Intraoperative Ultrasound Localization Research Articles

MELODY: A prospective non-interventional multicenter cohort study to evaluate different imaging-guided methods for localization of malignant breast lesions (EUBREAST-4/iBRA-NET).

TPS623 Background: In the last decades, the proportion of breast cancer patients receiving breast-conserving surgery has increased, reaching 70-80% in developed countries. In case of non-palpable lesions, surgical excision requires some form of breast localization. While wire-guided localization has long been considered gold standard, it carries several limitations, including logistical difficulties, the potential for displacement and patient discomfort, and re-excision rates reaching 21%. Other techniques (radioactive seed or radio-occult lesion localization, intraoperative ultrasound, magnetic, radiofrequency, and radar localization) have been developed with the aim of overcoming these disadvantages. However, comparative data on the rates of successful lesion removal, negative margins, and re-operations are limited. In most studies, the patient perspective, addressing e.g. discomfort and pain, has not been evaluated. The aim of MELODY (Methods for Localization of Different Types of Breast Lesions) is to evaluate different imaging-guided localization methods with regard to oncological safety, patient-reported outcomes, and surgeon and radiologist satisfaction. Methods: The EUBREAST and the iBRA-NET have initiated the MELODY study to assess breast localization techniques and devices from several perspectives (NCT05559411, http://eubreast.org/melody ). MELODY is a prospective intergroup cohort study which enrolls female and male patients. planned for breast-conserving surgery with imaging-guided localization for invasive breast cancer or DCIS. Multiple or bilateral lesions and neoadjuvant chemotherapy are allowed. Primary outcomes are: 1) Intended target lesion and/or marker removal and 2) Negative resection margin rates. Secondary outcomes are, among others: rates of second surgery and secondary mastectomy, Resection Ratio (defined as actual resection volume divided by the calculated optimum specimen volume), duration of surgery, marker dislocation rates, rates of marker placement or localization failure, patient-reported outcomes, rates of “lost markers”, radiologist and surgeon satisfaction, and health economic evaluation of the different techniques. Target accrual: 7,416 patients. The study will be conducted in 30 countries. Clinical trial information: NCT05559411 .

Abstract PO4-18-12: MELODY: A prospective non-interventional multicenter cohort study to evaluate different imaging-guided methods for localization of malignant breast lesions (EUBREAST-4/iBRA-NET, NCT 05559411)

Abstract Background: In the last decades, the proportion of breast cancer patients receiving breast-conserving surgery has increased, reaching 70-80% in developed countries. In case of non-palpable lesions, surgical excision requires some form of breast localization. While wire-guided localization has long been considered gold standard, it carries several limitations, including logistical difficulties, the potential for displacement and patient discomfort, and re-excision rates reaching 21%. Other techniques (radioactive seed or radio-occult lesion localization, intraoperative ultrasound, magnetic, radiofrequency and radar localization) have been developed with the aim of overcoming these disadvantages. However, comparative data on the rates of successful lesion removal, negative margins and re-operations are limited. In the majority of studies, the patient’s perspective with regard to discomfort and pain level has not been evaluated. The aim of MELODY (MEthods for LOcalization of Different types of breast lesions) is to evaluate different imaging-guided localization methods with regard to oncological safety, patient-reported outcomes, and surgeon and radiologist satisfaction. Methods: The EUBREAST and the iBRA-NET have initiated the MELODY study to assess breast localization techniques and devices from several perspectives (NCT05559411, http://melody.eubreast.com). MELODY is a prospective intergroup cohort study which enrolls female and male pts. requiring breast-conserving surgery and imaging-guided localization for invasive breast cancer or DCIS. Multiple or bilateral lesions and neoadjuvant chemotherapy are allowed. Primary outcomes are: 1) Intended target lesion and/or marker removal, independent of margin status on final histopathology, and 2) Negative resection margin rates at first surgery. Secondary outcomes are, among others: rates of second surgery and secondary mastectomy, Resection Ratio (defined as actual resection volume divided by the calculated optimum specimen volume), duration of surgery, marker dislocation rates, rates of marker placement or localization failure, comparison of patient-reported outcomes, rates of “lost markers” and diagnostician/radiologist’s and surgeon’s satisfaction as well as the health economic evaluation of the different techniques. Target accrual: 7,416 patients. Enrollment started in January 2023. The study will be conducted in 30 countries and is supported by the Oncoplastic Breast Consortium (OPBC), AWOgyn, AGO-B and SENATURK. Financial support will be provided by Endomag, Merit Medical, Sirius Medical and Hologic. Citation Format: Maggie Banys-Paluchowski, Thorsten Kühn, Yazan Masannat, Nina Ditsch, Antonio Esgueva, Neslihan Cabıoğlu, Dawid Murawa, Nuh Zafer Canturk, Isabel Rubio, Jana de Boniface, Andreas Karakatsanis, Rajiv Dave, Shelley Potter, Ashutosh Kothari, Oreste Davide Gentilini, Walter Weber, Natalia Krawczyk, Steffi Hartmann, Guldeniz Karadeniz Cakmak, Markus Hahn, Michael P. Lux, Tove Tvedskov, Lina Pankratjevaite, Michalis Kontos, Florentia Peintinger, Aoife Lowery, Marjolein Smidt, Lia Rebaza, Maria Vasconcelos, Bahadir M. Gulluoglu, Bilge Aktas Sezen, Rosa Di Micco, Sarah Nietz, Francois Malherbe, Maria Luisa Gasparri, Séverine Alran, SVS Deo, Mah Muneer Khan, James Harvey. MELODY: A prospective non-interventional multicenter cohort study to evaluate different imaging-guided methods for localization of malignant breast lesions (EUBREAST-4/iBRA-NET, NCT 05559411) [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-18-12.

