREAST-03) trial

BACKGROUND

Surgical staging procedures of the axilla in initially clinically node-positive (cN +) breast cancer patients receiving neoadjuvant chemotherapy (NACT) vary across countries. Different procedures such as axillary lymph node dissection, sentinel lymph node biopsy, target lymph node biopsy and targeted axillary dissection are currently in use. To date, data on radar reflectors as a non-wire and non-radioactive technique for marking target lymph nodes are limited. The present study aims at examining the detection rate, the rate of lost markers, and magnetic resonance imaging artifacts after TLN marking using a radar reflector before NACT in the largest available cohort of breast cancer patients enrolled in the international prospective AXSANA study.

METHODS

AXSANA (EUBREAST-03) is an international prospective cohort study including cN + patients managed with different surgical axillary staging techniques after NACT. Eligible patients have cT1-4c cN + breast cancer and receive neoadjuvant chemotherapy. Patients are followed up for 5 years. In the present subgroup analysis, only patients with a TLN marked by a radar reflector were included.

RESULTS

A TLN was marked by radar reflector insertion in 158 patients prior to NACT. Of these, 136 had final surgery results available at the time of analysis, and in 135 out of these 136 patients, localization of TLN was attempted. All radar markers were successfully removed. While lymphoid tissue corresponding to the TLN was identified in 132 patients (97.8%), no lymphoid tissue was detected on histopathology in three patients. It remains unclear whether the TLN was excised in these cases or not. In 1 out of 27 patients (3.7%) who underwent preoperative MRI, image assessment was compromised due to artifacts after radar marker placement.

CONCLUSION

To the best of our knowledge, this is the largest prospective series of patients receiving a radar reflector for the marking of a TLN prior to NACT for breast cancer. Our data demonstrate that radar reflectors are a reliable tool for marking target lymph nodes before neoadjuvant treatment.

TRIAL REGISTRATION NUMBER

NCT04373655 (date of registration May 4, 2020).

Localization procedure for breast lesions at time of biopsy - Which patients would benefit?

BACKGROUND

The diagnosis and treatment of non-palpable breast lesions is a multistep pathway that can involve imaging, tissue biopsy, clip placement, localization, and surgical resection. To minimize the procedural burden on patients, placement of localization seeds at time of initial biopsy has been considered. However, benefit to this patient population remains unclear. This study, therefore, aimed to determine the number of patients within our own institution that may benefit from upfront localization and characterize an appropriate target population.

METHODS

A single institution retrospective cross-sectional study was conducted with assessment of all patients who underwent core needle biopsy (CNB) and/or breast cancer surgery at a regional high-volume breast centre between January 1 and December 31, 2018. Patients who underwent CNB with a subsequent radiological localization procedure and breast cancer surgeries that utilized localization were evaluated in order to model seed use.

RESULTS

In total, 314 CNB and 634 breast cancer surgeries were performed. Within the CNB cohort, 60 (19.1 ​%) required localization. Of the breast cancer surgeries performed, 420 (66.2 ​%) were breast-conserving surgery and 303 (47.8 ​%) required localization.

CONCLUSION

With some localization technologies, the localization procedure can be coupled with biopsy and eliminate the need for a clip as the length of implantation is unrestricted. That said, our institutional data suggests that only a small portion of patients undergoing breast biopsy would benefit from upfront localization and a minority of breast cancer surgeries require localization. Further characterization of this specific patient population is needed to streamline management pathways.

The role and potential of digital breast tomosynthesis in neoadjuvant systemic therapy evaluation for optimising breast cancer management: a pictorial essay

Neoadjuvant therapy (NT) has become the gold standard for treating locally advanced breast cancer (BC). The assessment of pathological response (pR) post-NT plays a crucial role in predicting long-term survival, with contrast-enhanced MRI currently recognised as the preferred imaging modality for its evaluation. Traditional imaging techniques, such as digital mammography (DM) and ultrasonography (US), encounter difficulties in post-NT assessments due to breast density, lesion changes, fibrosis, and molecular patterns. Digital breast tomosynthesis (DBT) offers solutions to prevalent challenges in DM, such as tissue overlap, and facilitates a comprehensive assessment of lesion morphology, dimensions, and margins. Studies suggest that DBT correlates more accurately with pathology than DM and US, showcasing its potential advantages. This pictorial essay demonstrates the potential of DBT as a complementary tool to DM for assessing pR after NT, including instances of true- and false-positive assessments correlated with histopathological findings. In conclusion, DBT emerges as a valuable adjunct to DM, effectively addressing its limitations in post-NT assessment. The technology's potential to diminish tissue overlap, improve discrimination, and provide multi-dimensional perspectives demonstrates promising results, indicating its utility in scenarios where MRI is contraindicated or inaccessible.

Evaluation of Hologic LOCalizer™ RFID Tags for Preoperative Localization of Breast Lesions: A Single-Center Experience

Background: The increasing detection of non-palpable breast lesions necessitates accurate preoperative localization to ensure complete excision while preserving healthy tissue and optimizing cosmetic outcomes. Traditional wire-guided localization (WL) has been the gold standard; however, it has several drawbacks, including patient discomfort and scheduling challenges. This study evaluates the accuracy and feasibility of radiofrequency identification (RFID) tag localization using the Hologic LOCalizer™ system as an alternative technique. Methods: This retrospective study included 258 consecutive patients who underwent image-guided RFID tag localization from March 2021 to February 2023 from a single-center London breast unit. The primary outcome measured was the accuracy of RFID tag placement, defined as within 10 mm of the target lesion on post-clip mammograms. Secondary outcomes included type and size of lesions, re-excision rates, review of post-operative specimen radiographs, and patient demographics. Results: A total of 297 RFID tags were placed, with 95.6% accurately positioned within the target range. The median target size was 29 mm, with the most common abnormalities being mass lesions (64%). Among the 13 inaccurately placed RFID tags (4.4%), all were identified preoperatively, with two requiring additional wire placements. RFID tags were successfully identified in 92% of specimen radiographs, and 8% of patients required re-excision due to positive or close margins. Notably, patients with multiple RFID tags showed a higher incidence of re-excision. Conclusions: The LOCalizer™ RFID system demonstrated a high accuracy rate for preoperative localization of breast lesions, presenting a viable alternative to WL. This technique improves surgical scheduling flexibility and enhances patient comfort. Comparative studies with other wire-free localization technologies, such as magnetic seeds and radar reflectors, are needed to determine the optimal approach for clinical practice.

Magnetic surgical marker navigation for excision of non-palpable ultrasound visible breast lesions: first 200 cases in a French cancer center

Wire guided localization is widely used as the standard method of pre-operative localization of breast lesions. The aim was to assess outcomes following the introduction of a novel non-wire guided, magnetic surgical marker navigation system. A prospective study between May 2022 and June 2023 established a data base of the first 200 procedures performed using the Sirius Pintuition GPS Detect magnetic marker. The primary outcome measures were the successful excision of the target lesion and retrieval of the magnetic marker. The primary lesion was excised and the magnetic marker was retrieved in all 200 procedures. In 17 procedures (8.5% of the total sample), the magnetic marker was dislodged during surgery; however, the primary lesion was still effectively excised with clear margins without the need for an additional procedure or radiologic assistance. The re-excision rate to achieve margin clearance was 9%. Insertion of the marker was classified as "easy" and "in contact with the target" by the radiologist in all cases (100%). This study has shown that surgical marker navigation reliably localizes lesions and is associated with low re-excision rates. We also perceived improvement in theater planning.

SCOUT® radar reflectors for impalpable lesion localisation in the breast and axilla: our experience in the first 500 patients

AIM

This study aimed to detail our experience of using SCOUT® radar reflector for lesion localisation in the breast and axilla.

MATERIALS AND METHODS

This is a prospective cohort study describing our clinical experience with the first 500 patients who received SCOUT® to localise lesions in the breast and axilla (from 23 July 2020 to 4 April 2022). Study measures include patient demographics, lesion location, diagnostic pathways (screening or symptomatic), imaging, and surgical and pathology outcomes.

