Preoperative Localization Procedures Research Articles

Use of the lateral arm in tomosynthesis-guided SCOUT Reflector placement procedures

Preoperative localization procedures are important for guiding surgical excision of non-palpable findings in the breast. The SCOUT Reflector (Merit Medical, South Jordan UT, USA) is a non-wire-based localization device that has been incorporated into clinical use with great success. SCOUT Reflectors can be placed using several imaging modalities, including tomosynthesis. One drawback to SCOUT Reflector placement under tomosynthesis guidance is an inability to directly visualize the introducer needle tip, a factor that limits precision. In this brief communication, we describe the use of a lateral arm attachment for tomosynthesis guided SCOUT Reflector placement. Precise SCOUT Reflector placement can be achieved using the lateral arm due to the ability to clearly visualize the introducer needle and the SCOUT Reflector within the introducer needle bore prior to deployment.

Accuracy, costs and radiation exposure of current preoperative localization procedures in patients with primary hyperparathyroidism, a retrospective cohort study in a Swiss tertiary referral center

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Semillas radiactivas y no radiactivas como método de localización quirúrgica de las lesiones mamarias no palpables

The increasingly early diagnosis of breast disease and the more widespread use of primary systemic therapy leads to an increasing number of surgeries for non-palpable breast lesions (NPL) in clinical practice.Breast-conserving surgery often requires the use of an image-guided preoperative localization procedure, in which a device is placed within the lesion to be removed to guide the surgeon during surgery. These are patients with small, non-palpable tumors detected in the population screening mammogram, cases with significant reduction of the lesion after neoadjuvant chemotherapy and sometimes it is even necessary to mark axillary lymphadenopathies prior to systemic treatment.For decades, wire localization has been the standard for preoperative marking in breast cancer. Due to the external component of this device, extreme care must be taken not to alter its position before surgery, which is why it is placed hours before surgery and entails complex and limited flexibility in surgical programming.Intraoperative ultrasound improves this drawback but has the limitation that it can only be performed in those NPLs that have ultrasound translation. The Radioguided Occult Lesion Localization (ROLL) technique, although it is another alternative adopted by many institutions, is not without complications, among which the possibility of diffusion of the radiotracer into healthy tissue stands out.To overcome these problems, more recently, 125I radioactive seeds began to be used. Subsequently, thanks to technological advances, non-radioactive seed alternatives such as radar reflectors, magnetic seeds and radio frequency markers have emerged. These locating devices can be placed days before surgery, avoiding wire-related problems and complications. They are introduced percutaneously and identified intraoperatively using a detector device.There is no perfect intraoperative localization method for NPL excision, but fortunately, we have multiple techniques with different advantages and disadvantages that must be assessed and adapted to the center's own resources, the type of surgery, and always to the benefit of the patient.

Radioactive and non-radioactive seeds as surgical localization method of non-palpable breast lesions

The increasingly early diagnosis of breast disease and the more widespread use of primary systemic therapy leads to an increasing number of surgeries for non-palpable breast lesions (NPL) in clinical practice.Breast-conserving surgery often requires the use of an image-guided preoperative localization procedure, in which a device is placed within the lesion to be removed to guide the surgeon during surgery. These are patients with small, non-palpable tumors detected in the population screening mammogram, cases with significant reduction of the lesion after neoadjuvant chemotherapy and sometimes it is even necessary to mark axillary lymphadenopathies prior to systemic treatment.For decades, wire localization has been the standard for preoperative marking in breast cancer. Due to the external component of this device, extreme care must be taken not to alter its position before surgery, which is why it is placed hours before surgery and entails complex and limited flexibility in surgical programming.Intraoperative ultrasound improves this drawback but has the limitation that it can only be performed in those NPLs that have ultrasound translation. The Radioguided Occult Lesion Localization (ROLL) technique, although it is another alternative adopted by many institutions, is not without complications, among which the possibility of diffusion of the radiotracer into healthy tissue stands out.To overcome these problems, more recently, 125I radioactive seeds began to be used. Subsequently, thanks to technological advances, non-radioactive seed alternatives such as radar reflectors, magnetic seeds and radio frequency markers have emerged. These locating devices can be placed days before surgery, avoiding wire-related problems and complications. They are introduced percutaneously and identified intraoperatively using a detector device.There is no perfect intraoperative localization method for NPL excision, but fortunately, we have multiple techniques with different advantages and disadvantages that must be assessed and adapted to the center's own resources, the type of surgery, and always to the benefit of the patient.