Evolution of localization methods for non-palpable breast lesions: a literature review from a translational medicine perspective.

With an increasing number of non-palpable breast lesions detected due to improved screening, accurate localization of these lesions for surgery is crucial. This literature review explores the evolution of localization methods for non-palpable breast lesions, highlighting the translational journey from concept to clinical practice. A comprehensive search of PubMed, Embase, and Scopus databases until September 2023 was conducted. Multiple methods have been developed throughout the past few decades. (I) Wire-guided localization (WGL) introduced in 1966, has become a reliable method for localization. Its simplicity and cost-effectiveness are its key advantages, but challenges include logistical constraints, patient discomfort, and potential wire migration. (II) Intraoperative ultrasound localization (IOUS) has shown promise in ensuring complete lesion removal with higher negative margin rates. However, its utility is limited to lesions visible on ultrasound (US) imaging. (III) Breast biopsy marker localization: the use of markers has improved the precision of localization without the need for wire. However, marker visibility remains a challenge despite improvements in their design. (IV) Radioactive techniques: radio-guided occult lesion localization (ROLL) and radioactive seed localization (RSL) offer flexibility in scheduling and improved patient comfort. However, they require close multidisciplinary collaboration and specific equipment due to radioactive concerns. (V) Other wireless non-radioactive techniques: wireless non-radioactive techniques have been developed in recent three decades to provide flexible and patient-friendly alternatives. It includes magnetic seed localization, radar techniques, and radiofrequency techniques. Their usage has been gaining popularity due to their safety profile and allowance of more flexible scheduling. However, their high cost and need for additional training remain a barrier to a wider adoption. The evolution of breast lesion localization methods has progressed to more patient-friendly techniques, each with its unique advantages and limitations. Future research on patient-reported outcomes, cosmetic outcomes, breast biopsy markers and integration of augmented reality with breast lesion localization are needed.

880 Extraction of a Metal Arrow Entering the Skull Base Using a Three-Surgeon Combined Microscopic and Endoscopic Approach

INTRODUCTION: Low velocity penetrating brain injuries (PBI) present both a diagnostic and therapeutic challenge in management particularly in operative planning for the extraction of the impaled foreign body. METHODS: A 3-surgeon combined microscopic-endoscopic approach with the use of intraoperative ultrasound, angiogram, and C-arm localization was done. This involved a 5-part procedure: internal carotid angiography; parieto-occipital vertex craniotomy with ultrasound-guided localization; right transciliary cranio-orbito-zygomatic osteotomy transciliary approach; endoscopic guided advancement and extraction of foreign body and endoscopic endonasal transsphenoidal repair of skull base defect. RESULTS: The rationale for the procedures borders on obtaining information on the relationship of the arrow to the major vessels at the base of the brain, visualization of the arrow’s entry into the skull, guidance on the point of exit as the arrow was pushed upwards towards cortex and extracted it from the surface, and the integrated use of a basal approach for actual visualization of the shaft of the arrow. The patient remained clinically and neurologically stable post-operatively and was discharged after 10 days. He was back to pre-morbid functional status during follow-up at the outpatient two weeks after surgery. CONCLUSIONS: Presented is a successfully managed case of low-velocity PBI. The knowledge of surgical anatomy combined with the different concepts and principles of neurosurgery led to the development of combined techniques that can be used and may further be improved in the management of these injuries.

