- Email: [email protected]
Techniques Used to Localize Occult Breast Lesions: An Update
Accepted Manuscript Techniques Used to Localise Occult Breast Lesions: An Update M. Green, R. Vidya PII:
S1526-8209(17)30734-6
DOI:
10.1016/j.clbc.2018.01.001
Reference:
CLBC 744
To appear in:
Clinical Breast Cancer
Received Date: 13 November 2017 Accepted Date: 1 January 2018
Please cite this article as: Green M, Vidya R, Techniques Used to Localise Occult Breast Lesions: An Update, Clinical Breast Cancer (2018), doi: 10.1016/j.clbc.2018.01.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Techniques Used to Localise Occult Breast Lesions: An Update Green M, Vidya R 1) Mr. Matthew Green, Specialist Registrar, New Cross Hospital, Wednesfield Way, Wolverhampton, West Midlands WV10 0QP.
RI PT
[email protected]
2) Dr Raghavan Vidya, Consultant Breast Surgeon, New Cross Hospital,
[email protected]
Address for correspondence: R Vidya MS, MD, FRCS
M AN U
Keywords: breast, occult lesion, localisation
SC
Wednesfield Way, Wolverhampton, West Midlands WV10 0QP,
Honorary Senior Lecturer Birmingham University Consultant Breast and Oncoplastic Surgeon
TE D
Department of Breast Surgery, Royal Wolverhampton Hospital, Wolverhampton, WV10 0QP
Email: [email protected]
EP
Tel: 01902 695969
No Conflict of interest and no financial disclosures to make.
AC C
All authors have contributed to the manuscript.
ACCEPTED MANUSCRIPT Introduction Breast cancer is a common type of cancer worldwide with over 1.6 million new cases diagnosed in 20121. The rate of screen detected breast cancer is also increasing each year with 19235 cases of invasive and in-situ disease
RI PT
diagnosed in the 2012-2013 as compared to 10096 in 2004-2005 2 . Occult impalpable lesions are on the rise due to extension of the screening programme as well as increased use of new imaging modalities such as MRI,
SC
digital imaging and tomosynthesis. Over the last decade new techniques of
M AN U
tumour localisation have emerged which may replace the gold standard technique of wire localisation. In this article, we look at the new techniques and discuss their merits and limitations.
Traditional method – Wire localisation
TE D
Image guided wire localisation is the standard method used today. The tumour is localised using a variety of commercially available wires under ultrasound or stereotactic guidance3. The position of the wire is checked using
EP
mammogram and the wire should be within 1cm of the lesion (>95% of
AC C
cases4). A single wire is used in unifocal lesions while bracketing using two wires is used in wide spread microcalcification. The advantages include it being a simple technique which is readily available. The procedure is done on the day of surgery and leads to accurate lesion localisation
5
. The
disadvantages include potential displacement, transection of the wire, accuracy of the wire being operator dependent and planning needs6,7 .
ACCEPTED MANUSCRIPT The other alternative methods of occult lesion localisation are as in Table 1. We have discussed their role including advantages and disadvantages, all of which have been summarised in Table 2.
RI PT
Table 1: Alternative techniques available for breast lesion localisation o Carbon Marking
o ROLL – Radioguided Occult Lesion Localisation
o Radioactive Seed Localisation o Magnetic Tracers -
Magnetic
Sentinel
Node
M AN U
o MagSNOLL
SC
o SNOLL – Sentinel Node and Occult Lesion Localisation
and
Occult
Lesion Localisation in Breast Cancer
Carbon Marking
TE D
o Magnetic Seed Localisation (e.g. Magseed®)
This technique is based on administration of sterile charcoal powder dissolved in saline solution. This is administered into the site of the lesion under image
EP
guidance 8 and can potentially be undertaken at the time of the initial
AC C
diagnostic biopsy. The charcoal creates a tattoo at the site of the injection leading to a discoloured pathway leading to the site of lesion. The advantages include being easily available, the tattoo is stable for a few weeks and the technique is inexpensive. Disadvantages includes occlusion of needle tip and foreign body giant cell reactions 9 . This technique although simple is not routinely employed due to its side effects.
