- Email: [email protected]
Localization Methods for Excisional Biopsy in Women With Nonpalpable Mammographic Abnormalities
Original Study
Localization Methods for Excisional Biopsy in Women With Nonpalpable Mammographic Abnormalities Christine Rodhouse, Iman Soliman, Mariah Cruse, Joseph Kastrenakes, C.J. Augustine, Alexis Ludy, Eric Reintgen, Alexa Hoadley, Divya Desai, Minh Nguyen, Douglas Scott Reintgen Abstract Wire-localized excisional breast biopsy should remain a stable of the surgeon’s practice owing to the fact that radiologists and surgeons are familiar with the technique, it is low-cost, and it does not involve special expensive equipment or radioactivity handling. The use of wire-localized excisional breast biopsies in expanded scenarios will decrease costs for the health care system and make the technique accessible to more patients. Introduction: With the advent and proliferation of breast cancer screening programs, more women are being diagnosed with mammographic abnormalities that require tissue diagnosis. If imaged-guided biopsy is not possible or previous image-guided biopsies reveal pathologies that require more extensive surgery, guided excisional biopsy/ lumpectomy may be necessary. Methods: Fifteen women were enrolled in the study of the feasibility of off-site or daybefore wire-localization excisional biopsy of the breast with mammographic abnormalities. Five patients had their localization wire placed the day before, whereas 10 patients had their localization the same day with surgery in a distant procedure room under straight local anesthesia. Results: Two of the 15 patients had an eventual cancer diagnosis from their wire-localized excisional breast biopsy. All patients had their mammographic abnormality removed with the previously placed core biopsy clip, and there was 100% radiologic/clinical correlation. All patients’ wounds healed primarily without any surgical site infections. Conclusion: The protocol answers 2 questions concerning the wire-localized excisional breast biopsy technique. The series shows that the wire-localization technique can be performed the night before or in a location away from the procedure room that would allow better synchronization with surgical schedules or allow the procedure to take place in low-cost settings away from the expense of the hospital operating room. Clinical Breast Cancer, Vol. -, No. -, --- ª 2016 Elsevier Inc. All rights reserved. Keywords: Breast biopsy, Health care costs, Image-guidance, Localization methods, Mammographic abnormalities
Introduction With the introduction of screening mammography programs across the country in the 1980s and 1990s and clinical research showing that these programs can diagnose breast cancer at an earlier stage with accompanying better prognosis, more surgeons will be called upon to obtain tissue diagnosis of these nonpalpable Florida Hospital - N Pinellas, University of South Florida, Morsani College of Medicine, Tampa, FL Submitted: Jul 9, 2016; Accepted: Oct 12, 2016 Address for correspondence: Douglas Scott Reintgen, MD, Professor of Surgery, University of South Florida, Morsani College of Medicine, MDC 52, 12901 Bruce B. Downs Blvd, Tampa, FL 33612 E-mail contact: [email protected]
1526-8209/$ - see frontmatter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clbc.2016.10.007
mammographically detected lesions. Most of these abnormalities are initially biopsied with an image-guided core technique. The easiest method to implement is an ultrasound-directed core for most mammographic abnormalities or with the stereotactic technique that is primarily used to biopsy suspicious areas of microcalcifications that cannot be seen on ultrasound. Image-guided core biopsies may not be applicable to areas in the breast, including superficial lesions or abnormalities in the subareolar area or axillary tail. In addition, with some pathology reports from core biopsy, including atypical ductal hyperplasia (ADH), atypical lobular hyperplasia, nonconcordant pathologies, or a cancer diagnosis, an excisional biopsy or lumpectomy may be necessary. The wirelocalization technique has been the most popular method to direct the surgeon during excisional biopsies or guided
Clinical Breast Cancer Month 2016
-1
Techniques for Guided Excisional Breast Biopsy lumpectomies in these situations. Lately, a number of new technologies, including radio-guided surgery1 or radioefrequencyguided surgery2 have been proposed to be used in this situation. This report details the newer technologies used for localized excisional biopsies or lumpectomy and makes a case for the standard procedure of wire-localization in expanded scenarios of use.