MELODY (Methods for Localization of Different Types of Breast Lesions): A prospective non-interventional multicenter cohort study to evaluate different imaging-guided methods for localization of malignant breast lesions (EUBREAST-4/iBRA-NET).

TPS626 Background: In the last decades, the proportion of breast cancer patients receiving breast-conserving surgery has increased, reaching 70-80% in developed countries. In case of non-palpable lesions, surgical excision requires some form of breast localization. While wire-guided localization has long been considered gold standard, it carries several limitations, including logistical difficulties, the potential for displacement and patient discomfort, and re-excision rates reaching 21%. Other techniques (radioactive seed or radio-occult lesion localization, intraoperative ultrasound, magnetic, radiofrequency and radar localization) have been developed with the aim of overcoming these disadvantages. However, comparative data on the rates of successful lesion removal, negative margins and re-operations are limited. In the majority of studies, the patient’s perspective with regard to discomfort and pain level has not been evaluated. The aim of MELODY is to evaluate different imaging-guided localization methods with regard to oncological safety, patient-reported outcomes, and surgeon and radiologist satisfaction. Methods: The EUBREAST and the iBRA-NET have initiated the MELODY study to assess breast localization techniques and devices from several perspectives (NCT05559411, http://melody.eubreast.com ). MELODY is a prospective intergroup cohort study which enrolls female and male pts. requiring breast-conserving surgery and imaging-guided localization for invasive breast cancer or DCIS. Multiple or bilateral lesions and neoadjuvant chemotherapy are allowed. Primary outcomes are: 1) Intended target lesion and/or marker removal, independent of margin status on final histopathology, and 2) Negative resection margin rates at first surgery. Secondary outcomes are, among others: rates of second surgery and secondary mastectomy, Resection Ratio (defined as actual resection volume divided by the calculated optimum specimen volume), duration of surgery, marker dislocation rates, rates of marker placement or localization failure, comparison of patient-reported outcomes, rates of “lost markers” and diagnostician/radiologist’s and surgeon’s satisfaction as well as the health economic evaluation of the different techniques. Target accrual: 7,416 patients. Enrollment started in January 2023. The study will be conducted in 20 countries and is supported by the Oncoplastic Breast Consortium (OPBC), AWOgyn, AGO-B and SENATURK. Clinical trial information: NCT05559411 .

Case report of delayed metastasis from thyroid micropapillary carcinoma to the deltoid muscle in a patient with thyroglobulin elevated negative iodine scintigraphy (TENIS)

Differentiated thyroid cancers are common but distant metastasis to the muscles is rare. We present a case of 64-year-old male who underwent thyroidectomy for a suspicious thyroid lesion. His histopathology was reported as widely invasive follicular carcinoma of the thyroid with a focus of micropapillary carcinoma (MPC). He underwent radioiodine ablation. On follow-up, he had a serial increase in thyroglobulin but a whole-body radioiodine scan failed to detect any lesion. An 18-fluorodeoxyglucose positron emission tomography (PET)-computed tomography scan picked up a lesion in the left deltoid muscle. An intraoperative ultrasound localization was done and the nonpalpable lesion was successfully removed surgically. The deltoid lesion was a delayed metastasis of a thyroid MPC. A rising thyroglobulin level in a patient with negative iodine scintigraphy warrants further evaluation with PET since rare distant metastasis may be present. A surgeon performing intraoperative ultrasound is useful in effectively identifying and removing occult lesions with small incisions.

Ultrasound-Based Navigation for Open Liver Surgery with Active Tumor Tracking and Deformation Compensation: Preliminary Results

