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Localization of impalpable breast lesions: What are we aiming at?
The Breast 18 (2009) 267–269
Contents lists available at ScienceDirect
The Breast journal homepage: www.elsevier.com/brst
Short report
Localization of impalpable breast lesions: What are we aiming at? Brian Mucci a, *, Robert Shaw a, c, Jean Lauder b, d, Russell Pickard b, e a b
Department Of Radiology, South Glasgow University Hospitals, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF, UK Department Of Radiology, South Glasgow University Hospitals, Victoria Infirmary, Langside Road, Glasgow G42 9TY, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 March 2009 Received in revised form 7 May 2009 Accepted 8 May 2009
The European published target for wire placement is 95% being within 10 mm of impalpable breast lesions. Other suggested targets may be more relevant. We assessed 500 procedures of which 411 could be measured.
Results: Fail 10 mm target: 3 (0.7%); Fail 5 mm target: 11 (2.7%); Fail 2 mm target: 21 (4.9%); within 2 mm: 11 (2.7%); and Fail to traverse lesion in one or more projection: 32 (7.8%).
Keywords: Breast carcinoma Imaging Intervention
Conclusion: The European QA target has little supporting evidence and is easily met. Success in traversing lesions is a more measurable, achievable aim with clinical relevance. We suggest that this could be an improved target. Ó 2009 Elsevier Ltd. All rights reserved.
Introduction
In 411 remaining cases we recorded modality of localization and defined the proximity of the wire to the lesion. If the wire did not traverse the lesion in 2 planes the distance between wire and lesion edge was measured. If the wire traversed the lesion but was too far through this was recorded. The definition of too far through was defined as the stiff portion of the Kopans Wire (Cooks Medical Ltd) being 20 mm or more beyond the lesion. Lesion depth from skin on mammography was recorded.
Inaccurate needle placement is a cause of failed excision of impalpable breast lesions1–3 European guidelines4,5 give a target of 95% of wires being within 10 mm of the lesion. Distances of 5 mm, 2 mm, or failure to traverse the lesion have been suggested.1,6,7 The 10 mm target is easy to achieve making statistically meaningful audit difficult. We sought realistic targets upon which a radiologists performance can be measured.
Results Methods We undertook an audit to check our performance against various guidelines. As an audit neither patient consent nor institutional review board permission were required. The work of 3 operators was considered in the care of 500 lesions between January 2007 and August 2008. Of 500 consecutive localization procedures 20 skin markings, and 38 cases of deliberate placement at lesion margin were excluded. In 26 cases the lesion was mammographicaly occult on one or more view and those were excluded. Most lesions were localized using the modified Kopans needle, 5 localized by Homer wire were excluded.
* Corresponding author. Tel.: þ44 141 201 1310; fax: þ44 141 201 1161. E-mail addresses: [email protected] (B. Mucci), robert.shaw@ ggc.scot.nhs.uk (R. Shaw), [email protected] (J. Lauder), russell.pickard@ ggc.scot.nhs.uk (R. Pickard). c Tel.: þ44 141 201 1540; fax: þ44 141 201 1161. d Tel.: þ44 141 201 5559; fax: þ44 141 201 5497. e Tel.: þ44 141 201 5556; fax: þ44 141 201 5497. 0960-9776/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2009.05.006
411 Procedures were assessed: final modalities were: Ultrasound 251 (61%); Stereotaxis 160 (39%). Results are shown in Table 1 the relation of wire to targets illustrated in Fig. 1. Mean mammographic lesion depth for series was 41 mm, for cases failing to traverse mean depth was 44 mm, and for cases too far through mean depth was 30 mm. 3 Operators performed 98% of the procedures. They respectively had two, two and one failure of excision at surgery. There was no difference between operators in failure to traverse lesions. Discussion Accurate needle placement in localization of impalpable breast lesions is important.8 Jackman1 reviewed the literature showing excision failure rates ranging from 0% to 18%. Multiple factors influence outcome including imaging, surgical and histological features. The aim is to remove the lesion and all failures should be reviewed but the incidence of failure is so low as to make robust statistical analysis difficult even for large practices. Of the total 500