Figure 1 Medeolateral (ML) View Mammogram of the Left Breast After Wire-Localization of Core Biopsy Clip in the 4:00 Area
Methods The series includes 15 women with suspicious abnormal mammograms. Six patients had the mammographic finding of clustered microcalcifications in areas of the breast not amenable to imageguided core biopsy; 4 patients had new densities that wanted them completely removed; 2 patients had ADH on core biopsy, and an excisional biopsy was recommended; and 3 patients had no insurance and needed to limit costs of the procedure for out-of-pocket payment. Ten patients had their wire-localization placed the morning of their surgical procedure in the Radiology Department of the hospital and were then transported to the outpatient clinic building for their wire-localization procedure the same day under straight local anesthesia. The remaining 5 patients had their wirelocalization performed up to 18 hours prior and were sent home. The next day they underwent their surgical procedure in an outpatient surgery center under laryngeal mask airway-general anesthesia at 7:30 am the next morning. The localization wires were placed with mammography or ultrasound guidance, localizing the previously placed core-biopsy marker clip or the mammographic abnormality. In the procedures performed the previous day, the wire-localization was secured with taping to minimize any trauma to or movement of the localization wire. The anesthesia technique is important when this procedure is performed under straight local anesthesia. One percent Xylocaine with epinephrine is used, diluted 50% with normal saline. The skin incision is drawn over the approximate location of the mammographic abnormality and the skin and subcutaneous tissue is dissected sharply and with electrocautery. Hemostasis is secured with electrocautery. The localization wire is found in the subcutaneous tissues and brought into the wound. Flaps are created in all directions with local anesthesia being instilled as the flaps are created so that communication can occur with the patient as the anesthesia is administered to ascertain the correct location and judge the efficacy of the local anesthesia. Allis clamps are placed in each corner, and a retraction suture is placed at the approximate location of the mammographic abnormality. The remainder of the peripheral flaps are fashioned, and the biopsy is subsequently turned under to obtain a suitable deep margin. Again, local anesthesia is given to this deep margin as it is created to obtain patient feedback and not use excessive local anesthesia. Five patients had their wire-localization the night before and underwent successful excisional biopsy the next day with documented clinical/pathology correlation. Another 10 patients had their wire-localization in the radiology section of Tampa General Hospital and, with suitable taping, were transported to an off-site clinic procedure room for their wire-localization the same day.
abnormality as documented in the specimen or with specimen mammography. Two of 15 patients were diagnosed with malignancy, whereas the other 13 patients had a benign final diagnosis. Figures 1 and 2 shows the mediolateral oblique and craniocaudal views of the left breast of a case after wire-localization of a typical patient who had the diagnosis of ADH on image-guided core biopsy. The localization wire is left long and taped down to the chest wall throughout its length (Figure 3) to minimize the risk of movement or dislodgement. At the time of the biopsy, the localization wire is cut to a more manageable length (Figure 4), and the wire-localized biopsy proceeds under straight local anesthesia in the clinic or under monitored anesthesia care-general anesthesia in the outpatient surgical center. Figure 5 shows the surgical specimen with a localization wire in place. There were no surgical site infections in the 15 patients that underwent the delayed excisional biopsy after the wire-localization. There were no incidences of migration or displacement of the localization wire between the time of the wire placement and the excisional biopsy.