Introduction: Intraoperative ultrasound (US) localization of lesions after neoadjuvant chemotherapy is challenging because their size may decrease beyond the ultrasound resolution. To improve their localization, we introduce an ultrasound-based electromagnetic (EM) navigation system which maps the preoperative image with the intraoperative ultrasound, thus highlighting their location. Methods: Based on MRI or CT, a 3D model of the liver, lesions, hepatic and portal vein was generated and matched with the intraoperative organ position either by 1) identifying common landmarks between the pre- and intraoperative image or 2) automatically using deformable modeling of hepatic and portal vasculature extracted from 3DUS using deep learning. Accuracy was assessed as Euclidean distance between the lesion imaged in the preoperative image and the one identified in intraoperative 3DUS. Results: From March 2019 to May 2021, 45 navigated procedures were safely performed. Navigation provided additional localization features by overlaying preoperative 3D models of liver lesions, vasculature and biliary anatomy onto the intraoperative ultrasound. Accuracy, calculated in 36 patients, was 8.5 ± 4.2 mm for the landmark method (n=20), and 5.7 ± 3.6 mm for automatic generation of the vasculature (n=16) (p=0.043). Surgical navigation was available on average after 13.4 minutes. Conclusion: The proposed navigation system allows to accurately localize liver lesions and is improved by automatic vasculature detection in the US image and compensation of respiratory motion and liver manipulation.

ASO Visual Abstract: Implementation of Intraoperative Ultrasound Localization for Breast-Conserving Surgery in a Large, Integrated Health Care System is Feasible and Effective

ASO Visual Abstract: Implementation of Intraoperative Ultrasound Localization for Breast-Conserving Surgery in a Large, Integrated Health Care System is Feasible and Effective

Implementation of Intraoperative Ultrasound Localization for Breast-Conserving Surgery in a Large, Integrated Health Care System is Feasible and Effective

BackgroundIntraoperative ultrasound (IUS) localization for breast cancer is a noninvasive localization technique. In 2015, an IUS program for breast-conserving surgery (BCS) was initiated in a large, integrated health care system. This study evaluated the clinical results of IUS implementation.MethodsThe study identified breast cancer patients with BCS from 1 January to 31 October 2015 and from 1 January to 31 October 2019. Clinicopathologic characteristics were collected, and localization types were categorized. Clinical outcomes were analyzed, including localization use, surgeon adoption of IUS, day-of-surgery intervals, and re-excision rates. Multivariate logistic regression analysis was performed to evaluate predictors of re-excision.ResultsThe number of BCS procedures increased 23%, from 1815 procedures in 2015 to 2226 procedures in 2019. The IUS rate increased from 4% of lumpectomies (n = 79) in 2015 to 28% of lumpectomies (n = 632) in 2019 (p < 0.001). Surgeons using IUS increased from 6% (5 of 88 surgeons) in 2015 to 70% (42 of 60 surgeons) in 2019. In 2019, 76% of IUS surgeons performed at least 25% of lumpectomies with IUS. The mean time from admission to incision was shorter with IUS or seed localization than with wire localization (202 min with IUS, 201 with seed localization, 262 with wire localization in 2019; p < 0.001). The IUS re-excision rates were lower than for other localization techniques (13.6%, vs 19.6% for seed localization and 24.7% for wire localization in 2019; p = 0.006), and IUS predicted lower re-excision rates in a multivariable model (odds ratio [OR], 0.59).ConclusionsIn a high-volume integrated health system, IUS was adopted for BCS by a majority of surgeons. The use of IUS decreased the time from admission to incision compared with wire localization, and decreased re-excision rates compared with other localization techniques.

Optimizing surgical stabilization of rib fractures using intraoperative ultrasound localization.

Surgical stabilization of rib fractures (SSRF) significantly improve the outcomes of patients with rib fractures. Ultrasound is a specific modality for localizing rib fractures. We hypothesized that use of perioperative ultrasound localization of fracture sites optimizes surgical approach and clinical outcomes. We performed a retrospective cohort study of adult patients undergoing SSRF and compared those with and without adjunctive perioperative ultrasound fracture localization. Our primary outcome was improved surgical efficiency as measured by incision length and total operative time. Secondary clinical outcomes included numeric pain score on follow-up visit and daily morphine milligram equivalent prescribed within 30 days from discharge. We performed 49 surgical rib fixations between 2015 and 2020; of which, 13 (26.5%) additionally underwent ultrasound localization (26.5%). There were no significant differences between groups in age, sex, number of ribs repaired, or days till surgery. More patients in the ultrasound group had nonflail chest wall injury (76.9% vs. 27.8%, p = 0.003). Use of perioperative ultrasound was associated with shorter incision length (median, 9 vs. 15.5 cm; p = 0.0001), shorter operative time (median, 120 vs. 174 minutes; p = 0.003), less daily morphine milligram equivalent (25 vs. 68 mg, p = 0.009), and reduced numeric pain score on follow up (median, 4 vs. 7, p = 0.05). Use of perioperative ultrasound localization of rib fractures to optimize surgical approach for SSRF was associated with reduced incision length, operative time, and opioid requirements on patient discharge. We recommend considering routine perioperative localization to improve surgical approach and efficiency during SSRF. Therapeutic, level IV.