RESULTS

Of the 500 patients, most patients (n = 424; 84.8%) had a single device inserted. A total of 361 had SCOUT® inserted under ultrasound guidance, 128 under stereotactic guidance, and 11 under dual mammographic and ultrasonographic guidance. We successfully inserted SCOUT® in 33 patients for lymph node identification for potential targeted axillary dissection. The mean time between SCOUT® insertion and the planned surgical procedure was 40.6 days.

CONCLUSION

Our results suggest that SCOUT® is a promising preoperative localisation device for nonpalpable breast and axillary lesions. Its implementation has the potential to optimise the clinical workflow by eliminating the need for a separate localisation procedure using conventional localisation markers and streamlining the treatment pathway.

Axillary lymph node management strategies in cN + breast cancer patients after neoadjuvant chemotherapy

With the widespread use of neoadjuvant chemotherapy (NAC), the optimal management strategy for axillary lymph nodes following chemotherapy has become a hot topic of discussion. For patients with clinically positive axillary lymph nodes (cN +) (defined as axillary lymph nodes confirmed positive by pathology before NAC), axillary lymph node dissection (ALND) remains the current standard treatment. However, there is still no consensus on whether sentinel lymph node biopsy (SLNB) and other local axillary treatments following NAC can safely replace ALND to reduce injury and complications. This article provides a narrative review of strategies for managing axillary lymph nodes in this patient population.

Clip and Blue-An Easy and Cost-Effective Prechemotherapy Localization Technique in Patients With Breast Cancer Planned for Breast Conservation

PURPOSE

Breast conservation after systemic therapy requires accurate localization of the lesion and its margins, especially in nonpalpable tumors. The present study aims to describe a cost-effective technique of tumor localization using the combination of surgical clips and methylene blue.

METHODS

A minimum of three or four clips were inserted into the tumor to allow easy visualization of the clip mass. After insertion, measurements of the clips from the nipple and pectoral muscles were recorded to assess for clip migration. After chemotherapy, the disease and clip mass were localized intra-operatively using blue dye. A single-center review of breast conservations performed after neoadjuvant chemotherapy that used the above-described localization technique was undertaken. The primary aim was to assess successful detection and margin-negative resection rates.

RESULTS

The study included 65 patients, and the clip mass was detected on ultrasound following chemotherapy in all patients without clip migration. This detection was accurate even in cases of complete pathological and radiological response. Importantly, there were no procedure-related complications. Postchemotherapy disease localization was successfully achieved in all patients using the readily available and cost-effective methylene blue dye. No patient had an invasive margin positive at resection.

CONCLUSION

The combination of using multiple surgical clips and methylene blue is not only an extremely cheap and accurate technique for tumor site localization but also ensures precise surgical removal. The technique allows tumor localization even in low-income economies.

Reliability of Magseed® marking before neoadjuvant systemic therapy with subsequent contrast-enhanced mammography in patients with non-palpable breast cancer lesions after treatment: the MAGMA study

PURPOSE

To assess the reliability of excising residual breast cancer lesions after neoadjuvant systemic therapy (NAST) using a previously localized paramagnetic seed (Magseed®) and the subsequent use of contrast-enhanced spectral mammography (CESM) to evaluate response.

METHODS

Observational, prospective, multicenter study including adult women (> 18 years) with invasive breast carcinoma undergoing NAST between January 2022 and February 2023 with non-palpable tumor lesions at surgery. Radiologists marked tumors with Magseed® during biopsy before NAST, and surgeons excised tumors guided by the Sentimag® magnetometer. CESMs were performed before and after NAST to evaluate tumor response (Response Evaluation Criteria for Solid Tumors [RECIST]). We considered intraoperative, surgical, and CESM-related variables and histological response.

RESULTS

We analyzed 109 patients (median [IQR] age of 55.0 [46.0, 65.0] years). Magseed® was retrieved from breast tumors in all surgeries (100%; 95% CI 95.47-100.0%) with no displacement and was identified by radiology in 106 patients (97.24%), a median (IQR) of 176.5 (150.0, 216.3) days after marking. Most surgeries (94.49%) were conservative; they lasted a median (IQR) of 22.5 (14.75, 40.0) min (95% CI 23.59-30.11 min). Most dissected tumor margins (93.57%) were negative, and few patients (5.51%) needed reintervention. Magseed® was identified using CESM in all patients (100%); RECIST responses correlated with histopathological evaluations of dissected tumors using the Miller-Payne response grade (p < 0.0001) and residual lesion diameter (p < 0.0001). Also 69 patients (63.3%) answered a patient's satisfaction survey and 98.8% of them felt very satisfied with the entire procedure.

CONCLUSION

Long-term marking of breast cancer lesions with Magseed® is a reliable and feasible method in patients undergoing NAST and may be used with subsequent CESM.

Radiofrequency as a method of localizing impalpable breast lesions

BACKGROUND

The incidence of early stage breast cancer has risen as a result of increased detection of non-palpable tumors through the implementation of screening programs and greater public awareness. Performing breast-conserving surgery can be challenging due to the need for accurate localization of non-palpable breast lesions, particularly given the logistical difficulties associated with wire localization. After implementing a new technique for localizing non-palpable breast lesions (LOCalizerTM Radiofrequency identification TAG-Hologic®), a radiofrequency identification tag localization device manufactured by Hologic, Inc. in Marlborough, MA, was launched in 2017, our objective was to investigate its impact on surgical outcomes, whether there was an increase in re-excision rates for positive margins and whether the attainment of clear margins was dependent on the exact positioning of the RFID device.

METHOD

A single-center single-arm interventional study, data were gathered both in a forward-looking manner for 1 year (prospectively) and by looking back at past records for 1 year (retrospectively) for a total period of two years. Individuals who were diagnosed with non-palpable breast lesions, as confirmed by histological analysis, or invasive breast cancer and who were scheduled to undergo breast-conserving surgery were eligible for inclusion in the study. The RFID (Radiofrequency Identification) method was used to localize the lesions prior to surgery. Either with a mammogram or ultrasound scan position of the Tag was recorded, including the distance of the lesion from the center of the lesion and the lesion depth from the skin in millimeters. The rate of re-excision was documented and examined in relation to the parameters mentioned above.

RESULTS

Two hundred and twenty RFID Tags were inserted in two hundred and seventeen (three patient had bilateral tags insertion), patients aged between 30 and 85 had a localizer Tag inserted between Oct 2020 and Oct 2022. Three patients had non-palpable breast lesions in both breasts. Fourteen were inserted under stereotactic guidance and two hundred and six under ultrasound guidance. Ten patients subsequently had wire insertion also due to Tag position. Of 210 procedures, RFIF Tags within the lesion was seen in hundred and sixty patients (76.19 %). An additional 50 procedures were performed using the RFID Tag system, which were not directly related to the lesion but were deemed appropriate to proceed with. Out of a total of 220 procedures, positive margins were observed in 38 cases (17.27 %). Among these cases, eleven (28.94 %) involved the use of the RFID Tag system, not within the lesion but adjacent to it (within 15 mm surrounding the lesion).

CONCLUSION

RFID is a good alternative to wire localization of non-palpable breast lesions. Re-excision rates are higher in patients with Tag outside the lesion compared to those with Tag within the lesion.

The Oncological and Surgical Outcomes of Immediate Oncoplastic Breast Reconstruction With Contralateral Breast Adjustment

BACKGROUND

Oncoplastic surgery is an expanding approach for managing breast conservation because it offers improved cosmetic outcomes while maintaining oncological safety.

OBJECTIVES

This study aimed to assess the oncological and surgical outcomes of patients who underwent oncoplastic procedures at a single institution.

METHODS

The study population includes all consecutive breast cancer patients who underwent lumpectomy followed by immediate oncoplastic breast reconstruction with contralateral breast adjustment between 2010 and 2021. Following IRB approval, patient demographics, tumor characteristics, surgical details, complications, and follow-up were evaluated for this group. Quality of life (QOL) and patient-reported outcome measures were assessed through questionnaires.