Discussion Results
2
-
All 15 women underwent successful needle-localization biopsy with recovery of the previously placed biopsy clip and/or the mammographic
Clinical Breast Cancer Month 2016
With the advent of screening mammography programs in the United States and in the international community, more women are being seen with mammographic abnormalities that are not palpable
Christine Rodhouse et al Figure 2 Cranial-Caudal (CC) View Left Breast Mammogram After Wire-Localization Showing Core Biopsy Clip at 4:00 Retroareolar
and need to be biopsied. The old method of localization involved bringing the patient first to radiology for the wire placement and then the same day to the operating room where a needle-localized biopsy was performed under general anesthesia. The limitations of this method were that patients had localization wires inserted into their breast for a period of time, and it was difficult for surgeons to schedule early morning starts in the operating room (OR) while they waited for their radiology colleagues to perform the localization. In addition, this procedure used a tremendous amount of medical resources with involvement of a radiologist, surgeons, and an anesthesiologist in a usual hospital OR setting. The first attempt for alternative methods of mammographic lesion localization was reported in 2001 by Gray, Cox, and Reintgen from Moffitt Cancer Center in Tampa, FL.1 Taking advantage of original work performed for sentinel lymph node (SLN) localization with radio-guided surgery, the radio-guided technique involves the placement of a radioactive seed (I131) close to the mammographic abnormality, and with the use of a gamma detector probe (the same probe used in the common lymphatic mapping procedure), radioguided excision of the mammographic abnormality. The I131 seed is placed in radiology through a large-bore needle into the mammographic abnormality or biopsy clip, and the patient is taken
Figure 4 Wire-Localization in the 4:00 Area
to the OR for a radio-guided excisional biopsy. Figure 6 shows the I121 seed placed in an area of a nonpalpable mammographic abnormality. With radio-guided surgery and constant monitoring of the relationship of the biopsy margin and the location of the localization seed with the probe (Figure 7), the investigators showed that clear margins were obtained more frequently with less breast tissue being removed. This was thought to then influence the cosmetic result of the procedure. Figure 8 illustrates with specimen mammography the I121 seed and the mammographic density recovered in the surgical specimen with minimal breast tissue being excised. Disadvantages of the procedure include the fact that radioactivity needed to be handled in radiology, the OR, and the pathology department of the hospital. Mayo Clinic investigators3 have favored radio-guided localization and biopsy owing to the
Figure 5 Specimen With Wire in Place With a Retraction Suture
Figure 3 Taping to Secure Wire-Localization
Clinical Breast Cancer Month 2016
-3
Techniques for Guided Excisional Breast Biopsy Figure 6 An I125 Seed Is Placed to Mark the Mammographic Abnormality With Ultrasound Guidance
ability to monitor the position of the implanted seed and its relationship to the mammographic abnormality during the excision, resulting in a higher clear margin value. This technique is also very similar to the SLN procedure in which most surgeons are trained and comfortable. Other localization techniques have been proposed for the biopsy of nonpalpable lesions that seem to overcome the limitations of the wire-localization procedure. One technique uses a small implantable device placed through a needle via ultrasound or stereotactic guidance. Once implanted, the device is activated by infrared light from a hand piece, and an electromagnetic wave is reflected back to the console. In the OR, a hand piece and console is used with continuous audible feedback as the surgeon performs the dissection. In the feasibility study of the Savi Scout,2 Cox and colleagues retrieved the seed and the targeted lesion in 100% of the cases and subjectively thought the technique offered some advantages over the wire-localization technique. Disadvantages included the fact that, in
Figure 7 With Radio-Guided Surgery and the Use of a Gamma Probe in the Operating Room, the Breast Tissue Around the Localization Seed Is Removed by Continuously Monitoring the Margin’s Relationship to the Radioactive Seed
4
-
Clinical Breast Cancer Month 2016
Figure 8 Specimen Mammography Shows the Mammographic Density and the I125 Localization Seed