268
B. Mucci et al. / The Breast 18 (2009) 267–269
Table 1 Distribution of failures to reach localization targets. Total Fail to traverse lesion Fail 10 mm target Fail 5 mm target Fail 2 mm target Fails to traverse the lesion but was within 2 mm Pass ‘‘too far’’ through Lesion
32 3 11 21 11
(7.8%, (0.7%, (2.7%, (4.9%, (2.7%,
95% 95% 95% 95% 95%
CI CI CI CI CI
5.6–10.8%) 2.1–0.2%) 1.5–4.6%) 3.2–7.3%) 1.5–4.7%)
16 (3.9%, 95% CI 2.4–6.5%)
Ultrasound
Stereotaxis
20 1 7 15 5
12 2 4 6 6
(62%) (33%) (64%) (71%) (45%)
12 (75%)
(38%) (67%) (36%) (29%) (55%)
4 (25%)
procedures we had 5 failures (1%). We could not discern any pattern for this in modality, operator, or lesion depth. In 4 cases wire placement was difficult to asses: one being a bracketing by 3 wires others were visible by ultrasound only making check mammograms limited value. One had documented failure to traverse the lesion with the wire, the distance being 2 mm. Current European guideline is that over 95% of marker wires should be within 10 mm of the lesion in any plane.4,5 Abrahamson6 found that being within 5 mm of the lesion increased the probability of excision. The Boston group7 have suggested that being within 2 mm of the lesion allows accurate excision combined with minimal volume of specimen excised, while Jackman1 found that no lesion pierced by the wire was missed at surgery. For auditing performance we found the 10 mm target of little value. It is achieved in the majority of procedures: 99.3% in this series. There is little evidence in the literature that it relates to outcome. In our series the 5 mm target was reached in 97% of cases and 2 mm in 95%. Jackman1 found that traversing the lesion in both
mammographic planes was the factor most likely to lead to successful excision surgery. This assessment does not require distance measurements. The failure rate is such that statistically meaningful analysis is more likely than with the easier targets. We reached this target in 92.2% of procedures with 95% confidence interval of 89.2–94.4%. Figures for individual radiologists are a valuable self assessment audit tool, and are more likely to be meaningful using this target. While traversing the lesion is important the distance from needle tip is also a consideration since a lesion traversed but with tip well beyond the lesion may mislead the surgeon. It has been suggested that the tip of the wire should ideally be placed within 1 cm of the lesion.9 The modified Kopans needle used in our series has a stiff portion to guide the surgeon and where possible we try to place this in the lesion. For this reason the 1 cm from tip target may not be appropriate for that needle. We felt that 2 cm beyond stiff portion was too far through: this group had a high proportion of ultrasound procedures which could reflect poor technique, but the result may be biased by lesion size, depth and the nature of those lesions. We had a relatively high proportion of parenchymal distortions. This sub group it is too small a sample to have significant results. Success in traversing the lesion is predominantly influenced by radiological performance, and there is evidence that it is of importance to excision outcome. The rate of failure to achieve this is enough to produce a statistically meaningful measure of performance. We have achieved this in over 92%. We suggest a minimum target of 90% of wires to traverse the lesion in both planes would be meaningful and measurable. A target of 95% may be achievable. If our results are replicated in other studies this or a similar target could replace or be added to the current European and NHSBSP guidelines.
Fails 10 mm Target N=3
Between 5mm and 10mm N=8
Fails 5mm Target N=11
Between 2mm and 5mm N=10
Within 2mm N =11
Fails 2mm Target N=21
Fig. 1. Summary of distance from lesion of wires failing to traverse the lesion in both planes.