RESULTS

Following multidisciplinary tumor board discussion, 77 patients (82 breasts) underwent oncoplastic surgery. Of these, 92.2% underwent breast MRI prior to surgery with mean mass enhancement of 2.35 cm (range, 0-8.5 cm) and non-mass enhancement of 5.77 cm (range, 0-14 cm), and 44% presented with multifocal disease. The final positive surgical margin rate was 2.4%, and all conserved breasts received adjuvant radiation therapy. The 5-year local recurrence rate for invasive tumors was 4.1%. QOL scores were generally high, with most patients reporting good to excellent cosmetic outcomes and high personal satisfaction with breast appearance and softness. Physicians reported breast symmetry in 89.5%.

CONCLUSIONS

The findings suggest that oncoplastic surgery with contralateral breast adjustment is safe, effective, and an excellent option for breast cancer patients wishing for breast conservation even for large or multifocal masses, with favorable oncologic and cosmetic outcomes. The QOL analysis indicates high patient satisfaction. These results support the use of oncoplastic surgery in the management of breast cancer.

LEVEL OF EVIDENCE: 4

SCOUT® Localization Using MRI Guidance: Initial Experience

OBJECTIVE

The Food and Drug Administration approved the MRI-compatible wireless SCOUT localization system in April 2022. The purpose of this study was to evaluate feasibility of SCOUT localization under MRI guidance. We present our initial experience adopting MRI-guided SCOUT localization and compare it to MRI-guided wire localization.

METHODS

Electronic medical records and imaging were retrospectively reviewed for all patients who underwent MRI-guided SCOUT or wire localization at our institution between October 2022 and July 2023. Statistical analysis was performed using 2-sample proportion and Wilcoxon rank-sum tests.

RESULTS

There were 14 MRI-guided SCOUT and 23 MRI-guided wire localization cases during the study period. All SCOUTs were placed without complication and were considered to be in adequate proximity to the target. There was no significant difference in complication rate (P = .25) or days lapsed from MRI-detected abnormality to surgery (P = .82) between SCOUT and wire cases. SCOUT was placed at time of biopsy for 71% (10/14) of cases. 57% (8/14) of SCOUT cases were used for breast conservation surgery (BCS) compared to 100% (23/23) of wire cases (P <.01), with all 6 SCOUTs not used for BCS placed at time of biopsy.

CONCLUSION

MRI-guided SCOUT localization is feasible and offers an alternative to MRI-guided wire localization, with no SCOUT complications reported. SCOUT placement at time of biopsy obviates the need for an additional procedure, but predicting appropriateness is challenging, with 60% (6/10) of SCOUTs placed at time of MRI-guided biopsy not used for subsequent localization surgery.

Contrast-enhanced mammography and preoperative magnetic seed placement in breast cancer patients for the detection of residual disease following neoadjuvant systemic therapy

PURPOSE

Assess whether contrast-enhanced mammography (CEM) enables an evaluation of the residual size of breast tumours following neoadjuvant systemic therapy (NAST) in patients initially marked with magnetic seed.

MATERIALS AND METHODS

This single-centre prospective study was performed between March 2022 and April 2023 with patients with invasive breast carcinoma and lesional marking with magnetic seed. CEM was performed before and after NAST. The lesion size in CEM after NAST was compared to the pathological examination after surgery. Differences between sizes were evaluated and we determined the diagnostic capability indices.

RESULTS

The breast lesions marked with magnetic seed were successfully localised in the preoperative stage for the 42 patients included in the study and selective surgical excision was also achieved in all cases. Tumour diameter after NAST was determined by comparing enhancement on combined CEM images from before and after NAST. The mean diameter was 13.6 mm while post-surgical pathological examination determined the mean diameter to be 12.9 mm. There were therefore no statistically significant differences between the measurements.

CONCLUSIONS

There is a positive correlation and similarity between CEM and pathological examination with regards to the detection of residual disease after NAST, with high specificity and PPV.

Wirelessly Powered Visible Light-Emitting Implant for Surgical Guidance during Lumpectomy

Achieving negative surgical margins, defined as no tumor found on the edges of the resected tissue, during lumpectomy for breast cancer is critical for mitigating the risk of local recurrence. To identify nonpalpable tumors that cannot be felt, pre-operative placements of wire and wire-free localization devices are typically employed. Wire-free localization approaches have significant practical advantages over wired techniques. In this study, we introduce an innovative localization system comprising a light-emitting diode (LED)-based implantable device and handheld system. The device, which is needle injectable and wire free, utilizes multiple wirelessly powered LEDs to provide direct visual guidance for lumpectomy. Two distinct colors, red and blue, provide a clear indication of tissue depth: blue light is absorbed strongly in tissue, visible within a close range of <1 cm, while red light remains visible through several centimeters of tissue. The LEDs, integrated with an impedance-matching circuit and receiver coil, are encapsulated in biocompatible epoxy for injection with a 12 G needle. Our findings demonstrate that the implant exhibits clearly perceivable depth-dependent color changes and remains visible through >2 cm of ex vivo chicken breast and bovine muscle tissue using less than 4 W of transmitted power from a handheld antenna. These miniaturized needle-injectable localization devices show promise for improving surgical guidance of nonpalpable breast tumors.

Comparison of magnetic seed and RFID methods in the localization of non-palpable breast lesions

BACKGROUND

Many methods have been developed for localizing non-palpable breast lesions. This study investigated the success rate and surgical results of the magnetic seed (Magseed) and radiofrequency identification (RFID) method, which are relatively new compared to standard wire-guided localizations.

MATERIALS AND METHODS

20 simulation (10 Magseed, 10 RFID) models were created using turkey breasts and raisins. Raisins containing magnetic seed and RFID tags were placed on the turkey breast. Sentimag® probe was used for the Magseed group, and Faxitron LOCalizer™ System device was used in the RFID group. Both methods were evaluated in terms of accuracy in detecting breast lesion localization, operation times, excised tissue weights, total resection volume, surgical margin negativity, and re-excision rates.

RESULTS

Lesion localization success in both techniques was 100%. While procedure times were statistically significantly shorter in the Magseed group, incision lengths were shorter in the RFID group (P = 0.013, P = 0.007, respectively). No statistically significant difference was found between the groups for the weight of the removed parts, total resection volume, and surgical margin distance (P > 0.05).

CONCLUSION

In this feasibility study, it was concluded that neither the RFID nor Magseed methods had a significant advantage over each other, in terms of localization detection and surgical margin negativity, and both methods could be used successfully for localization.

Assessing the Efficacy of Radioactive Iodine Seed Localisation in Targeted Axillary Dissection for Node-Positive Early Breast Cancer Patients Undergoing Neoadjuvant Systemic Therapy: A Systematic Review and Pooled Analysis

Targeted axillary dissection (TAD), employing marked lymph node biopsy (MLNB) alongside sentinel lymph node biopsy (SLNB), is increasingly recognised for its efficacy in reducing false negative rates (FNRs) in node-positive early breast cancer patients receiving neoadjuvant systemic therapy (NST). One such method, 125I radioactive seed localisation (RSL), involves implanting a seed into a biopsy-proven lymph node either pre- or post-NST. This systematic review and pooled analysis aimed to assess the performance of RSL in TAD among node-positive patients undergoing NST. Six studies, encompassing 574 TAD procedures, met the inclusion criteria. Results showed a 100% successful deployment rate, with a 97.6% successful localisation rate and a 99.8% retrieval rate. Additionally, there was a 60.0% concordance rate between SLNB and MLNB. The FNR of SLNB alone was significantly higher than it was for MLNB (18.8% versus 5.3%, respectively; p = 0.001). Pathological complete response (pCR) was observed in 44% of cases (248/564). On average, the interval from 125I seed deployment to surgery was 75.8 days (range: 0-272). These findings underscore the efficacy of RSL in TAD for node-positive patients undergoing NST, enabling precise axillary pCR identification and facilitating the safe omission of axillary lymph node dissection.

SCOUT® Radar Localization at Time of Breast Biopsy

OBJECTIVE

Evaluate surgical utilization of SCOUT reflectors placed at breast biopsy.