12% of the cases, the reflector placed in the breast could not be located by the surgeon prior to skin incision. In 2 other cases, the reflector either malfunctioned or was deactivated by contact with the electrocautery. The surgeons believed that 2-view postlocalization mammograms and preoperative ultrasounds were adequate in planning the breast incisions. One of the inclusion criteria of the study required that the radiofrequency device be placed a maximum of 3 cm deep into the breast parenchyma. Two of the reflectors were placed outside this limit (4.5 cm and 6.0 cm). It would seem that this condition is related to the breast density and the distance between the reflector and probe. Margin status was described in the study; 2 of 41 patients had a positive margin and 6 were within 1 mm. With the ability to monitor the location of the mammographic abnormality continuously with the probe during the excision, the incidence of positive margins should be decreased. Cost may also be a concern. Unlike a wire-localization, incorporation of the Savi Scout requires the purchase of new equipment. New technology has been recently launched in Europe for the localization of nonpalpable breast abnormalities (Magseed) as well as SLNs (SentimagIC) that involves a magnetic technique. The procedure eliminates the need for radioactive tracers and blues dyes typically used with lymphatic mapping and is dark in color, which stains the lymph nodes or abnormal breast area in a similar fashion as the blue dye. The tracer can be injected up to 7 days ahead of the surgery or as little as 20 minutes before knife-to-skin without any diminution in the quality or success of the localization of nonpalpable breast lesions. The technique has been used mostly for SLN biopsy in over 13,000 patients across Europe, and multiple clinical trials have been performed that substantiate the technique. The search for the “Holy Grail” of localization for mammographic abnormalities continues. Jakub3 questions whether surgeons of the future will become experts in intraoperative ultrasound so that localizations will not be necessary. Will nuclear regulations be relaxed so that minimal doses of radioactivity can be handled in the various departments of the hospital with a specific radioactivity license or much oversight? Will nonradioactive magnetic iron oxide particles or nanoparticles4,5 be able to localize both the breast
Christine Rodhouse et al cancer and the draining SLNs, potentially only migrating to the SLN if disease is present? The future is uncertain, but certainly exciting.
Conclusion This report details a new version of an old technique—the wirelocalized excisional biopsy—used under expanded scenarios that include the day-before placement of the localization wire so that surgical schedules are not disrupted by activity in the radiology department. The important modification of leaving the wirelocalization long so that it can be secured throughout its length against the chest wall minimizes the chance of movement or dislodgement and allows placement up to 18 hours prior to the excisional biopsy in this series. Additionally, this report demonstrates that, with proper local anesthesia techniques, the wirelocalized biopsy can be performed in procedure rooms under straight local anesthesia. The technique is advantageous because all surgeons are familiar with this old standard procedure of wirelocalization, and all radioactivity handling is eliminated. In this way, more patients can be accommodated, and costs to the health care system and patient’s out-of-pocket expenses can be kept to a minimum.
Clinical Practice Points More patients will be identified with mammographic abnor-
malities because of the proliferation of breast cancer screening programs.
If the mammographic abnormalities cannot be biopsied with
image-guided core biopsy techniques, localized excisional biopsies may be needed for tissue diagnosis. New technologies including radio-guided surgery or radioefrequencyguided surgery are being introduced to meet the demand for these localization techniques. The wire-localized excisional breast biopsy technique used under expanded scenarios meets the need for a low-cost, outpatient procedure that eliminates the need for handling radioactivity in hospital departments.
Disclosure The authors have stated that they have no conflicts of interest.
References 1. Gray R, Giuliano R, Dauway E, Cox C, Reintgen DS. Seed localization breast biopsy and dual isotope scanning for lymphatic mapping. Paper presented at The Second Annual Meeting of the American Society of Breast Surgeons, May 3-6, 2001; La Jolla, CA. 2. Cox CE, Garcia-Henriquez N, Glancy MJ, et al. Pilot study of a new nonradioactive surgical guidance technology for locating nonpalpable breast lesions. Ann Surg Oncol 2016; 10:1245-7. 3. Jakub JW. The search continues for the ideal method to localize nonpalpable breast lesions. Ann Surg Oncol 2016; 23:1799-800. 4. Douek M, Klaase J, Monypenny I, et al. Sentinel node biopsy using a magnetic tracer versus standard technique: the SentiMAG multicentre trial. Ann Surg Oncol 2014; 21:1237-45. 5. Beitsch P, Hunt K, Bold R, et al. Magnetic nano-device for identification of the breast sentinel nodes - a novel method. Paper presented at the Thirty-eighth Annual San Antonio Breast Cancer Symposium, 2015 (Abstract OT2-02-03), December 8-12, 2015; San Antonio, TX.