ACCEPTED MANUSCRIPT Radioguided Occult Lesion Localisation (ROLL) This technique involves injection of human serum albumin labelled with radioactive Technetium-99m under image guidance into the site of the lesion
10
. Injection can be performed under stereotactic or ultrasound
RI PT
guidance. Whilst various centres have used differing doses of Tc-99m, the largest reported series suggested 6MBq for diagnostic excision biopsy or wide local excision without sentinel node biopsy. If sentinel node biopsy was also
SC
being performed, the dose was increased to 30MBq11. A scintigram can be used to ascertain the accuracy of the localisation following injection. The
M AN U
gamma probe is used to detect the site of the lesion following which it is excised 12 with appropriate margins if required. Disadvantages include the need for nuclear medicine including its heavy legislation, disposal of nuclear
TE D
waste and injected material not being visible on plain radiographs13.
Sentinel Node and Occult Lesion Localisation (SNOLL) This approach is an extension of the above ROLL method. As suggested in
EP
the previous discussion, a dose of 30MBq rather than 6MBq is used to allow
AC C
localisation of the sentinel lymph node as well as the occult lesion. The advantage includes using a single technique to identify both the lesion and the sentinel node 14 . Furthermore, this can be undertaken on the day prior to surgery rather than on the same day. Disadvantages include the requirement of nuclear medicine including its strict legislation and the need for disposal of nuclear waste15.
ACCEPTED MANUSCRIPT Radioactive Seed Localisation In this method radioactive seeds, usually Iodine 125 (I-125) seeds, are injected into the centre of the occult lesion under stereotactic or ultrasound guidance. The I-125 seeds are visible on imaging including mammogram and
RI PT
ultrasound allowing correct placement to be verified. The lesion can then be detected for surgical excision using a gamma probe16. As the I-125 emits a 27 KeV gamma source, rather than the 140 KeV from Tc-99m, the signal can be
SC
differentiated from that found in a sentinel node biopsy. Furthermore, most
sources independently.
M AN U
commercially available gamma probes are able to detect both of these
The advantages of this technique include the fact that the injection can be undertaken many days before surgery, ease of administration and detection as well as non-interference with sentinel node biopsy 17 . However, the
TE D
disadvantages again include dedicated nuclear medicine facilities and its strict legislation and radiation hazards.
EP
Magnetic tracer
AC C
This technique involves image guided intratumoural injection of a magnetic tracer to allow surgical detection with the use of a magnetometer. The tracer contains iron oxide particles at a concentration of 27mg per ml. After injection into the tumour, the tracer produces a transient magnetic response which can be detected extra-corporally.
Furthermore, this technique can be used to
detect both the tumour and the sentinel node, a method which was evaluated in the MagSNOLL Trial. The tracer is filtered by lymphatics and retained by the sentinel lymph nodes.
ACCEPTED MANUSCRIPT This technique avoids the use of radioisotopes and the radiation and legislation associated with it. Additionally, the injection can be undertaken up to 7 days prior to the surgery allowing for better logistics. It is a somewhat novel technique however which requires additional training and the use of
RI PT
magnetometers which will impact on the cost of delivery.
Magnetic Seed Localisation
SC
This is a recent technique which involves placing a magnetic seed marker (e.g. Magseed®) into the centre of the lesion under ultrasound or stereotactic
M AN U
guidance. Subsequently, its position can be verified using a mammogram. The occult lesion is detected using a magnetic probe (eg Sentimag®) during surgery. At 1mm x 5mm in size, the seed can be placed with the use of an 18 gauge needle. It can then be detected up to a depth of 30mm.
TE D
The advantages include localisation of the lesion up to 30 days prior to surgery, no signal decay over time, avoidance of radioactive materials and ease of administration. However, as suggested above the probe only has a
EP
sensing zone of up to 30 mm so deeper lesions may need alternative
AC C
methods of localisation. The probe may also receive interference from ferromagnetic surgical instruments. Furthermore, the technique is new and needs more long-term data. As for the magnetic tracer, this technique will also require acquisition of new technology at initial setup of the service.