METHODS

Consent was waived for this retrospective IRB-approved, HIPAA-compliant study. Breast biopsy examinations that reported the term "SCOUT" between January 2021 and June 2022 were identified using an institutional search engine. Cases were included if a SCOUT reflector was placed at time of breast biopsy and excluded if lesion pathology was already known. Analysis was performed at the lesion level. A multivariate-regression analysis evaluated 6 variables with potential impact on SCOUT utilization.

RESULTS

One hundred twenty-one lesions in 112 patients met inclusion criteria. Biopsy yielded 93% (113/121) malignant, 3% (4/121) elevated risk, 2% (2/121) benign-discordant, and 2% (2/121) benign-concordant results. Two cases lost to follow-up were excluded. SCOUT reflectors were utilized for lumpectomy (58%, 69/119 lesions) and excisional biopsy (6%, 7/119 lesions). SCOUTs were not utilized due to mastectomy (23%, 27/119), subsequent wire localization (2%, 2/119), and nonsurgical cases (12%, 14/119). Reflector placement utilization was 52% higher for findings less than 3.5 cm in size (P <.001), 33% higher in patients without prior treated breast cancer (P = .012), and 19% higher in patients with no suspicious ipsilateral lymph node (P = .048).

CONCLUSION

SCOUT reflector placement at time of biopsy was utilized for surgery 64% (76/119) of the time, although most (98%, 119/121) biopsies were malignant, elevated risk, or benign-discordant. Factors increasing reflector utilization include smaller lesion size, no suspicious ipsilateral lymph node, and no prior treated breast cancer.

Evaluating Magnetic Seed Localization in Targeted Axillary Dissection for Node-Positive Early Breast Cancer Patients Receiving Neoadjuvant Systemic Therapy: A Comprehensive Review and Pooled Analysis

Background/Objectives: De-escalation of axillary surgery is made possible by advancements in both neoadjuvant systemic therapy (NST) and in localisation technology for breast lesions. Magseed®, developed in 2013 by Dr. Michael Douk of Cambridge, United Kingdom, is a wire-free localisation technology that facilitates the localisation and retrieval of lymph nodes for staging. Targeted axillary dissection (TAD), which entails marked lymph node biopsy (MLNB) and sentinel lymph node biopsy (SLNB), has emerged as the preferred method to assess residual disease in post-NST node-positive patients. This systematic review and pooled analysis evaluate the performance of Magseed® in TAD. Methods: The search was carried out in PubMed and Google Scholar. An assessment of localisation, retrieval rates, concordance between MLNB and SLNB, and pathological complete response (pCR) in clinically node-positive patients post NST was undertaken. Results: Nine studies spanning 494 patients and 497 procedures were identified, with a 100% successful deployment rate, a 94.2% (468/497) [95% confidence interval (CI), 93.7-94.7] localisation rate, a 98.8% (491/497) retrieval rate, and a 68.8% (247/359) [95% CI 65.6-72.0] concordance rate. pCR was observed in 47.9% (220/459) ) [95% CI 43.3-52.6] of cases. Subgroup analysis of studies reporting the pathological status of MLNB and SLNB separately revealed an FNR of 4.2% for MLNB and 17.6% for SLNB (p = 0.0013). Mean duration of implantation was 37 days (range: 0-188). Conclusions: These findings highlight magnetic seed localisation's efficacy in TAD for NST-treated node-positive patients, aiding in accurate axillary pCR identification and safe de-escalation of axillary surgery in excellent responders.

Resection Ratios and Tumor Eccentricity in Breast-Conserving Surgery Specimens for Surgical Accuracy Assessment

This study aims to evaluate several defined specimen parameters that would allow to determine the surgical accuracy of breast-conserving surgeries (BCS) in a representative population of patients. These specimen parameters could be used to compare surgical accuracy when using novel technologies for intra-operative BCS guidance in the future. Different specimen parameters were determined among 100 BCS patients, including the ratio of specimen volume to tumor volume (resection ratio) with different optimal margin widths (0 mm, 1 mm, 2 mm, and 10 mm). Furthermore, the tumor eccentricity [maximum tumor-margin distance - minimum tumor-margin distance] and the relative tumor eccentricity [tumor eccentricity ÷ pathological tumor diameter] were determined. Different patient subgroups were compared using Wilcoxon rank sum tests. When using a surgical margin width of 0 mm, 1 mm, 2 mm, and 10 mm, on average, 19.16 (IQR 44.36), 9.94 (IQR 18.09), 6.06 (IQR 9.69) and 1.35 (IQR 1.78) times the ideal resection volume was excised, respectively. The median tumor eccentricity among the entire patient population was 11.29 mm (SD = 3.99) and the median relative tumor eccentricity was 0.66 (SD = 2.22). Resection ratios based on different optimal margin widths (0 mm, 1 mm, 2 mm, and 10 mm) and the (relative) tumor eccentricity could be valuable outcome measures to evaluate the surgical accuracy of novel technologies for intra-operative BCS guidance.

Evaluation of the SmartClip™ Nonradioactive Seed, a Novel Wireless Localization Method for the Breast: Initial Clinical Experience and Surgical Outcome

INTRODUCTION

Wire localization has been the gold standard for breast localization of non-palpable lesions for decades. This technique remains robust but has disadvantages relative to scheduling, complications of vasovagal reactions in placement, wire migration, or transection. With more modern technologies available, several implantable markers have been developed to allow uncoupling of localization by radiology and the surgical procedure on the same day. This study summarizes our experience with the EnVisio Navigation System™ utilizing SmartClip™ as the implantable tissue localization marker.

METHODS

An IRB-approved retrospective database of benign and malignant breast disease was used to perform a review of 100 consecutive patients who underwent SmartClip™ localized breast and axillary procedures in 2021. Demographic information, localization accuracy, associated surgical procedure(s) with resultant pathology findings, margin status for malignancies, and re-excision rate were collected.

RESULTS

The localized breast lesion or lymph node was excised and SmartClip™ retrieved in all cases, confirmed by intraoperative specimen radiograph. The distribution of gender and race/ethnicity among the patients who underwent surgery reflects the community population and frequency of breast cancer development among men versus women. 45.1% of the cases involved malignancy, as determined pre-operatively. Positive margins requiring re-excision constituted 18.2% of cases. In twenty-six patients, two or three SmartClips™ were placed per case for either a bracketed lesion, two separate breast lesions, and/or a breast lesion and lymph node.

CONCLUSION

Although this study is limited in patient number, it demonstrates safety of this technique and its reliability in guiding the surgeon directly to the lesion(s) of concern.

Systematic review of targeted axillary dissection in node-positive breast cancer treated with neoadjuvant systemic therapy: variation in type of marker and timing of placement

BACKGROUND

In node-positive (cN+) breast cancer treated with neoadjuvant systemic therapy, combining sentinel lymph node biopsy and targeted lymph node excision, that is targeted axillary dissection, increases accuracy. Targeted axillary dissection procedures differ in terms of the targeted lymph node excision technique. This systematic review aimed to provide an overview of targeted axillary dissection procedures regarding definitive marker type and timing of placement: before neoadjuvant systemic therapy (1-step procedure) or after neoadjuvant systemic therapy adjacent to a clip placed before the neoadjuvant therapy (2-step procedure).

METHODS

PubMed and Embase were searched, to 4 July 2023, for RCTs, cohort studies, and case-control studies with at least 25 patients. Studies of targeted lymph node excision only (without sentinel lymph node biopsy), or where intraoperative localization of the targeted lymph node was not attempted, were excluded. For qualitative synthesis, studies were grouped by definitive marker and timing of placement. The targeted lymph node identification rate was reported. Study quality was assessed using a National Institutes of Health quality assessment tool.