Combined LOCalizer™ and Intraoperative Ultrasound Localization: First Experience in Localization of Non-palpable Breast Cancer.

Wire-guided localization is the gold-standard for the detection of non-palpable breast lesions, although with acknowledged limitations. The aim of this study was to evaluate the combined use of LOCalizerr™ (Hologic, Santa Carla, CA, USA), and intraoperative ultrasound (IOUS) for localization and surgery of non-palpable breast cancer. Patients with non-palpable breast lesions underwent localization procedure with LOCalizer™ and IOUS. After the placement of the marker, eight measures were made to guide the excision. LOCalizerr™ Pencil and IOUS were performed to obtain the distance between the dissection plane and the margins of lesions. The procedure was feasible in the five enrolled patients and associated with clear oncological margins in all cases. Moreover, a high satisfaction according to Likert scale for surgeons, radiologists and patients, performing limited and tailored resections, was reported. Combining LOCalizerr™ and IOUS is an effective method for locating non-palpable breast cancer, guarantying excellent oncological and cosmetic results.

Retroperitoneal laparoscopic hepatectomy of recurrent hepatocellular carcinoma: case report and literature review

BackgroundAlmost all liver tumours can be removed laparoscopically, but some difficult tumour locations complicate laparoscopic surgery. Recurrent liver tumours often pose great difficulties to laparoscopic surgery due to adhesions caused by previous operations. Referring to laparoscopic adrenalectomy, a retroperitoneal approach is proposed to remove liver tumours near the adrenal gland, which will provide a new method for liver surgery.Case presentationOur case involves a patient with recurrent hepatocellular carcinoma (HCC) whose last operation was laparoscopic hepatectomy in our department, with a recurrence of HCC 2 years after the first surgery. In this case, based on preoperative CT and MRI, through a retroperitoneal approach, combined with intraoperative ultrasound (IOUS) localization and indocyanine green (ICG) fluorescence navigation, laparoscopic hepatectomy was successfully performed to precisely resect recurrent hepatocellular carcinoma in segment VII. The patient was discharged on the third day after the operation. The AFP decreased to normal levels on the 28th postoperative day.ConclusionsRetroperitoneal hepatectomy has the advantages of less trauma, shorter operation times, fewer complications and faster recovery for hepatic tumours near the adrenal gland. Accurate localization of tumours is needed to ensure accurate resection; therefore, IOUS and ICG fluorescence are very important. Liver parenchyma was severed strictly according to fluorescent labelling during hepatectomy, which prevented the deviation of liver parenchyma from the plane and ensured that the margin of hepatectomy was tumour-free. In order to ensure a radical resection of the tumour, it may be necessary to enter the abdominal cavity.

Abstract P1-20-20: Intraoperative ultrasound localization (IOUS) for non-palpable breast cancer

Abstract Background: With the introduction of breast cancer screening the number of non-palpable breast cancers and so the number of breast conserving surgery (BCS) has increased. Wire-guided localization (WGL) is used as invasive standard method for localization. IOUS is an alternative non-invasive, time-sparing and safe localization method with many cost benefits. Patient and methods: A retrospective observational study was performed in a single breast unit where IOUS was used as localization method by two surgeons in the period June 2013 to October2016. The surgeons did not have any special experience with Ultrasound (US) apart from one week of bed-side training. Results: During a 41 months period the two surgeons treated 452 with BCS. Of them 126 were non-palpable and visible by US 28%. The 126 cancers were identified with IOUS at surgery and removed successfully by the surgeons. In the period a total of 156 had a BCS with WGL. These cases had a nonpalpable cancer which were non-visible on US with either calcifications, DCIS or non-specific lesions. In the study we also found that the re-lumpectomy rate for BCS with IOUS was lower than without IOUS. In the entire breast unit, the number of BCS were 848 and number of BCS+WGL were 320 in the same period. Of them 263 (22.5%) had a re-lumpectomy. The number BCS with IOUS were 452 and the number of BCS+WGL with IOUS were 156. Of them 72 (11.8%) had a re-lumpectomy. Conclusion: In our breast unit, IOUS was used after a short bed-side training, with 100% success rate, to remove non-palpable cancers if visible on US. IOUS is easy to learn and easy to use and offers many financial and time-sparing benefits. IOUS has a reasonable learning curve and can reduce the work load on the Radiology Department. Citation Format: Shideh Pour Zahed, Thor Knudsen Andersen. Intraoperative ultrasound localization (IOUS) for non-palpable breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-20.