ACCEPTED MANUSCRIPT Table 2 Comparison of different techniques to detect occult lesions Technique
Advantages
Disadvantages
Readily available, simple, carried out in radiology
Wire displacement, transection, vasovagal attack, radiology expertise needed and theatre scheduling required Simple, Foreign body cheap reaction, needle occlusion while administering Performed Radioactivedays before Nuclear surgery medicine, cost, legislation etc Detects both Radioactivelesion and Nuclear sentinel node medicine, cost, legislation etc Administered Needs magnetic up to 7 days probe, possible before interference surgery, from avoids ferromagnetic radioisotopes instruments Administered Needs magnetic up to 30 probe, probe days before sensitivity surgery, detection low avoids below 30mm, radioisotopes possible interference from ferromagnetic instruments
SC
RI PT
Wire localisation
Available Negative Margin rate Yes, gold 70-88%18,19,20,21. standard
Yes
81%22
ROLL
Yes
75-94%18,24
SNOLL
Yes
82 - 92%12,23
Magnetic tracer injection
New
TE D
M AN U
Carbon marking
EP
Novel technique as yet unclear
AC C
Magnetic New seed (Magseed®)
Novel technique as yet unclear
ACCEPTED MANUSCRIPT Discussion A review has found that wire guided localisation of impalpable lesions to be safe. A recent Cochrane review of the different methods available has found they are difficult to compare due to the heterogeneous nature and paucity of
RI PT
long term data24.
However, it is estimated that the breast localisation market could surpass the $1 Billion threshold by 2024. As such, new techniques are also industry driven
SC
as they strive to find their place in this evolving marketplace. This drive has seen a number of newer technologies available over the last decade.
M AN U
One of the main hurdles which these all face however is the presence of a “tried and tested” technique in wire localisation. However, the logistical and planning issues which this technique causes are undeniable. As such, the presence of methods which can be used to localise tumours prior to the day of
TE D
surgery is understandably tempting and should help to allow smoother running of operating lists. In the correct, and appropriately trained hands, these techniques should also help with more accurate lesion localisation and
EP
remove the potential for dislodging wires.
AC C
Another aspect which should be addressed in this review is the ability for two of the above described techniques to also isolate the sentinel lymph nodes without the need for a separate localisation technique. SNOLL and Magnetic Tracers allow for both lesion and sentinel node localisation with one injection and both can be performed prior to the day of surgery hence avoiding logistical problems on the day of surgery. The most recent advance in these techniques is the varying use of magnetic detection (Magnetic Tracers and Seeds) which avoid the nuclear legislation
ACCEPTED MANUSCRIPT associated with the use of radioactive tracers. This is understandably tempting, especially with a number of hospitals now outsourcing their delivery of such services and the associated costs. However, with novel techniques inevitably comes the cost of setting up these services including new hardware
RI PT
and the required initial training. There may also be hesitation from surgeons and radiologists alike who are comfortable with their current practices.
Whilst these new techniques are emerging and there are still a number of
SC
questions to be answered, it is important to have stratified randomised trial
AC C
EP
TE D
M AN U
data to compare the different approaches and collate long term data.
ACCEPTED MANUSCRIPT References 1
Cancer Research UK, http://www.cancerresearchuk.org/health-professional/cancer-
statistics/worldwide-cancer/incidence#heading-Zero, Accessed October 2017. 2
Centre for Cancer Prevention,
http://webarchive.nationalarchives.gov.uk/20150506050650/http://www.cancerscreening.nhs. uk//breastscreen/statistics.html, Accessed October 2017. Kopans DB, Swan CA. Preoperative imaging-guided needle placement and localisation of
RI PT
3
clinically occult breast lesions. Am J Roentgenol 1989; vol 152(1), pp. 1–9. 4
Sibbering M, Watkins R, Winstanley J, Patnick J (eds). Quality Assurance Guidelines for
Surgeons in Breast Cancer Screening, Fourth Edition. NHSBSP Publication No 20. Sheffield: NHS Cancer Screening Programmes, 2009.
Besic N, Zgajnar J, Hocevar M, Rener M, Frkovic-Grazio S, Snoj N, Lindtner J. Breast
SC
5
biopsy with wire localisation: factors influencing complete excision of nonpalpable carcinoma. Eur Radiol 2002;12:2684-2689.