RESULTS

Of 277 unique records, 51 studies with a total of 4512 patients were included. Six definitive markers were identified: wire, 125I-labelled seed, 99mTc, (electro)magnetic/radiofrequency markers, black ink, and a clip. Fifteen studies evaluated one-step procedures, with the identification rate of the targeted lymph node at surgery varying from 8 of 13 to 47 of 47. Forty-one studies evaluated two-step procedures, with the identification rate of the clipped targeted lymph node on imaging after neoadjuvant systemic therapy varying from 49 to 100%, and the identification rate of the targeted lymph node at surgery from 17 of 24 to 100%. Most studies (40 of 51) were rated as being of fair quality.

CONCLUSION

Various targeted axillary dissection procedures are used in clinical practice. Owing to study heterogeneity, the optimal targeted lymph node excision technique in terms of identification rate and feasibility could not be determined. Two-step procedures are at risk of not identifying the clipped targeted lymph node on imaging after neoadjuvant systemic therapy.

Magnetic Localization of Breast Lesions: A Large-Scale European Evaluation in a National Cancer Institute

INTRODUCTION

For decades the standard for preoperative breast lesions' localization has been wire localization. In recent years the options for nonwired localization have significantly expanded and include radioactive seeds, radar reflectors, radiofrequency identification tags and magnetic seeds. The aim of our study is to evaluate on a large scale the performance of preoperative magnetic seed localization of nonpalpable breast lesions.

MATERIAL AND METHODS

We prospectively collected data on all patients undergoing image-guided magnetic seed localization from September 2019 to December 2022. We analyzed imaging findings, histological results, and type of surgery. The primary outcome was the successful localization rate. Secondary outcomes were the successful placement rate, the ease of percutaneous positioning, the procedural complications, and the reintervention rate.

RESULTS

A total of 1123 magnetic seeds were placed in 1084 patients by 4 radiologists under ultrasound (1053) or stereotactic (70) guidance. All seeds were detectable transcutaneously in all breasts sizes and at all depths by 7 surgeons with a success rate of 100%. A total of 97.5% seeds were correctly placed into the target lesions (only 2.5% were dislocated). All radiologists have shown good compliance during the procedure, and there were no complications or safety issues. The reoperation rate was 5.1%.

CONCLUSIONS

Image-guided localization with magnetic seeds is an easy, safe, reliable, and effective method for localizing nonpalpable breast lesions. Both radiologists and surgeons agreed that the technology was intuitive to use and that it can be widely applied in preoperative localization in breast units.

Customised 3D-Printed Surgical Guide for Breast-Conserving Surgery after Neoadjuvant Chemotherapy and Its Clinical Application

For patients eligible to undergo breast-conserving surgery (BCS) after neoadjuvant chemotherapy, accurate preoperative localisation of tumours is vital to ensure adequate tumour resection that can reduce recurrence probability effectively. For this reason, we have developed a 3D-printed personalised breast surgery guide (BSG) assisted with supine magnetic resonance imaging (MRI) and image 3D reconstruction technology, capable of mapping the tumour area identified on MRI onto the breast directly using dual positioning based on the manubrium and nipple. In addition, the BSG allows the colour dye to be injected into the breast to mark the tumour region to be removed, yielding more accurate intraoperative resection and satisfactory cosmetic outcomes. The device has been applied to 14 patients from January 2018 to July 2023, with two positive margins revealed by the intraoperative biopsy. This study showed that the BSG-based method could facilitate precise tumour resection of BCS by accurately localising tumour extent and margin, promoting the clinical efficacy in patients with breast cancer as well as simplifying the surgical process.

Evaluating Receptor-Specific Fresh Specimen Staining for Tumor Margin Detection in Clinical Breast Specimens

PURPOSE

Reliable and rapid identification of tumor in the margins of breast specimens during breast-conserving surgery to reduce repeat surgery rates is an active area of investigation. Dual-stain difference imaging (DDSI) is one of many approaches under evaluation for this application. This technique aims to topically apply fluorescent stain pairs (one targeted to a receptor-of-interest and the other a spectrally distinct isotype), image both stains, and compute a normalized difference image between the two channels. Prior evaluation and optimization in a variety of preclinical models produced encouraging diagnostic performance. Herein, we report on a pilot clinical study which evaluated HER2-targeted DDSI on 11 human breast specimens.

PROCEDURES

Gross sections from 11 freshly excised mastectomy specimens were processed using a HER2-receptor-targeted DDSI protocol shortly after resection. After staining with the dual-probe protocol, specimens were imaged on a fluorescence scanner, followed by tissue fixation for hematoxylin and eosin and anti-HER2 immunohistochemical staining. Receiver operator characteristic curves and area under the curve (AUC) analysis were used to assess diagnostic performance of the resulting images. Performance values were also compared to expression level determined from IHC staining.

RESULTS

Eight of the 11 specimens presented with distinguishable invasive ductal carcinoma and/or were not affected by an imaging artifact. In these specimens, the DDSI technique provided an AUC = 0.90 ± 0.07 for tumor-to-adipose tissue and 0.81 ± 0.15 for tumor-to-glandular tissue, which was significantly higher than AUC values recovered from images of the targeted probe alone. DDSI values and diagnostic performance did not correlate with HER2 expression level, and tumors with low HER2 expression often produced high AUC, suggesting that even the low expression levels were enough to help distinguish tumor.

CONCLUSIONS

The results from this preliminary study of rapid receptor-specific staining in human specimens were consistent with prior preclinical results and demonstrated promising diagnostic potential.

The Role of Sentinel Lymph Node Biopsy in Breast Cancer Patients Who Become Clinically Node-Negative Following Neo-Adjuvant Chemotherapy: A Literature Review

BACKGROUND

In clinically node-positive (cN+) breast cancer (BC) patients who become clinically node-negative (cN0) following neoadjuvant chemotherapy (NACT), sentinel lymph node biopsy (SLNB) after lymphatic mapping with lymphoscintigraphy is not widely accepted; therefore, it has become a topic of international debate.

OBJECTIVE

Our literature review aims to evaluate the current use of this surgical practice in a clinical setting and focuses on several studies published in the last six years which have contributed to the assessment of the feasibility and accuracy of this practice, highlighting its importance and oncological safety. We have considered the advantages and disadvantages of this technique compared to other suggested methods and strategies. We also evaluated the role of local irradiation therapy after SLNB and state-of-the-art SLN mapping in patients subjected to NACT.

METHODS

A comprehensive search of PubMed and Cochrane was conducted. All studies published in English from 2018 to August 2023 were evaluated.

RESULTS

Breast units are moving towards a de-escalation of axillary surgery, even in the NACT setting. The effects of these procedures on local irradiation are not very clear. Several studies have evaluated the oncological outcome of SLNB procedures. However, none of the alternative techniques proposed to lower the false negative rate (FNR) of SLNB are significant in terms of prognosis.

CONCLUSIONS

Based on these results, we can state that lymphatic mapping with SLNB in cN+ BC patients who become clinically node-negative (ycN0) following NACT is a safe procedure, with a good prognosis and low axillary failure rates.

How to do an ultrasound or computed tomography guided hook-wire localization excisional biopsy of non-palpable lymph nodes

This article describes the use of USS or CT guided hook-wire localization to aid the excisional biopsy of non-palpable lymph nodes in the cervical, axillary and inguinal regions. This technique allows a more focussed surgical approach intra-operatively to reduce surgical time and morbidity for the patients.