Intraoperative ultrasound in neurosurgical procedures

Introduction: The objective of the present study was to study the utility and the effectiveness of intraoperative ultrasound in neurosurgical procedures and to assess the outcome. Material and Methods: In this prospective study, operative procedures by a single surgeon under intraoperative ultrasound localization for basal ganglia/thalamic haematoma or traumatic brain contusions or brain tumours were included. Ultrasound scanning of the brain was performed before and after the excision of the lesion and during the procedure to verify the extent of removal of the lesion. Results: 74 patients underwent surgery for brain tumor/basal ganglia bleed/head injury with hemorrhagic contusion with the help of intraoperative ultrasound. Gross tumor resection was noted in 25 out of 36 cases of brain tumors (69.44%), complete evacuation of hematoma was noted in 14 out of 34 cases(41.2%) of basal ganglia bleed and in 2 out of 4 cases (50%) of intracerebral contusion. As per Modified Rankin scale (MRS)score, among the brain tumor cases, all patients had fared well in recovery and had better MRS scores except in one patient who expired during postoperative period. Conclusions: IoUS is a widely accessible, cheap, portable and less space occupying and reliable imaging tool to follow and modify the surgical plan in real time, and is more accurate and helpful in complete tumor resection, evacuation of intracerebral bleeds and contusions, and biopsy of deep seated lesions. It is easy and safe to handle with no risk of radiation.

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

BackgroundThe uptake of breast screening has led to a rise in the number of nonpalpable breast cancer diagnoses. Breast conserving therapy (BCT) is the treatment of choice for early breast cancer, and this requires localization of the lesion. Commonly detection is achieved by wire-guided localization in the radiology department. This technique has complications and requires utilization of a radiologist. Intraoperative ultrasound (IOUS) has been shown to be a safe alternative, but there is little data on its use. The aim of this study is to report the use of surgeon-led IOUS over the past 5 years, assessing the ability to detect lesions and the re-excision rate for involved margins. Patients and MethodsA retrospective observational study was performed on consecutive patients undergoing IOUS-marked BCT between 2014 and 2018. The technique is described, and patients’ records were reviewed to assess the histologic specimen reports and need for subsequent re-excision. ResultsNinety-five IOUS BCT operations were performed. Every cancer was identified by IOUS and removed. Fourteen margins were positive and required re-excision. Of these, only 2 contained residual tumor. ConclusionThis is the first data from the United Kingdom for IOUS skin marking without wire localization. IOUS is a safe method of localization in BCT. It offers advantages both to the patient and the unit as it reduces pressure on the radiology department.

Value of intra-operative ultrasound in localization of palpable or non-palpable breast tumors during breast conserving surgery

PurposeOur study was designed to assess the role of intra-operative ultrasound (IOUS) as a method of localization of palpable or non-palpable breast tumors during breast conserving surgery (BCS) and ensuring adequate margins by comparing pathological results of these lesions to be sure if the IOUS localization is effective as a localization tool or not. We included both palpable and non-palpable to add a great effect to the BCS to ensure adequate margins that are not accurately palpated by the surgeon. IntroductionBreast conserving surgery (BCS) is an alternative to mastectomy in treatment of cancer breast. The matter of tumor localization is a problematic issue with the wire localization being the commonest with multiple drawbacks. Another method for localization which is the IOUS is investigated. Patients and methodsThis prospective, controlled study enrolled 60 female patients. 30 of them comprised case group (group I) had breast conserving surgeries guided by IOUS and the other 30 patients as a control (group II) who had breast conserving surgeries without any guidance. Specimens Pathological examination was done to ensure the adequacy of free margins. Results6 patients from the case group and 14 of the control group had involved inadequate margins. ConclusionIOUS is an essential adjunct to surgery that should be experienced to maintain safety and cosmoses as the two major impacts of BCS.