B. Mucci et al. / The Breast 18 (2009) 267–269
Conclusions As a quality control target for wire placement in clinically occult breast lesions success in traversing the lesion in both planes in 90% of procedures is measurable and achievable with clinical relevance. We believe that this could be an improvement on the current European target of 95% of wires being within 10 mm of the lesion.
Conflict of interest None declared.
References 1. Jackman RJ, Marzoni FA. Needle-localized breast biopsy: why do we fail? Radiology 1997;204:677–84.
269
2. Verkooijen HM, Peeters PH, Pijnappel RM, Koot VC, Schipper ME, Borel Rinkes IH. Diagnostic accuracy of needle-localized open biopsy for impalpable breast disease. Br J Surg 2000;87:344–7. 3. Landercasper J, Gundersen Jr SB, Gundersen AL, Cogbill TH, Travelli R, Strutt P. Needle localization and biopsy of nonpalable lesions of the beast. Surg Gynecol Obstet 1987;164:399–403. 4. European Comission. European guidelines for quality assurance in breast cancer screening and diagnosis. In: Perry N, Broedrers M, de Wolf C, Tornberg S, Holland R, von Karsa L, et al., 4th ed. Luxombourg: Office for Official Publications of the European Communities, ISBN 92-79-01258-4; 2006. 5. Consolidated guidance on standards for the NHS breast screening programme. NHSBSP No 60 (Version 2). Sheffield: NHS Cancer Screening Programmes; 2005. 6. Abrahamson PE, Dunlap LA, Amammoo MA, Schell MJ, Braeuning MP, Pisano ED. Factors predicting successful needle-localized breast biopsy. Acad Radiol 2003;10:601–6. 7. Gallagher WJ, Cardenosa G, Rubens JR, McCarthy KA, Kopans DB. Minimalvolume excision of nonpalpable breast lesions. AJR Am J Roentgenol 1989;153:957–61. 8. De Paredes ES, Langer TG, Cousins J. Interventional breast procedures. Curr Probl Diagn Radiol 1998;27:133–84. 9. Teh W, Singhal H. Breast, needle localization 2008 Emedicine, http://emedicine. medscape.com/article/347407.
Contents lists available at ScienceDirect
The Breast journal homepage: www.elsevier.com/brst
Short report
Localization of impalpable breast lesions: What are we aiming at? Brian Mucci a, *, Robert Shaw a, c, Jean Lauder b, d, Russell Pickard b, e a b
Department Of Radiology, South Glasgow University Hospitals, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF, UK Department Of Radiology, South Glasgow University Hospitals, Victoria Infirmary, Langside Road, Glasgow G42 9TY, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 March 2009 Received in revised form 7 May 2009 Accepted 8 May 2009
The European published target for wire placement is 95% being within 10 mm of impalpable breast lesions. Other suggested targets may be more relevant. We assessed 500 procedures of which 411 could be measured.
Results: Fail 10 mm target: 3 (0.7%); Fail 5 mm target: 11 (2.7%); Fail 2 mm target: 21 (4.9%); within 2 mm: 11 (2.7%); and Fail to traverse lesion in one or more projection: 32 (7.8%).
Keywords: Breast carcinoma Imaging Intervention
Conclusion: The European QA target has little supporting evidence and is easily met. Success in traversing lesions is a more measurable, achievable aim with clinical relevance. We suggest that this could be an improved target. Ó 2009 Elsevier Ltd. All rights reserved.
Introduction
In 411 remaining cases we recorded modality of localization and defined the proximity of the wire to the lesion. If the wire did not traverse the lesion in 2 planes the distance between wire and lesion edge was measured. If the wire traversed the lesion but was too far through this was recorded. The definition of too far through was defined as the stiff portion of the Kopans Wire (Cooks Medical Ltd) being 20 mm or more beyond the lesion. Lesion depth from skin on mammography was recorded.
Inaccurate needle placement is a cause of failed excision of impalpable breast lesions1–3 European guidelines4,5 give a target of 95% of wires being within 10 mm of the lesion. Distances of 5 mm, 2 mm, or failure to traverse the lesion have been suggested.1,6,7 The 10 mm target is easy to achieve making statistically meaningful audit difficult. We sought realistic targets upon which a radiologists performance can be measured.