Comparison of Wire and Non-Wire Localisation Techniques in Breast Cancer Surgery: A Review of the Literature with Pooled Analysis

Background and Objectives: Wide local excision is a common procedure in the treatment of breast cancer. Wire-guided localisation (WGL) has been the gold standard for many years; however, several issues have been identified with this technique, and therefore, wire-free techniques have been developed. This scoping review synthesises the available literature comparing wire-guided localisation with the wire-free techniques used in breast-conserving cancer surgery. Materials and Methods: Multiple databases including Pubmed and MEDLINE were used to search articles between 1 January 2000 and 31 December 2022. Terms included "breast neoplasms", "margins of excision", and "reoperation". In total, 34/256 papers were selected for review. Comparisons were made between positive margins and re-excision rates of WGL with wire-free techniques including SAVI SCOUT, Magseed, ROLL, and RSL. Pooled p-values were calculated using chi-square testing to determine statistical significance. Results: Pooled analysis demonstrated statistically significant reductions in positive margins and re-excision rates when SAVI SCOUT, RSL, and ROLL were compared with WGL. When SAVI SCOUT was compared to WGL, there were fewer re-excisions {(8.6% vs. 18.8%; p = 0.0001) and positive margins (10.6% vs. 15.0%; p = 0.0105)}, respectively. This was also the case in the ROLL and RSL groups. When compared to WGL; lower re-excision rates and positive margins were noted {(12.6% vs. 20.8%; p = 0.0007), (17.0% vs. 22.9%; p = 0.0268)} for ROLL and for RSL, respectively {(6.8% vs. 14.9%),(12.36% vs. 21.4%) (p = 0.0001)}. Magseed localisation demonstrated lower rates of re-excision than WGL (13.44% vs. 15.42%; p = 0.0534), but the results were not statistically significant. Conclusions: SAVI SCOUT, Magseed, ROLL, and RSL techniques were reviewed. Pooled analysis indicates wire-free techniques, specifically SAVI SCOUT, ROLL, and RSL, provide statistically significant reductions in re-excision rates and positive margin rates compared to WGL. However, additional studies and systematic analysis are required to ascertain superiority between techniques.

Axillary staging in node-positive breast cancer converting to node negativity through neoadjuvant chemotherapy: Current evidence and perspectives

PURPOSE

Over the recent years, axillary staging of initially node-positive breast cancer patients converting to clinical node negativity after neoadjuvant chemotherapy has seen rapid changes. This narrative review aims to give a contemporary overview over published evidence and clinical practice, and thus provide some guidance to the surgical community in the process of re-evaluating and re-shaping surgical practice.

METHODS

The search strategy aimed at finding relevant studies. Only articles in English were considered.

RESULTS

The introduction of modern techniques offer more precise staging surgery and thus hopefully reduced arm morbidity. Clinical practice has however diverged both within countries and internationally. While some countries have adapted de-escalated axillary staging techniques such as targeted axillary dissection, targeted lymph node biopsy or sentinel lymph node biopsy, others continue to recommend a full axillary lymph node dissection. With the implementation of new techniques, many questions arise, regarding aspects of oncological safety, technical performance, budget and practicality, patient selection and indications for different levels of axillary staging procedures.

CONCLUSIONS

There is a growing body of evidence on de-escalation of axillary surgery in the setting of cN+ → ycN0 breast cancer treated with neoadjuvant chemotherapy. However, standards differ between countries and future studies are necessary to fully assess the optimal strategy for these patients.

Comparison of 3 Different Systems for Non-wire Localization of Lesions in Breast Cancer Surgery

PURPOSE

Localizing breast lesions by marking tumors and their detection using probes during surgery is a common part of clinical practice. Various nonwire localization systems were intended to be compared from different perspectives.

METHODS

Various measurement experiments were performed. Localization techniques, including radioactive seed (RSLS), magnetically guided (MGLS), or radar (SLS), were compared in signal propagation in water and tissue environments, signal interference by surgical instruments, and the practical experience of surgeons. Individual experiments were thoroughly prospectively planned.

RESULTS

The RSLS signal was detectable at the largest evaluated distance, ie, 60 mm. The SLS and MGLS signal detection was shorter, up to 25 mm to 45 mm and 30 mm, respectively. The signal intensity and the maximum detection distance in water differed slightly depending on the localization marker orientation to the probe, especially for SLS and MGLS. Signal propagation in the tissue was noted to a depth of 60 mm for RSLS, 50 mm for SLS, and 20 mm for MGLS. Except for the expected signal interferences by approaching surgical instruments from any direction for MGLS, the signal interruption for RSLS and SLS was observed only by inserting instruments directly between the localization marker and probe. Moreover, the SLS signal interference by instrument touch was noted. Based on surgeons' results, individual systems did not differ significantly for most measurement condition settings.

CONCLUSION

Apparent differences noted among localization systems can help experts choose an appropriate system for a specific situation or reveal small nuances that have not yet been observed in clinical practice.

Image-Guided Localization Techniques for Metastatic Axillary Lymph Nodes in Breast Cancer; What Radiologists Should Know

Targeted axillary dissection (TAD) is an axillary staging technique after NACT that involves the removal of biopsy-proven metastatic lymph nodes in addition to sentinel lymph node biopsy (SLNB). This technique avoids the morbidity of traditional axillary lymph node dissection and has shown a lower false-negative rate than SLNB alone. Therefore, marking positive axillary lymph nodes before NACT is critical in order to locate and remove them in the subsequent surgery. Current localization methods include clip placement with intraoperative ultrasound, carbon-suspension liquids, localization wires, radioactive tracer-based localizers, magnetic seeds, radar reflectors, and radiofrequency identification devices. The aim of this paper is to illustrate the management of axillary lymph nodes based on current guidelines and explain the features of axillary lymph node markers, with relative advantages and disadvantages.

Iodine-125 seed versus hook-wire guided breast conserving surgery: do post operative complication rates differ?

BACKGROUND

Radio-guided occult lesion localisation using iodine 125 seeds (ROLLIS) is used to localize impalpable breast cancers for breast conserving surgery (BCS). Previous studies have suggested improved efficiency and patient outcomes with ROLLIS compared with hook-wire localisation (HWL). The aim of this report is to compare the post-operative complication rates and safety profiles of ROLLIS versus hook-wire guided surgery.

METHODS

Between September 2013 and March 2018, 690 women with non-palpable breast cancer eligible for breast-conserving surgery were randomly assigned to either pre-operative localisation with 125 I seed or hook-wire as part of the ROLLIS clinical trial. Medical record review of 170 women (30% of the total participants) from three tertiary hospitals in Western Australia was performed. Post-operative complications were classified using the Common Terminology Criteria for Adverse Events(CTCAE) grade I to V.

RESULTS

Total of 170 surgeries were performed: 82 by ROLLIS and 88 by hook-wire. The overall complication rate in the ROLLIS group was 19.5%, with 15.9% being grade II and 3.66% grade III. In the HWL group, the complication rate was 22.7% with 20.5% being grade II and 2.27% grade III. There was no statistically significant difference in complication grades between the 2 groups. No grade IV or grade V complications were reported. Complications observed included drainable seroma, drainable haematoma and surgical site infection.

CONCLUSION

ROLLIS is a safe method of localisation for surgical resection with similar complication rates as hookwires. We encourage its use as an alternative localisation technique as it has demonstrable superiority and efficacy.

Localization Techniques for Non-Palpable Breast Lesions: Current Status, Knowledge Gaps, and Rationale for the MELODY Study (EUBREAST-4/iBRA-NET, NCT 05559411)

BACKGROUND

Surgical excision of a non-palpable breast lesion requires a localization step. Among available techniques, wire-guided localization (WGL) is most commonly used. Other techniques (radioactive, magnetic, radar or radiofrequency-based, and intraoperative ultrasound) have been developed in the last two decades with the aim of improving outcomes and logistics.

METHODS

We performed a systematic review on localization techniques for non-palpable breast cancer.

RESULTS

For most techniques, oncological outcomes such as lesion identification and clear margin rate seem either comparable with or better than for WGL, but evidence is limited to small cohort studies for some of the devices. Intraoperative ultrasound is associated with significantly higher negative margin rates in meta-analyses of randomized clinical trials (RCTs). Radioactive techniques were studied in several RCTs and are non-inferior to WGL. Smaller studies show higher patient preference towards wire-free localization, but little is known about surgeons' and radiologists' attitudes towards these techniques.

CONCLUSIONS

Large studies with an additional focus on patient, surgeon, and radiologist preference are necessary. This review aims to present the rationale for the MELODY (NCT05559411) study and to enable standardization of outcome measures for future studies.