Abstract P2-12-04: Surgeon performed intraoperative ultrasound accurately predicts margin status after neaoadjuvant chemotheraphy

Abstract Objective: Neoadjuvant chemotraphy (NACT) is the preferred option of treatment in locally advanced and select cases of early stage breast cancer, currently. One of the major aims is to downstage tumor status allowing more conservative surgery with the most acceptable cosmetic outcome. The presence or absence of residual invasive cancer after NACT, is one of the strong prognostic factors for risk of recurrence and the margin status is the other. Due to the excess degree of fibrosis after tumor shrinkage, to accurately predict margin status intraoperatively after NACT is a challenge for surgeon. The aim of the presented study is to evaluate the efficacy of continuous intraoperative ultrasound guided breast conserving surgery (IUG-BCS) in terms of margin status and re-excision rate. The relationship between intraoperative assessment of gross macroscopic and ultrasonographic margins and cavity shavings results, were also analyzed. Methods: Between 2014 and 2017, IUG-BCS were performed to 194 patients after NACT. Surgeon performed continuous peroperative real-time sonographic margin assessment during resection, macroscopic evaluation, specimen US including sonographic analysis of six faces of each specimen, and shaved cavity margins for permanent pathologic assessment were the standard steps of our methodology. Results: Of the 194 patients, 82 (42.5%) had pathologic complete response (pCR) after NAC. The sensitivity of intraoperative ultrasound localization was 100% (194/194 cases). Patients were on average 53 years old (range, 28-65). There was no difference with respect to patient characteristics including age, menopausal status, personal-family history, oral contraceptive usage, body mass index and tumor localization. Mean tumor size was 5.42 cm before NAC and 2.56 cm after NAC, for those excluding ypT0. Of the 112 patients without pCR, tumor free margins were obtained by means of IUG-BCS in 99% (665/672) of margins evaluated sonographically. Moreover, the involved margins were correctly identified by the surgeon via specimen sonography in %71.4 of the cases (5/7) which was confirmed by cavity shaving results. No frozen section analysis was performed and macroscopic evaluation of the specimen predicted nothing significant. According to permanent section analysis of the resected specimens and cavity shavings, no further intervention was required due to margin positivity. IUG-BCS with real-time specimen sonography were unable to predict involved margins in only two cases, both of them proved to be invasive lobular carcinoma without evidence of residual cancer on pathological examination of cavity shavings. Accordingly, negative margins were achieved in 100% of cases at the initial procedure verified by permanent analysis. Conclusion: Continuous intraoperative ultrasound with specimen sonography is an invaluable and effective modality to achieve negative surgical margins after NACT. Furthermore, meticulous sonographic assessment of specimen margins together with cavity shavings from tumor bed could be a feasible method to decrease re-excision rates without frozen section analysis leading to cost-effectiveness. However, the accuracy of sonography should be questioned in case of lobular histology. Citation Format: Karadeniz Cakmak G, Mutlu S, Sen H, Engin H, Bahadir B, Bakkal H. Surgeon performed intraoperative ultrasound accurately predicts margin status after neaoadjuvant chemotheraphy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-04.

Clinical efficacy of precise liver resection of liver tumors adjacent to the main pipeline

Objective To investigate the clinical efficacy of precise liver resection of liver tumors adjacent to the main pipeline. Methods The retrospective and descriptive study was conducted. The clinical data of 22 patients who underwent precise resection of liver tumors adjacent to the main pipeline in the Affiliated Tumor Hospital of Zhengzhou University between December 2014 and June 2016 were collected. According to preoperative precise evaluation and fully intraoperative exposed tumors, different methods of blood flow occlusion were choosed timely, and then precise resection of the liver was evaluated based on tumor location and size, relationship between tumor and blood vessels and the degree of liver cirrhosis. The operation procedures, operation time, time of liver resection, volume of intraoperative blood loss, number of patients with perioperative blood transfusion, postoperative complications, duration of postoperative hospital stay and follow-up were observed. The follow-up was performed by outpatient examination and telephone interview up to September 2016. Tumor recurrence of patients with hepatocellular carcinoma (HCC) was monthly detected by alpha-fetoprotein retest and color Doppler ultrasound of the liver or computed tomography (CT) within 3 months postoperatively. Tumor recurrence of patients with cholangiocarcinoma was monthly detected by tumor marker retests, color Doppler ultrasound of the liver or CT, and then patients without tumor recurrence received reexamination once every 2 months after 3 months. Patients with liver hemangioma were followed up once every 2-3 months and once every 6 months after half a year, and follow-up included the liver function, ultrasound and other imaging examinations to detect the tumor recurrence. Measurement data with normal distribution were represented as ±s. Results All the 22 patients underwent successful precise resection of liver tumors. Twenty patients received intraoperative ultrasound localization. Blood flow occlusion of 22 patients: Pringle was conducted in 6 patients, treatment of the corresponding hepatic pedicle in 3 patients, selective hepatic blood flow occlusion in 8 patients, total hepatic blood flow occlusion in 2 patients and non-hepatic portal occlusion in 3 patients. Precise resection of the liver of 22 patients: 1 patient underwent right trisegmentectomy, 2 underwent left hepatectomy, 2 underwent segment Ⅳa resection of the liver, 2 underwent segment Ⅳ resection of the liver, 3 underwent segment Ⅴ resection of the liver, 3 underwent segment Ⅷ resection of the liver, 1 underwent middle lobe resection of the liver and 8 underwent partial resection of the liver. Operation time, time of liver resection, volume of intraoperative blood loss and number of patients with perioperative blood transfusion were (213±39)minutes, (57±19)minutes, (518±98)mL and 3, respectively. Of 22 patients, 5 with postoperative complications were improved after symptomatic treatment, including 2 with effusion at surgical site, 2 with right pleural effusion and 1 with bile leakage. The duration of postoperative hospital stay of 22 patients was (8.9±1.6)days. Twenty-one patients were followed up for 3-20 months, with a median time of 12 months. Two of 22 patients had recurrence during the follow-up, and no recurrence at surgical site was detected. Conclusion Precise resection of liver tumors adjacent to the first and second hepatic hilum is safe and feasible, with the advantages of less intraoperative bleeding and low incidence of postoperative complications. Key words: Liver neoplasms; Precise hepatic surgery; Hepatectomy; Special location