Clinical Breast Cancer Month 2016
-5
Localization Methods for Excisional Biopsy in Women With Nonpalpable Mammographic Abnormalities Christine Rodhouse, Iman Soliman, Mariah Cruse, Joseph Kastrenakes, C.J. Augustine, Alexis Ludy, Eric Reintgen, Alexa Hoadley, Divya Desai, Minh Nguyen, Douglas Scott Reintgen Abstract Wire-localized excisional breast biopsy should remain a stable of the surgeon’s practice owing to the fact that radiologists and surgeons are familiar with the technique, it is low-cost, and it does not involve special expensive equipment or radioactivity handling. The use of wire-localized excisional breast biopsies in expanded scenarios will decrease costs for the health care system and make the technique accessible to more patients. Introduction: With the advent and proliferation of breast cancer screening programs, more women are being diagnosed with mammographic abnormalities that require tissue diagnosis. If imaged-guided biopsy is not possible or previous image-guided biopsies reveal pathologies that require more extensive surgery, guided excisional biopsy/ lumpectomy may be necessary. Methods: Fifteen women were enrolled in the study of the feasibility of off-site or daybefore wire-localization excisional biopsy of the breast with mammographic abnormalities. Five patients had their localization wire placed the day before, whereas 10 patients had their localization the same day with surgery in a distant procedure room under straight local anesthesia. Results: Two of the 15 patients had an eventual cancer diagnosis from their wire-localized excisional breast biopsy. All patients had their mammographic abnormality removed with the previously placed core biopsy clip, and there was 100% radiologic/clinical correlation. All patients’ wounds healed primarily without any surgical site infections. Conclusion: The protocol answers 2 questions concerning the wire-localized excisional breast biopsy technique. The series shows that the wire-localization technique can be performed the night before or in a location away from the procedure room that would allow better synchronization with surgical schedules or allow the procedure to take place in low-cost settings away from the expense of the hospital operating room. Clinical Breast Cancer, Vol. -, No. -, --- ª 2016 Elsevier Inc. All rights reserved. Keywords: Breast biopsy, Health care costs, Image-guidance, Localization methods, Mammographic abnormalities
Introduction With the introduction of screening mammography programs across the country in the 1980s and 1990s and clinical research showing that these programs can diagnose breast cancer at an earlier stage with accompanying better prognosis, more surgeons will be called upon to obtain tissue diagnosis of these nonpalpable Florida Hospital - N Pinellas, University of South Florida, Morsani College of Medicine, Tampa, FL Submitted: Jul 9, 2016; Accepted: Oct 12, 2016 Address for correspondence: Douglas Scott Reintgen, MD, Professor of Surgery, University of South Florida, Morsani College of Medicine, MDC 52, 12901 Bruce B. Downs Blvd, Tampa, FL 33612 E-mail contact: [email protected]
1526-8209/$ - see frontmatter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clbc.2016.10.007
mammographically detected lesions. Most of these abnormalities are initially biopsied with an image-guided core technique. The easiest method to implement is an ultrasound-directed core for most mammographic abnormalities or with the stereotactic technique that is primarily used to biopsy suspicious areas of microcalcifications that cannot be seen on ultrasound. Image-guided core biopsies may not be applicable to areas in the breast, including superficial lesions or abnormalities in the subareolar area or axillary tail. In addition, with some pathology reports from core biopsy, including atypical ductal hyperplasia (ADH), atypical lobular hyperplasia, nonconcordant pathologies, or a cancer diagnosis, an excisional biopsy or lumpectomy may be necessary. The wirelocalization technique has been the most popular method to direct the surgeon during excisional biopsies or guided
Clinical Breast Cancer Month 2016
-1
Techniques for Guided Excisional Breast Biopsy lumpectomies in these situations. Lately, a number of new technologies, including radio-guided surgery1 or radioefrequencyguided surgery2 have been proposed to be used in this situation. This report details the newer technologies used for localized excisional biopsies or lumpectomy and makes a case for the standard procedure of wire-localization in expanded scenarios of use.