Targeted Near-Infrared Fluorescence Imaging With Iodized Indocyanine Green in Preoperative Pulmonary Localization: Comparative Efficacy, Safety, Patient Perception With Hook-Wire Localization

BackgroundPrecise preoperative localization is of great importance to improve the success rate and reduce the operation time of VATS surgery. This study aimed to assess the efficacy, safety, patient perception between CT-guided indocyanine green (ICG) preoperative localization of lung nodule and hook-wire localization.Methods65 patients with 85 clinically suspicious pulmonary nodules underwent ICG preoperative localization in this study, and 92 patients with 95 nodules localized by conventional hook-wire served as controls. Both hook-wire localization and ICG injection were performed under CT guidance. Successful targeting rate, success rate in the operative field, incidence rate of complications and respiratory pain score were recorded and compared.ResultsThe successful targeting rate for both groups is 100%, however, due to hook-wire dislodgement, the success rate in the VATS operation field of the hook-wire group (95.6%) is lower than that of the ICG group (100%), with no significant difference(p=0.056). The overall complication rate of the hook-wire group (37.0%) is significantly higher than the ICG group (35.4%) (p=0.038). The mean respiratory pain score of the hook-wire group is 3.70 ± 1.25, which is significantly higher than that of the ICG group (2.85 ± 1.05) (p<0.001).ConclusionsICG composed with contrast mixture are superior to the conventional hook-wire preoperative lung nodule localization procedure, with a lower complication rate, lower pain score, and relatively higher success rate. ICG is a promising alternative method for pulmonary nodule preoperative localization.

Impact of Electronic Procedural Protocoling on the Timeliness of Pre-operative Breast Localization Procedures

ObjectiveTo evaluate the impact of a new electronic procedural protocol on start times of pre-operative breast localization procedures. MethodsThis HIPAA-compliant, Institutional Review Board-exempted, quality improvement initiative was performed at a large tertiary academic center. In May 2018, an electronic version of the pre-procedure protocol for breast localizations was created within the electronic health record; prior to this time, the protocol was completed manually on a paper form. Mean time between: (1) appointment time and procedure start time, (2) procedure begin-to-end time, and (3) arrival to appointment time were compared for all female patients undergoing pre-operative breast localization procedures during 4-month periods pre-implementation of the electronic procedural protocol (January-April 2018), and post-implementation (June-September 2018), excluding the May 2018 implementation month. Statistical analysis was done by two tailed t-test and statistical process control charting. ResultsPre-implementation, 427 procedures were performed, and post-implementation 409 procedures were performed. Three pre-implementation cases performed more than 3 hours prior to appointment time were excluded (presumed to be rescheduled cases). Mean time between appointment time and procedure start time decreased from 2.7 minutes after to 5.6 minutes before appointment start time, an 8.3-minute improvement (P = 0.0001), with sustained improvement by statistical process control analysis. Mean time for procedure length increased by 4.7 minutes (P = 0.001). There was no significant difference in mean time of patient arrival to appointment time pre- and post-implementation. ConclusionImplementation of an electronic protocol process for pre-operative breast localizations was associated with a significant and sustained reduction in time between appointment time and procedure start time.