Savi-Scout Radar Localization: Transitioning From the Traditional Wire Localization to Wireless Technology for Surgical Guidance at Lumpectomies

Breast-conserving surgery or lumpectomy requires localization of the lesion prior to surgery, which is traditionally accomplished by imaging-guided wire localization. Over the last decade, alternatives to wire localization have emerged. This work reviews the literature on one such wireless technology, SaviScout radar (SSR) system, and shares our experience with using this technology for presurgical tumor localization. The SSR surgical guidance system is non-radioactive. The radiologist implants a reflector device in the breast under mammography or ultrasound guidance at any time prior to surgery. The placement of this reflector can be confirmed from the cadence of a handheld percutaneous probe of a handpiece and console system. Results from several studies show that the surgical outcomes from SSR and wire-localization are similar. SSR provides operational advantages as the scheduling for reflector placement by radiologists is decoupled from surgery, but at an increased cost compared to wire-localization.

Mammography-Guided Interventional Procedure

Mammography has been the standard screening method for breast cancer. In women with suspicious calcifications and architectural distortion identified on mammography or digital breast tomosynthesis only without detected on breast US, stereotactic biopsy and mammography-guided preoperative localization is one of the method for pathologic diagnosis. This review aims to describe the indication, contraindication, technique of stereotactic biopsy, clip placement after stereotactic biopsy, and digital breast tomosynthesis-guided stereotactic biopsy. In addition, this article reviews mammography-guided preoperative localization using a wire or non-wire device.

The Beneficial Impact of Intraoperative Ultrasound on Resection Margin Status during Breast Conserving Surgery

Background. Surgical resection with clear surgical cut margins is the mainstay of managing malignant breast neoplasms. Multiple techniques have been suggested to enhance resection status during breast-conserving surgery (BCS), including intraoperative ultrasonography (IOUS). Herein, we conducted the current investigation to reveal the benefit of IOUS on the achievement of R0 resection. Patients and Methods. This retrospective investigation included 140 patients who underwent BCS. They were divided into two groups: the IOUS group (40 cases) and the control group (100 cases). Our primary objective was to determine the free resection margin status (R0). Results. Both study groups expressed statistically comparable demographic and clinical data. Additionally, histopathological examination revealed no significant difference between the two groups regarding the tumor type, stage, or grade. Nonetheless, the R0 resection margin was more frequently encountered in association with IOUS application (97.5% compared to 79% in the control group), and that difference was statistically significant ( $p=0.007$ ). Conclusion. The application of IOUS has a significant beneficial impact on the outcomes of BCS. It is associated with a marked decline in positive resection margins, and its application should be encouraged in the breast oncological practice.

Radiofrequency Identification—RFID using LOCalizer-Tag in Non-palpable Breast Lump

For many years, wire-guided localization represented the gold standard method for the detection of non-palpable breast lesions, despite the acknowledged limitations. LOCalizer™ is the most recent and promising radiofrequency identification system, characterized by the capability of measuring the distance from the tagged lesion in millimeters and the association of each marker with a unique code. A 45-year-old woman with two lesions suspected of cancer in the same breast was referred to our department. She underwent double localization with LOCalizer™ (Hologic, Santa Carla, CA, USA) of the lumps into opposite quadrants. We performed a mini-invasive and oncologically safe surgical excision through a tunneling approach after a peri-areolar incision. The surgical technique realized with Localizer™ could be an effective method for locating multiple non-palpable breast lesions and is able to offer excellent oncological and cosmetic results, as also confirmed by several reports in the literature.

Exploiting the advantages of a wireless seed localization system that differentiates between the seeds: Breast cancer resection following neoadjuvant chemotherapy

BACKGROUND

Most wireless localization methods utilize only one means of detection for the surgeon, sufficient to localize a single small breast lesion for excision. Complex cases requiring bracketing of a larger lesion or localization of two or more close lesions can superimpose the signal from separate "seeds" with such methods. The lack of discernment between the localization "seeds" can disorient the surgeon, risking a missed lesion on excision and longer operative times. with the use of neoadjuvant chemotherapy prior to breast surgery, the necessity of localizing both a breast lesion and an axillary lymph node previously biopsied is becoming frequent.

CASE

A 44 year-old woman underwent neoadjuvant chmotherapy for a breast cancer the did not express estrogen receptor, progesterone receptor, or HER2 receptor. In establishing the extent of disease, a suspicious ipsilateral lymph node was biopsied and found to contain metastatic disease. She had an excellent response to the chemotherapy, with decreased size of the primary tumor and the previously biopsied lymph node. The patient desired breast conservation. The primary tumor and associated calcifications were bracketed using two different Smartclips™, with a third localizing the lymph node biopsied.

CONCLUSION

This report illustrates how the use of three SmartClips™, within the EnVisioTM system, allowed for separate tracking of each "seed" throughout a complex surgery in a patient following neoadjuvant chemotherapy. This resulted in successful resection of both the tumor and the tagged lymph node.

Preoperative localisation of nonpalpable breast lesions using magnetic markers in a tertiary cancer centre

Background

We retrospectively evaluated safety and performance of magnetic seed localisation of nonpalpable breast lesions.

Methods

We reviewed records of patients with nonpalpable breast lesions preoperative localised by placing magnetic Magseed® marker between February 2019 and December 2020. During surgery, Sentimag® magnetic probe was used to localise the marker and guide surgery. Safety, lesion identification and excision with tumour with free margins and re-excision rate were assessed.

Results

A total of 77 Magseed® devices were placed into the breasts of 73 patients, 44 under ultrasound and 33 under stereotactic guidance (4 bilateral). All devices were retrieved as were the target lesions. Magnetic marker placement was successful in all cases without any adverse event. Intraoperative identification and excision of the localised lesion were successful in 77 of 77 of cases (100%). In three cases (all of them calcifications with the seed placed under stereotactic guidance), the seed did not reach the exact target position of the biopsy clip; thus, larger excision was needed, with localisation failure attributed to incorrect clip insertion (n = 1) or to clip dislocation (n = 2). Migration of the marker was negligible in all patients. Complete excision after the initial procedure with at least 1-mm disease-free margins was obtained in 74 out of 77 (96.1%) lesions. The re-excision rate was 3 out of 77 (4%).

Conclusions

Magnetic marker localisation for nonpalpable breast lesions was safe, reliable, and effective in terms of lesion identification, excision with tumour-free margins and re-excision rate.

Clinical Outcomes Using Magnetic Seeds as a Non-wire, Non-radioactive Alternative for Localization of Non-palpable Breast Lesions

BACKGROUND

Nonpalpable breast lesions require precise preoperative localization to facilitate negative margins with breast-conserving therapy. The traditional use of wires has several challenges including patient discomfort, wire migration, and coordination of schedules between radiology and the operating room. Radioactive seed localization overcomes some of these challenges, but radiation safety requirements have limited adoption of this technology. The authors examined their institutional experience with Magseed as an alternative technology for localization and compared outcomes with those of wire and radioactive seed localization.

METHODS

An institutional review board (IRB)-approved retrospective study was performed to evaluate patients who underwent excisional biopsy or segmental mastectomy after wire-guided localization (WGL), radioactive seed localization (RSL), or Magseed localization (ML). The clinical and pathologic factors of the three groups were assessed with a negative margin rate as the primary outcome measure.

RESULTS

Of the 1835 patients in the study, 825 underwent WGL, 449 underwent RSL, and 561 underwent ML. For the patients with either multiple lesions or a large lesion that required bracketing, multiple localization devices were placed in 31% of the WGL patients, 28% of the RSL patients, and 23% of the ML patients (p = 0.006). Negative margins were achieved in 91% of the WGL patients, 89% of the RSL patients, and 89% of the ML patients (p = 0.4).

CONCLUSION

Localization of non-palpable breast lesions using Magseed is a safe and effective alternative to WGL and RSL that overcomes radiation safety limitations and increases radiology and surgery scheduling efficiency.

Comparison of Wireless Localization Alternatives with Wire Localization for Nonpalpable Breast Lesions

BACKGROUND

Radiofrequency identification tag localization (TL) and magnetic seed localization (MSL) are alternatives to wire localization (WL) for excision of nonpalpable breast lesions. We sought to compare localization methods with respect to operative time, specimen volume, and re-excision rate.