Kopans DB. Migration of breast biopsy localisation wire. Am J Roentgenol 1988; vol 151(3),
M AN U
6
pp. 614–615. 7
Bronstein AD, Kilcoyne RF, Moe RE. Complications of needle localisation of foreign bodies
and nonpalpable breast lesions. Arch Surg 1988; 123:775-779. 8
Canavese G, Catturich A, Vecchio C, Tomei D, Estienne M, Moresco L, Imperiale A, Parodi
GC, Massa T, Badellino F. Pre-operative localisation of non-palpable lesions in breast cancer
TE D
by charcoal suspension. Eur J Surg Oncol 1995; vol. 21(1), 47–49. 9
Ruiz-Delgado ML, López-Ruiz JA, Sáiz-López A, Abnormal mammography and sonography
associated with foreign-body giant-cell reaction after stereotactic vacuum- assisted breast biopsy with carbon marking, Acta Radiologica 2008; vol. 49(10), 1112–1118. 10
Luini A, Zurrida S, Galimberti V, Paganelli G. Radio- guided surgery of occult breast
11
EP
lesions. Eur J Cancer 1998; vol 34(1), 204–205. Hawkins SC, Brown I, King P, El-Gammal M, Stepp K, Widdison S, Barta M, Jackson N,
English R, Ahmad S, Drew P. Eur J Surg Onc 2017; vol. 43(1), 62 – 67. Heller S, Zanzonico P. Nuclear probes and intraoperative gamma cameras. Semin Nucl
AC C
12
Med 2011; 41:166-181. 13
Rampaul RS, MacMillan RD, Evans AJ. Intraductal injection of the breast: a potential pitfall
radioisotope occult lesion localisation. Br J Radiol 2003; vol. 76, (906), 425–426. 14
Monti S, Galimberti V, Trifiro G, De Cicco C, Peradze N, Brenelli F, Fernandez-Rodriguez
J, Rotmensz N, Latronico A, Berrettini A, Mauri M, Machado L, Luini A, Paganelli G. Occult breast lesion localisation plus sentinel node biopsy (SNOLL): experience with 959 patients at the European Institute of Oncology. Ann Surg Onc 2007; vol. 14(10), 2928–2931. 15
Ahmed M, Douek M. Sentinel node and occult lesion localisation (SNOLL): A systematic
review. The Breast 2013; 22(6); 1034.
ACCEPTED MANUSCRIPT 16
Alderliesten T, Loo CE, Pengel KE, Rutgers EJ, Gilhuijs KG, Vrancken Peeters MJ.
Radioactive seed localisation of breast lesions: an adequate localisation method without seed migration. Breast J 2011; 17: 594-601. 17
Gray RJ, Pockaj BA, Karstaedt PJ, Roarke MC. Radioactive seed localisation of
nonpalpable breast lesions is better than wire localisation. Am J Surg 2004; 188:877-880. 18
Langhans L, Tvedskov TF, Klausen TL, Jensen MB, Talman ML, Vejborg I, Benian C,
RI PT
Roslind A, Hermansen J, Oturai PS, Bentzon N, Kroman N. Radioactive Seed Localisation or Wire-guided localisation of nonpalpable invasive and In Situ Breast Cancer: A Randomized, Multicenter, Open-label trial. Ann Surg 2017; vol 266(1): 29-35. 19
Sajid MS, Parampali U, Haider Z, Bonomi R. Comparison of radioguided occult lesion
localisation (ROLL) and wire localisation for non-palpable breast cancers: a meta-analysis. J
SC
Surg Oncol 2012; vol 105(8): 852-858. 20
Krekel NM, Zonderhuis BM, Stockmann HB, Schreurs WH, van der Veen H, de Lange de
M AN U
Klerk ES, Meijer S, van den Tol MP. A comparison of three methods for nonpalpable breast cancer excision. Eur J Surg Oncol 2011; vol37(2): 109-115. 21
Corsi F, Sorrentino L, Bossi D, Sartani A, Foschi D. Preoperative localisation and surgical
margins in conservative breast surgery. Int J Surg Oncol 2013; 2013: 1-9. 22
Rose A, Collins JP, Neerhut P, Bishop CV, Mann GB. Carbon localisation of impalpable
breast lesions. Breast 2003; vol 12(4): 264-269. 23
Ahmed M, Douek M. Sentinel node and occult lesion localisation (SNOLL): a systematic
24
TE D
review. Breast 2013; vol 22(6): 1034-1040.