Results Methods We undertook an audit to check our performance against various guidelines. As an audit neither patient consent nor institutional review board permission were required. The work of 3 operators was considered in the care of 500 lesions between January 2007 and August 2008. Of 500 consecutive localization procedures 20 skin markings, and 38 cases of deliberate placement at lesion margin were excluded. In 26 cases the lesion was mammographicaly occult on one or more view and those were excluded. Most lesions were localized using the modified Kopans needle, 5 localized by Homer wire were excluded.
* Corresponding author. Tel.: þ44 141 201 1310; fax: þ44 141 201 1161. E-mail addresses: [email protected] (B. Mucci), robert.shaw@ ggc.scot.nhs.uk (R. Shaw), [email protected] (J. Lauder), russell.pickard@ ggc.scot.nhs.uk (R. Pickard). c Tel.: þ44 141 201 1540; fax: þ44 141 201 1161. d Tel.: þ44 141 201 5559; fax: þ44 141 201 5497. e Tel.: þ44 141 201 5556; fax: þ44 141 201 5497. 0960-9776/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.breast.2009.05.006
411 Procedures were assessed: final modalities were: Ultrasound 251 (61%); Stereotaxis 160 (39%). Results are shown in Table 1 the relation of wire to targets illustrated in Fig. 1. Mean mammographic lesion depth for series was 41 mm, for cases failing to traverse mean depth was 44 mm, and for cases too far through mean depth was 30 mm. 3 Operators performed 98% of the procedures. They respectively had two, two and one failure of excision at surgery. There was no difference between operators in failure to traverse lesions. Discussion Accurate needle placement in localization of impalpable breast lesions is important.8 Jackman1 reviewed the literature showing excision failure rates ranging from 0% to 18%. Multiple factors influence outcome including imaging, surgical and histological features. The aim is to remove the lesion and all failures should be reviewed but the incidence of failure is so low as to make robust statistical analysis difficult even for large practices. Of the total 500
268
B. Mucci et al. / The Breast 18 (2009) 267–269
Table 1 Distribution of failures to reach localization targets. Total Fail to traverse lesion Fail 10 mm target Fail 5 mm target Fail 2 mm target Fails to traverse the lesion but was within 2 mm Pass ‘‘too far’’ through Lesion
32 3 11 21 11
(7.8%, (0.7%, (2.7%, (4.9%, (2.7%,
95% 95% 95% 95% 95%
CI CI CI CI CI
5.6–10.8%) 2.1–0.2%) 1.5–4.6%) 3.2–7.3%) 1.5–4.7%)
16 (3.9%, 95% CI 2.4–6.5%)
Ultrasound
Stereotaxis
20 1 7 15 5
12 2 4 6 6
(62%) (33%) (64%) (71%) (45%)
12 (75%)
(38%) (67%) (36%) (29%) (55%)
4 (25%)
procedures we had 5 failures (1%). We could not discern any pattern for this in modality, operator, or lesion depth. In 4 cases wire placement was difficult to asses: one being a bracketing by 3 wires others were visible by ultrasound only making check mammograms limited value. One had documented failure to traverse the lesion with the wire, the distance being 2 mm. Current European guideline is that over 95% of marker wires should be within 10 mm of the lesion in any plane.4,5 Abrahamson6 found that being within 5 mm of the lesion increased the probability of excision. The Boston group7 have suggested that being within 2 mm of the lesion allows accurate excision combined with minimal volume of specimen excised, while Jackman1 found that no lesion pierced by the wire was missed at surgery. For auditing performance we found the 10 mm target of little value. It is achieved in the majority of procedures: 99.3% in this series. There is little evidence in the literature that it relates to outcome. In our series the 5 mm target was reached in 97% of cases and 2 mm in 95%. Jackman1 found that traversing the lesion in both