Ultrasound-Guided Segmental Mastectomy and Excisional Biopsy Using Hydrogel-Encapsulated Clip Localization as an Alternative to Wire Localization.

Wire localization is currently the most widely used localization strategy for excision of nonpalpable breast lesions. Its disadvantages include patient discomfort, wire-related complications such as wire displacement/fracture, and operating room delays related to difficulties during wire placement. We have implemented the technique of intraoperative ultrasound-guided excision using hydrogel-encapsulated (HydroMARK) biopsy clips for lesion localization. We hypothesize that this method is as effective as wire localization for breast conserving therapy. This is a retrospective review of 220 consecutive patients who underwent segmental mastectomy or excisional biopsy using wire localization or hydrogel-encapsulated clip localization from January 2014 to July 2015. Data were collected and analyzed. Statistical analyses for differences between groups were performed using t tests and Mann-Whitney rank-sum analyses. A total of 107 excisions were performed using hydrogel-encapsulated clip localization, and 113 excisions were performed using the traditional wire localization technique; 68% of our patients underwent excision for malignant pathology. Wire placement took a mean of 46 minutes (range 20-180 min), compared with 5 minutes for ultrasound localization (p< .001). Successful intraoperative ultrasound localization and excision was performed on 100% of patients. There was no difference in re-excision rates for positive margins or overall specimen size between the two groups. Intraoperative ultrasound-guided excision of nonpalpable breast lesions using a hydrogel-encapsulated biopsy clip for breast conserving therapy is a safe and feasible alternative to the traditional preoperative wire localized excision. This technique will lead to improvement in patient experience, operative efficiency, and alleviate wire-related complications.

Intraoperative ultrasound control of surgical margins during partial nephrectomy.

Aims:To evaluate a simple and fast technique to ensure negative surgical margins on partial nephrectomies, while correlating margin statuses with the final pathology report.Subjects and Methods:This study was conducted for patients undergoing partial nephrectomy (PN) with T1–T2 renal tumors from January 2010 to the end of December 2015. Before tumor removal, intraoperative ultrasound (US) localization was performed. After tumor removal and before performing hemostasis of the kidney, the specimens were placed in a saline solution and a US was performed to evaluate if the tumor's capsule were intact, and then compared to the final pathology results.Results:In 177 PN(s) (147 open procedures and 30 laparoscopic procedures) were performed on 147 patients. Arterial clamping was done for 32 patients and the mean warm ischemia time was 19 ± 6 min. The mean US examination time was 41 ± 7 s. The US analysis of surgical margins was negative in 172 cases, positive in four, and in only one case it was not possible to conclude. The final pathology results revealed one false positive surgical margin and one false negative surgical margin, while all other margins were in concert with US results. The mean tumor size was 3.53 ± 1.43 cm, and the mean surgical margin was 2.8 ± 1.5 mm.Conclusions:The intraoperative US control of resection margins in PN is a simple, efficient, and effective method for ensuring negative surgical margins with a small increase in warm ischemia time and can be conducted by the operating urologist.