Chan BK, Wiseberg-Firtell JA, Jois RH, Jensen K, Audisio RA. Localisation techniques for
guided surgical excision of non-palpable breast lesions. Cochrane Data base Sst Rev 2015;
AC C
EP
31(12); CD009206. doi: 10.1002/14651858.CD009206.pub2
S1526-8209(17)30734-6
DOI:
10.1016/j.clbc.2018.01.001
Reference:
CLBC 744
To appear in:
Clinical Breast Cancer
Received Date: 13 November 2017 Accepted Date: 1 January 2018
Please cite this article as: Green M, Vidya R, Techniques Used to Localise Occult Breast Lesions: An Update, Clinical Breast Cancer (2018), doi: 10.1016/j.clbc.2018.01.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Techniques Used to Localise Occult Breast Lesions: An Update Green M, Vidya R 1) Mr. Matthew Green, Specialist Registrar, New Cross Hospital, Wednesfield Way, Wolverhampton, West Midlands WV10 0QP.
RI PT
[email protected]
2) Dr Raghavan Vidya, Consultant Breast Surgeon, New Cross Hospital,
[email protected]
Address for correspondence: R Vidya MS, MD, FRCS
M AN U
Keywords: breast, occult lesion, localisation
SC
Wednesfield Way, Wolverhampton, West Midlands WV10 0QP,
Honorary Senior Lecturer Birmingham University Consultant Breast and Oncoplastic Surgeon
TE D
Department of Breast Surgery, Royal Wolverhampton Hospital, Wolverhampton, WV10 0QP
Email: [email protected]
EP
Tel: 01902 695969
No Conflict of interest and no financial disclosures to make.
AC C
All authors have contributed to the manuscript.
ACCEPTED MANUSCRIPT Introduction Breast cancer is a common type of cancer worldwide with over 1.6 million new cases diagnosed in 20121. The rate of screen detected breast cancer is also increasing each year with 19235 cases of invasive and in-situ disease
RI PT
diagnosed in the 2012-2013 as compared to 10096 in 2004-2005 2 . Occult impalpable lesions are on the rise due to extension of the screening programme as well as increased use of new imaging modalities such as MRI,
SC
digital imaging and tomosynthesis. Over the last decade new techniques of
M AN U
tumour localisation have emerged which may replace the gold standard technique of wire localisation. In this article, we look at the new techniques and discuss their merits and limitations.
Traditional method – Wire localisation
TE D
Image guided wire localisation is the standard method used today. The tumour is localised using a variety of commercially available wires under ultrasound or stereotactic guidance3. The position of the wire is checked using
EP
mammogram and the wire should be within 1cm of the lesion (>95% of
AC C
cases4). A single wire is used in unifocal lesions while bracketing using two wires is used in wide spread microcalcification. The advantages include it being a simple technique which is readily available. The procedure is done on the day of surgery and leads to accurate lesion localisation
5
. The
disadvantages include potential displacement, transection of the wire, accuracy of the wire being operator dependent and planning needs6,7 .
ACCEPTED MANUSCRIPT The other alternative methods of occult lesion localisation are as in Table 1. We have discussed their role including advantages and disadvantages, all of which have been summarised in Table 2.
RI PT
Table 1: Alternative techniques available for breast lesion localisation o Carbon Marking
o ROLL – Radioguided Occult Lesion Localisation
o Radioactive Seed Localisation o Magnetic Tracers -
Magnetic
Sentinel
Node
M AN U
o MagSNOLL
SC
o SNOLL – Sentinel Node and Occult Lesion Localisation
and
Occult
Lesion Localisation in Breast Cancer
Carbon Marking
TE D
o Magnetic Seed Localisation (e.g. Magseed®)
This technique is based on administration of sterile charcoal powder dissolved in saline solution. This is administered into the site of the lesion under image
EP
guidance 8 and can potentially be undertaken at the time of the initial
AC C
diagnostic biopsy. The charcoal creates a tattoo at the site of the injection leading to a discoloured pathway leading to the site of lesion. The advantages include being easily available, the tattoo is stable for a few weeks and the technique is inexpensive. Disadvantages includes occlusion of needle tip and foreign body giant cell reactions 9 . This technique although simple is not routinely employed due to its side effects.
ACCEPTED MANUSCRIPT Radioguided Occult Lesion Localisation (ROLL) This technique involves injection of human serum albumin labelled with radioactive Technetium-99m under image guidance into the site of the lesion
10
. Injection can be performed under stereotactic or ultrasound
RI PT
guidance. Whilst various centres have used differing doses of Tc-99m, the largest reported series suggested 6MBq for diagnostic excision biopsy or wide local excision without sentinel node biopsy. If sentinel node biopsy was also
SC
being performed, the dose was increased to 30MBq11. A scintigram can be used to ascertain the accuracy of the localisation following injection. The
M AN U
gamma probe is used to detect the site of the lesion following which it is excised 12 with appropriate margins if required. Disadvantages include the need for nuclear medicine including its heavy legislation, disposal of nuclear
TE D
waste and injected material not being visible on plain radiographs13.