mammographic planes was the factor most likely to lead to successful excision surgery. This assessment does not require distance measurements. The failure rate is such that statistically meaningful analysis is more likely than with the easier targets. We reached this target in 92.2% of procedures with 95% confidence interval of 89.2–94.4%. Figures for individual radiologists are a valuable self assessment audit tool, and are more likely to be meaningful using this target. While traversing the lesion is important the distance from needle tip is also a consideration since a lesion traversed but with tip well beyond the lesion may mislead the surgeon. It has been suggested that the tip of the wire should ideally be placed within 1 cm of the lesion.9 The modified Kopans needle used in our series has a stiff portion to guide the surgeon and where possible we try to place this in the lesion. For this reason the 1 cm from tip target may not be appropriate for that needle. We felt that 2 cm beyond stiff portion was too far through: this group had a high proportion of ultrasound procedures which could reflect poor technique, but the result may be biased by lesion size, depth and the nature of those lesions. We had a relatively high proportion of parenchymal distortions. This sub group it is too small a sample to have significant results. Success in traversing the lesion is predominantly influenced by radiological performance, and there is evidence that it is of importance to excision outcome. The rate of failure to achieve this is enough to produce a statistically meaningful measure of performance. We have achieved this in over 92%. We suggest a minimum target of 90% of wires to traverse the lesion in both planes would be meaningful and measurable. A target of 95% may be achievable. If our results are replicated in other studies this or a similar target could replace or be added to the current European and NHSBSP guidelines.
Fails 10 mm Target N=3
Between 5mm and 10mm N=8
Fails 5mm Target N=11
Between 2mm and 5mm N=10
Within 2mm N =11
Fails 2mm Target N=21
Fig. 1. Summary of distance from lesion of wires failing to traverse the lesion in both planes.
B. Mucci et al. / The Breast 18 (2009) 267–269
Conclusions As a quality control target for wire placement in clinically occult breast lesions success in traversing the lesion in both planes in 90% of procedures is measurable and achievable with clinical relevance. We believe that this could be an improvement on the current European target of 95% of wires being within 10 mm of the lesion.
Conflict of interest None declared.
References 1. Jackman RJ, Marzoni FA. Needle-localized breast biopsy: why do we fail? Radiology 1997;204:677–84.
269
2. Verkooijen HM, Peeters PH, Pijnappel RM, Koot VC, Schipper ME, Borel Rinkes IH. Diagnostic accuracy of needle-localized open biopsy for impalpable breast disease. Br J Surg 2000;87:344–7. 3. Landercasper J, Gundersen Jr SB, Gundersen AL, Cogbill TH, Travelli R, Strutt P. Needle localization and biopsy of nonpalable lesions of the beast. Surg Gynecol Obstet 1987;164:399–403. 4. European Comission. European guidelines for quality assurance in breast cancer screening and diagnosis. In: Perry N, Broedrers M, de Wolf C, Tornberg S, Holland R, von Karsa L, et al., 4th ed. Luxombourg: Office for Official Publications of the European Communities, ISBN 92-79-01258-4; 2006. 5. Consolidated guidance on standards for the NHS breast screening programme. NHSBSP No 60 (Version 2). Sheffield: NHS Cancer Screening Programmes; 2005. 6. Abrahamson PE, Dunlap LA, Amammoo MA, Schell MJ, Braeuning MP, Pisano ED. Factors predicting successful needle-localized breast biopsy. Acad Radiol 2003;10:601–6. 7. Gallagher WJ, Cardenosa G, Rubens JR, McCarthy KA, Kopans DB. Minimalvolume excision of nonpalpable breast lesions. AJR Am J Roentgenol 1989;153:957–61. 8. De Paredes ES, Langer TG, Cousins J. Interventional breast procedures. Curr Probl Diagn Radiol 1998;27:133–84. 9. Teh W, Singhal H. Breast, needle localization 2008 Emedicine, http://emedicine. medscape.com/article/347407.