STUDY DESIGN

A retrospective cohort analysis was performed on TL, MSL, and WL lumpectomies and excisional biopsies at a single institution. Association between localization method and operative time, specimen volume, and re-excision rate was assessed by multiple logistic regression using odds ratios (ORs) and 95% CIs.

RESULTS

A total of 506 procedures were included: 147 TL (29.0%), 140 MSL (27.7%), and 219 WL (43.3%). On logistic regression analysis, MSL was associated with longer operative times than WL for excisional biopsies only (OR 4.24, 95% CI 1.92 to 9.34, p < 0.001). Mean excisional biopsy time was 39.1 minutes for MSL and 33.0 minutes for WL. Specimen volume did not vary significantly across surgery types between localization methods. In an analysis of all lumpectomies with an indication of carcinoma, marker choice was not associated with rate of re-excision (TL vs WL OR 0.64, 95% CI 0.26 to 1.60, p = 0.342; MSL vs WL OR 1.22, 95% CI 0.60 to 2.49, p = 0.587; TL vs MSL OR 0.65, 95% CI 0.26 to 1.64, p = 0.359).

CONCLUSION

TL, MSL, and WL are comparable in performance for excision of nonpalpable breast lesions. Although increased operative time associated with MSL vs WL excisional biopsies is statistically significant, clinical significance warrants additional study. With similar outcomes, physicians may choose the marker most appropriate for the patient and setting.

ROLLIS roll‐out: Pitfalls, errors, lessons learned and recommendations from Australian and New Zealand experience during the randomised controlled trial, implementing a novel localisation method for impalpable malignant breast lesions, radio‐guided occult lesion localisation with iodine‐125 ( 125 I) seed ( ROLLIS )

INTRODUCTION

Breast cancer surgery aims to excise lesions with clear margins and provide optimal cosmesis with a low re-excision rates. These aims are aided by accurate lesion localisation and a surgical choice of incision site with minimal removal of healthy tissue. Problems associated with hookwires have led to adoption of non-wire methods including radioguided occult lesion localisation using iodine-125 (ROLLIS). This paper outlines the problems encountered and lessons learnt during the largest RCT involving 659 participants, conducted at eight sites (seven Australian, one New Zealand centres) between September 2013 and April 2018.* METHODS: Data, along with substantive comments, regarding each ROLLIS procedure, documenting each step from the seed insertion, ease of operative retrieval, to return of the seed to medical physics, from a shared on-line secure database and a separate site email survey, were synthesised and categorised.

RESULTS

The Australian and New Zealand ROLLIS RCT experience highlights several important issues. Lessons learned were related to licencing the seed and tracking protocols. A Designated Team Lead, who is a good communicator, ensuring the Tracking Protocols were accurately followed and updated, subspecialty leads and a Co-ordinator, responsible for training, logbook maintenance and seed ordering, enhanced the success and acceptance of the programme. Addressing radiation issues, fears, education of staff and seed loss was imperative.

CONCLUSION

The Australian and New Zealand ROLLIS RCT experience highlights the need for adherence to local licencing laws and protocols, appointing a dedicated ROLLIS Designated Team Lead with good communication and a ROLLIS Co-ordinator. These facilitate the adoption of a successful ROLLIS programme.

Use of Needle Localization in the Surgical Management of Non-seroma, Mass-forming BIA-ALCL

Outcomes related to the treatment of breast implant-associated anaplastic large cell lymphoma, a rare extranodal T-cell lymphoma associated with textured breast implants, are largely dependent on the successful resection to negative margins via en bloc capsulectomy and resection of any associated masses. To date, the use of needle localization, a common technique used in breast surgery, to assist in the complete removal of breast implant-associated anaplastic large cell lymphoma has not been described. We present the case report of a 66-year-old woman, with a previous medical history of left-sided invasive ductal carcinoma, who presented 7 years after textured breast implant placement with a left-sided mass without peri-implant seroma. Biopsy demonstrated breast implant-associated anaplastic large cell lymphoma and the associated breast mass extended beyond the capsule borders. The present report describes the novel use of needle localization in this patient to facilitate the complete removal of the malignancy-associated mass with maximal preservation of the overlying soft tissue envelope.

Optimal localization strategies for non-palpable breast cancers -A network meta-analysis of randomized controlled trials

PURPOSE

Mammographic screening programmes have increased detection rates of non-palpable breast cancers. In these cases, wire-guided localization (WGL) is the most common approach used to guide breast conserving surgery (BCS). Several RCTs have compared WGL to a range of novel localization techniques. We aimed to perform a network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing methods of non-palpable breast cancer localization.

METHODS

A NMA was performed according to PRISMA-NMA guidelines. Analysis was performed using R packages and Shiny.

RESULTS

24 RCTs assessing 9 tumour localization methods in 4236 breasts were included. Margin positivity and reoperation rates were 16.9% (714/4236) and 14.3% (409/2870) respectively. Cryo-assisted localization had the highest margin positivity (28.2%, 58/206) and reoperation (18.9%, 39/206) rates. Compared to WGL (n = 2045 from 24 RCTs) only ultrasound guided localization (USGL) (n = 316 from 3 RCTs) significantly lowered margin positivity (odds ratio (OR): 0.192, 95% confidence interval (CI): 0.079-0.450) and reoperation rates (OR: 0.182, 95%CI: 0.069-0.434). Anchor-guided localization (n = 52, 1 RCT) significantly lowered margin positivity (OR: 0.229, 95%CI: 0.050-0.938) and magnetic-marker localization improved patient satisfaction (OR: 0.021, 95%CI: 0.001-0.548). There was no difference in operation duration, overall complications, haematoma, seroma, surgical site infection rates, or specimen size/vol/wt between methods.

CONCLUSION

USGL and AGL are non-inferior to WGL for the localization of non-palpable breast cancers. The reported data suggests that these techniques confer reduced margin positivity rates and requirement for re-operation. However, caution when interpreting results relating to RCTs with small sample sizes and further validation is required in larger prospective, randomized studies.

A multicenter prospective cohort study to evaluate feasibility of radio-frequency identification surgical guidance for nonpalpable breast lesions: design and rationale of the RFID Localizer 1 Trial

BACKGROUND

Breast cancer screening and improving imaging techniques have led to an increase in the detection rate of early, nonpalpable breast cancers. For early breast cancer, breast conserving surgery is an effective and safe treatment. Accurate intraoperative lesion localization during breast conserving surgery is essential for adequate surgical margins while sparing surrounding healthy tissue to achieve optimal cosmesis. Preoperative wire localization and radioactive seed localization are accepted standard methods to guide surgical excision of nonpalpable breast lesions. However, these techniques present significant limitations. Radiofrequency identification (RFID) technology offers a new, nonradioactive method for localizing nonpalpable breast lesions in patients undergoing breast conserving surgery. This study aims to evaluate the feasibility of RFID surgical guidance for nonpalpable breast lesions.

METHODS

This multicenter prospective cohort study was approved by the Institutional Review Board of the University Medical Center Utrecht. Written informed consent is obtained from all participants. Women with nonpalpable, histologically proven in situ or invasive breast cancer, who can undergo breast conserving surgery with RFID localization are considered eligible for participation. An RFID tag is placed under ultrasound guidance, up to 30 days preoperatively. The surgeon localizes the RFID tag with a radiofrequency reader that provides audible and visual real-time surgical guidance. The primary study outcome is the percentage of irradical excisions and reexcision rate, which will be compared to standards of the National Breast Cancer Organisation Netherlands (NABON)(≤ 15% irradical excisions of invasive carcinomas). Secondary outcomes include user acceptability/experiences, learning curve, duration and ease of the placement- and surgical procedure and adverse events.

DISCUSSION

This study evaluates the feasibility of RFID surgical guidance for nonpalpable breast lesions. Results may have implications for the future localization techniques in women with nonpalpable breast cancer undergoing breast conserving surgery.

TRIAL REGISTRATION

Netherlands National Trial Register, NL8019 , registered on September 12^th 2019.