Sentinel Node and Occult Lesion Localisation (SNOLL) This approach is an extension of the above ROLL method. As suggested in
EP
the previous discussion, a dose of 30MBq rather than 6MBq is used to allow
AC C
localisation of the sentinel lymph node as well as the occult lesion. The advantage includes using a single technique to identify both the lesion and the sentinel node 14 . Furthermore, this can be undertaken on the day prior to surgery rather than on the same day. Disadvantages include the requirement of nuclear medicine including its strict legislation and the need for disposal of nuclear waste15.
ACCEPTED MANUSCRIPT Radioactive Seed Localisation In this method radioactive seeds, usually Iodine 125 (I-125) seeds, are injected into the centre of the occult lesion under stereotactic or ultrasound guidance. The I-125 seeds are visible on imaging including mammogram and
RI PT
ultrasound allowing correct placement to be verified. The lesion can then be detected for surgical excision using a gamma probe16. As the I-125 emits a 27 KeV gamma source, rather than the 140 KeV from Tc-99m, the signal can be
SC
differentiated from that found in a sentinel node biopsy. Furthermore, most
sources independently.
M AN U
commercially available gamma probes are able to detect both of these
The advantages of this technique include the fact that the injection can be undertaken many days before surgery, ease of administration and detection as well as non-interference with sentinel node biopsy 17 . However, the
TE D
disadvantages again include dedicated nuclear medicine facilities and its strict legislation and radiation hazards.
EP
Magnetic tracer
AC C
This technique involves image guided intratumoural injection of a magnetic tracer to allow surgical detection with the use of a magnetometer. The tracer contains iron oxide particles at a concentration of 27mg per ml. After injection into the tumour, the tracer produces a transient magnetic response which can be detected extra-corporally.
Furthermore, this technique can be used to
detect both the tumour and the sentinel node, a method which was evaluated in the MagSNOLL Trial. The tracer is filtered by lymphatics and retained by the sentinel lymph nodes.
ACCEPTED MANUSCRIPT This technique avoids the use of radioisotopes and the radiation and legislation associated with it. Additionally, the injection can be undertaken up to 7 days prior to the surgery allowing for better logistics. It is a somewhat novel technique however which requires additional training and the use of
RI PT
magnetometers which will impact on the cost of delivery.
Magnetic Seed Localisation
SC
This is a recent technique which involves placing a magnetic seed marker (e.g. Magseed®) into the centre of the lesion under ultrasound or stereotactic
M AN U
guidance. Subsequently, its position can be verified using a mammogram. The occult lesion is detected using a magnetic probe (eg Sentimag®) during surgery. At 1mm x 5mm in size, the seed can be placed with the use of an 18 gauge needle. It can then be detected up to a depth of 30mm.
TE D
The advantages include localisation of the lesion up to 30 days prior to surgery, no signal decay over time, avoidance of radioactive materials and ease of administration. However, as suggested above the probe only has a
EP
sensing zone of up to 30 mm so deeper lesions may need alternative
AC C
methods of localisation. The probe may also receive interference from ferromagnetic surgical instruments. Furthermore, the technique is new and needs more long-term data. As for the magnetic tracer, this technique will also require acquisition of new technology at initial setup of the service.
ACCEPTED MANUSCRIPT Table 2 Comparison of different techniques to detect occult lesions Technique
Advantages
Disadvantages
Readily available, simple, carried out in radiology
Wire displacement, transection, vasovagal attack, radiology expertise needed and theatre scheduling required Simple, Foreign body cheap reaction, needle occlusion while administering Performed Radioactivedays before Nuclear surgery medicine, cost, legislation etc Detects both Radioactivelesion and Nuclear sentinel node medicine, cost, legislation etc Administered Needs magnetic up to 7 days probe, possible before interference surgery, from avoids ferromagnetic radioisotopes instruments Administered Needs magnetic up to 30 probe, probe days before sensitivity surgery, detection low avoids below 30mm, radioisotopes possible interference from ferromagnetic instruments
SC
RI PT
Wire localisation
Available Negative Margin rate Yes, gold 70-88%18,19,20,21. standard
Yes
81%22
ROLL
Yes
75-94%18,24
SNOLL
Yes
82 - 92%12,23
Magnetic tracer injection
New
TE D
M AN U
Carbon marking
EP
Novel technique as yet unclear
AC C
Magnetic New seed (Magseed®)
Novel technique as yet unclear
ACCEPTED MANUSCRIPT Discussion A review has found that wire guided localisation of impalpable lesions to be safe. A recent Cochrane review of the different methods available has found they are difficult to compare due to the heterogeneous nature and paucity of
RI PT
long term data24.