Figure 1 Medeolateral (ML) View Mammogram of the Left Breast After Wire-Localization of Core Biopsy Clip in the 4:00 Area
Methods The series includes 15 women with suspicious abnormal mammograms. Six patients had the mammographic finding of clustered microcalcifications in areas of the breast not amenable to imageguided core biopsy; 4 patients had new densities that wanted them completely removed; 2 patients had ADH on core biopsy, and an excisional biopsy was recommended; and 3 patients had no insurance and needed to limit costs of the procedure for out-of-pocket payment. Ten patients had their wire-localization placed the morning of their surgical procedure in the Radiology Department of the hospital and were then transported to the outpatient clinic building for their wire-localization procedure the same day under straight local anesthesia. The remaining 5 patients had their wirelocalization performed up to 18 hours prior and were sent home. The next day they underwent their surgical procedure in an outpatient surgery center under laryngeal mask airway-general anesthesia at 7:30 am the next morning. The localization wires were placed with mammography or ultrasound guidance, localizing the previously placed core-biopsy marker clip or the mammographic abnormality. In the procedures performed the previous day, the wire-localization was secured with taping to minimize any trauma to or movement of the localization wire. The anesthesia technique is important when this procedure is performed under straight local anesthesia. One percent Xylocaine with epinephrine is used, diluted 50% with normal saline. The skin incision is drawn over the approximate location of the mammographic abnormality and the skin and subcutaneous tissue is dissected sharply and with electrocautery. Hemostasis is secured with electrocautery. The localization wire is found in the subcutaneous tissues and brought into the wound. Flaps are created in all directions with local anesthesia being instilled as the flaps are created so that communication can occur with the patient as the anesthesia is administered to ascertain the correct location and judge the efficacy of the local anesthesia. Allis clamps are placed in each corner, and a retraction suture is placed at the approximate location of the mammographic abnormality. The remainder of the peripheral flaps are fashioned, and the biopsy is subsequently turned under to obtain a suitable deep margin. Again, local anesthesia is given to this deep margin as it is created to obtain patient feedback and not use excessive local anesthesia. Five patients had their wire-localization the night before and underwent successful excisional biopsy the next day with documented clinical/pathology correlation. Another 10 patients had their wire-localization in the radiology section of Tampa General Hospital and, with suitable taping, were transported to an off-site clinic procedure room for their wire-localization the same day.
abnormality as documented in the specimen or with specimen mammography. Two of 15 patients were diagnosed with malignancy, whereas the other 13 patients had a benign final diagnosis. Figures 1 and 2 shows the mediolateral oblique and craniocaudal views of the left breast of a case after wire-localization of a typical patient who had the diagnosis of ADH on image-guided core biopsy. The localization wire is left long and taped down to the chest wall throughout its length (Figure 3) to minimize the risk of movement or dislodgement. At the time of the biopsy, the localization wire is cut to a more manageable length (Figure 4), and the wire-localized biopsy proceeds under straight local anesthesia in the clinic or under monitored anesthesia care-general anesthesia in the outpatient surgical center. Figure 5 shows the surgical specimen with a localization wire in place. There were no surgical site infections in the 15 patients that underwent the delayed excisional biopsy after the wire-localization. There were no incidences of migration or displacement of the localization wire between the time of the wire placement and the excisional biopsy.