However, it is estimated that the breast localisation market could surpass the $1 Billion threshold by 2024. As such, new techniques are also industry driven
SC
as they strive to find their place in this evolving marketplace. This drive has seen a number of newer technologies available over the last decade.
M AN U
One of the main hurdles which these all face however is the presence of a “tried and tested” technique in wire localisation. However, the logistical and planning issues which this technique causes are undeniable. As such, the presence of methods which can be used to localise tumours prior to the day of
TE D
surgery is understandably tempting and should help to allow smoother running of operating lists. In the correct, and appropriately trained hands, these techniques should also help with more accurate lesion localisation and
EP
remove the potential for dislodging wires.
AC C
Another aspect which should be addressed in this review is the ability for two of the above described techniques to also isolate the sentinel lymph nodes without the need for a separate localisation technique. SNOLL and Magnetic Tracers allow for both lesion and sentinel node localisation with one injection and both can be performed prior to the day of surgery hence avoiding logistical problems on the day of surgery. The most recent advance in these techniques is the varying use of magnetic detection (Magnetic Tracers and Seeds) which avoid the nuclear legislation
ACCEPTED MANUSCRIPT associated with the use of radioactive tracers. This is understandably tempting, especially with a number of hospitals now outsourcing their delivery of such services and the associated costs. However, with novel techniques inevitably comes the cost of setting up these services including new hardware
RI PT
and the required initial training. There may also be hesitation from surgeons and radiologists alike who are comfortable with their current practices.
Whilst these new techniques are emerging and there are still a number of
SC
questions to be answered, it is important to have stratified randomised trial
AC C
EP
TE D
M AN U
data to compare the different approaches and collate long term data.
ACCEPTED MANUSCRIPT References 1
Cancer Research UK, http://www.cancerresearchuk.org/health-professional/cancer-
statistics/worldwide-cancer/incidence#heading-Zero, Accessed October 2017. 2
Centre for Cancer Prevention,
http://webarchive.nationalarchives.gov.uk/20150506050650/http://www.cancerscreening.nhs. uk//breastscreen/statistics.html, Accessed October 2017. Kopans DB, Swan CA. Preoperative imaging-guided needle placement and localisation of
RI PT
3
clinically occult breast lesions. Am J Roentgenol 1989; vol 152(1), pp. 1–9. 4
Sibbering M, Watkins R, Winstanley J, Patnick J (eds). Quality Assurance Guidelines for
Surgeons in Breast Cancer Screening, Fourth Edition. NHSBSP Publication No 20. Sheffield: NHS Cancer Screening Programmes, 2009.
Besic N, Zgajnar J, Hocevar M, Rener M, Frkovic-Grazio S, Snoj N, Lindtner J. Breast
SC
5
biopsy with wire localisation: factors influencing complete excision of nonpalpable carcinoma. Eur Radiol 2002;12:2684-2689.
Kopans DB. Migration of breast biopsy localisation wire. Am J Roentgenol 1988; vol 151(3),
M AN U
6
pp. 614–615. 7
Bronstein AD, Kilcoyne RF, Moe RE. Complications of needle localisation of foreign bodies
and nonpalpable breast lesions. Arch Surg 1988; 123:775-779. 8
Canavese G, Catturich A, Vecchio C, Tomei D, Estienne M, Moresco L, Imperiale A, Parodi
GC, Massa T, Badellino F. Pre-operative localisation of non-palpable lesions in breast cancer
TE D
by charcoal suspension. Eur J Surg Oncol 1995; vol. 21(1), 47–49. 9
Ruiz-Delgado ML, López-Ruiz JA, Sáiz-López A, Abnormal mammography and sonography
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