Discussion Results
2
-
All 15 women underwent successful needle-localization biopsy with recovery of the previously placed biopsy clip and/or the mammographic
Clinical Breast Cancer Month 2016
With the advent of screening mammography programs in the United States and in the international community, more women are being seen with mammographic abnormalities that are not palpable
Christine Rodhouse et al Figure 2 Cranial-Caudal (CC) View Left Breast Mammogram After Wire-Localization Showing Core Biopsy Clip at 4:00 Retroareolar
and need to be biopsied. The old method of localization involved bringing the patient first to radiology for the wire placement and then the same day to the operating room where a needle-localized biopsy was performed under general anesthesia. The limitations of this method were that patients had localization wires inserted into their breast for a period of time, and it was difficult for surgeons to schedule early morning starts in the operating room (OR) while they waited for their radiology colleagues to perform the localization. In addition, this procedure used a tremendous amount of medical resources with involvement of a radiologist, surgeons, and an anesthesiologist in a usual hospital OR setting. The first attempt for alternative methods of mammographic lesion localization was reported in 2001 by Gray, Cox, and Reintgen from Moffitt Cancer Center in Tampa, FL.1 Taking advantage of original work performed for sentinel lymph node (SLN) localization with radio-guided surgery, the radio-guided technique involves the placement of a radioactive seed (I131) close to the mammographic abnormality, and with the use of a gamma detector probe (the same probe used in the common lymphatic mapping procedure), radioguided excision of the mammographic abnormality. The I131 seed is placed in radiology through a large-bore needle into the mammographic abnormality or biopsy clip, and the patient is taken
Figure 4 Wire-Localization in the 4:00 Area
to the OR for a radio-guided excisional biopsy. Figure 6 shows the I121 seed placed in an area of a nonpalpable mammographic abnormality. With radio-guided surgery and constant monitoring of the relationship of the biopsy margin and the location of the localization seed with the probe (Figure 7), the investigators showed that clear margins were obtained more frequently with less breast tissue being removed. This was thought to then influence the cosmetic result of the procedure. Figure 8 illustrates with specimen mammography the I121 seed and the mammographic density recovered in the surgical specimen with minimal breast tissue being excised. Disadvantages of the procedure include the fact that radioactivity needed to be handled in radiology, the OR, and the pathology department of the hospital. Mayo Clinic investigators3 have favored radio-guided localization and biopsy owing to the
Figure 5 Specimen With Wire in Place With a Retraction Suture
Figure 3 Taping to Secure Wire-Localization
Clinical Breast Cancer Month 2016
-3
Techniques for Guided Excisional Breast Biopsy Figure 6 An I125 Seed Is Placed to Mark the Mammographic Abnormality With Ultrasound Guidance
ability to monitor the position of the implanted seed and its relationship to the mammographic abnormality during the excision, resulting in a higher clear margin value. This technique is also very similar to the SLN procedure in which most surgeons are trained and comfortable. Other localization techniques have been proposed for the biopsy of nonpalpable lesions that seem to overcome the limitations of the wire-localization procedure. One technique uses a small implantable device placed through a needle via ultrasound or stereotactic guidance. Once implanted, the device is activated by infrared light from a hand piece, and an electromagnetic wave is reflected back to the console. In the OR, a hand piece and console is used with continuous audible feedback as the surgeon performs the dissection. In the feasibility study of the Savi Scout,2 Cox and colleagues retrieved the seed and the targeted lesion in 100% of the cases and subjectively thought the technique offered some advantages over the wire-localization technique. Disadvantages included the fact that, in
Figure 7 With Radio-Guided Surgery and the Use of a Gamma Probe in the Operating Room, the Breast Tissue Around the Localization Seed Is Removed by Continuously Monitoring the Margin’s Relationship to the Radioactive Seed
4
-
Clinical Breast Cancer Month 2016
Figure 8 Specimen Mammography Shows the Mammographic Density and the I125 Localization Seed
12% of the cases, the reflector placed in the breast could not be located by the surgeon prior to skin incision. In 2 other cases, the reflector either malfunctioned or was deactivated by contact with the electrocautery. The surgeons believed that 2-view postlocalization mammograms and preoperative ultrasounds were adequate in planning the breast incisions. One of the inclusion criteria of the study required that the radiofrequency device be placed a maximum of 3 cm deep into the breast parenchyma. Two of the reflectors were placed outside this limit (4.5 cm and 6.0 cm). It would seem that this condition is related to the breast density and the distance between the reflector and probe. Margin status was described in the study; 2 of 41 patients had a positive margin and 6 were within 1 mm. With the ability to monitor the location of the mammographic abnormality continuously with the probe during the excision, the incidence of positive margins should be decreased. Cost may also be a concern. Unlike a wire-localization, incorporation of the Savi Scout requires the purchase of new equipment. New technology has been recently launched in Europe for the localization of nonpalpable breast abnormalities (Magseed) as well as SLNs (SentimagIC) that involves a magnetic technique. The procedure eliminates the need for radioactive tracers and blues dyes typically used with lymphatic mapping and is dark in color, which stains the lymph nodes or abnormal breast area in a similar fashion as the blue dye. The tracer can be injected up to 7 days ahead of the surgery or as little as 20 minutes before knife-to-skin without any diminution in the quality or success of the localization of nonpalpable breast lesions. The technique has been used mostly for SLN biopsy in over 13,000 patients across Europe, and multiple clinical trials have been performed that substantiate the technique. The search for the “Holy Grail” of localization for mammographic abnormalities continues. Jakub3 questions whether surgeons of the future will become experts in intraoperative ultrasound so that localizations will not be necessary. Will nuclear regulations be relaxed so that minimal doses of radioactivity can be handled in the various departments of the hospital with a specific radioactivity license or much oversight? Will nonradioactive magnetic iron oxide particles or nanoparticles4,5 be able to localize both the breast
Christine Rodhouse et al cancer and the draining SLNs, potentially only migrating to the SLN if disease is present? The future is uncertain, but certainly exciting.
Conclusion This report details a new version of an old technique—the wirelocalized excisional biopsy—used under expanded scenarios that include the day-before placement of the localization wire so that surgical schedules are not disrupted by activity in the radiology department. The important modification of leaving the wirelocalization long so that it can be secured throughout its length against the chest wall minimizes the chance of movement or dislodgement and allows placement up to 18 hours prior to the excisional biopsy in this series. Additionally, this report demonstrates that, with proper local anesthesia techniques, the wirelocalized biopsy can be performed in procedure rooms under straight local anesthesia. The technique is advantageous because all surgeons are familiar with this old standard procedure of wirelocalization, and all radioactivity handling is eliminated. In this way, more patients can be accommodated, and costs to the health care system and patient’s out-of-pocket expenses can be kept to a minimum.
Clinical Practice Points More patients will be identified with mammographic abnor-
malities because of the proliferation of breast cancer screening programs.
If the mammographic abnormalities cannot be biopsied with
image-guided core biopsy techniques, localized excisional biopsies may be needed for tissue diagnosis. New technologies including radio-guided surgery or radioefrequencyguided surgery are being introduced to meet the demand for these localization techniques. The wire-localized excisional breast biopsy technique used under expanded scenarios meets the need for a low-cost, outpatient procedure that eliminates the need for handling radioactivity in hospital departments.
Disclosure The authors have stated that they have no conflicts of interest.
References 1. Gray R, Giuliano R, Dauway E, Cox C, Reintgen DS. Seed localization breast biopsy and dual isotope scanning for lymphatic mapping. Paper presented at The Second Annual Meeting of the American Society of Breast Surgeons, May 3-6, 2001; La Jolla, CA. 2. Cox CE, Garcia-Henriquez N, Glancy MJ, et al. Pilot study of a new nonradioactive surgical guidance technology for locating nonpalpable breast lesions. Ann Surg Oncol 2016; 10:1245-7. 3. Jakub JW. The search continues for the ideal method to localize nonpalpable breast lesions. Ann Surg Oncol 2016; 23:1799-800. 4. Douek M, Klaase J, Monypenny I, et al. Sentinel node biopsy using a magnetic tracer versus standard technique: the SentiMAG multicentre trial. Ann Surg Oncol 2014; 21:1237-45. 5. Beitsch P, Hunt K, Bold R, et al. Magnetic nano-device for identification of the breast sentinel nodes - a novel method. Paper presented at the Thirty-eighth Annual San Antonio Breast Cancer Symposium, 2015 (Abstract OT2-02-03), December 8-12, 2015; San Antonio, TX.
Clinical Breast Cancer Month 2016
-5