Modified Microcoil for Preoperative Localization of Solitary Pulmonary Nodules: A Prospective, Single-Arm, Multicenter Clinical Study

PurposeTo evaluate the efficacy and safety of placement of a modified microcoil for precise preoperative localization of solitary pulmonary nodules (SPNs) before video-assisted thoracoscopic surgery (VATS). Materials and MethodsThis prospective, single-arm, multicenter study included patients who underwent computed tomography (CT)-guided modified microcoil insertion prior to SPN resection by VATS between January 2018 and June 2018. The patient demographics, nodule characteristics, and histopathologic findings were recorded. The primary endpoints included efficacy and safety. ResultsA total of 96 patients (41 men and 55 women; mean age, 59.3 years ± 8.9) with 96 SPNs were eligible for enrolment in the study. The mean maximal transverse diameter of the nodules was 10.3 mm ± 5.2 (range, 8–20 mm). The mean time between CT-guided microcoil insertion and the start of the surgical procedure was 14.6 hours (range, 12–24 hours). The duration of the preoperative CT-guided microcoil localization procedure was 29 minutes ± 9 (range, 10–35 minutes), and the intraoperative fluoroscopy time was 0.7 minutes ± 0.7 (range, 0.5–3 minutes). The clinical success rate was 96.9% (93/96), and all nodules were successfully resected using VATS. One patient experienced asymptomatic pneumothorax, but there were no cases of pulmonary hemorrhage. ConclusionsSPN localization with the modified microcoil is feasible and safe. The modified microcoil can facilitate the thoracoscopic resection of SPNs.

Management of primary and renal hyperparathyroidism: guidelines from the German Association of Endocrine Surgeons (CAEK)

The purpose of this review is to provide updated recommendations for the surgical management of primary (pHPT) and renal (rHPT) hyperparathyroidism, formulating a new guideline of the German Association of Endocrine Surgeons (CAEK). Evidence-based recommendations for the diagnosis and therapy of pHPT and rHPT were assessed by a multidisciplinary panel using PubMed for a comprehensive literature search together with a structured consensus dialogue (S2k guideline of the Association of the German Scientific Medical Societies, AWMF). During the last 20 years, a variety of new preoperative localization procedures, such as sestamibi-SPECT, 4D-CT, and various PET/CT procedures, were established for pHPT. High-resolution imaging, together with intraoperative parathyroid hormone (IOPTH) measurement, enabled focused or minimally invasive surgery to become the most favored surgical technique. Patients with pHPT and nonlocalizing imaging have a higher risk of multiglandular disease. Surgical therapy provides very high cure rates, with a clear relation to the surgeon's experience in parathyroid procedures. Reoperative parathyroidectomy, children with pHPT or familial forms, and parathyroid carcinoma are addressed and require special surgical expertise. A multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons should assess the diagnosis and treatment of renal HPT. Surgery is the only curative treatment for pHPT and should be considered for all patients with pHPT. For rHPT, a more selective approach is required, and parathyroidectomy is indicated only when conservative treatment options fail. In parathyroid carcinoma, the adequacy of local resection influences local disease control.

European multicentre study on outcome of surgery for sporadic primary hyperparathyroidism.

International multicentre outcome studies of surgery for primary hyperparathyroidism (pHPT), especially for rate of conversion to bilateral neck surgery and persistent hypercalcaemia, are scarce. Eurocrine® is a European database for endocrine surgery. Data are entered according to predefined data fields. Outcomes for patients who underwent first surgery for sporadic pHPT were analysed. Multivariable analysis was performed to identify risk factors for adverse outcome using Cox regression with constant follow-up. A total of 5861 patients were registered between 2015 and 2018. Preoperative localization procedures were used in most patients, with moderate sensitivity. Intraoperative parathyroid hormone (ioPTH) measurement was used in three-quarters of patients. Bilateral surgery was performed in 1574 patients (26·9 per cent). Among 4683 patients (79·7 per cent) for whom unilateral or focused operation was planned, the procedure was converted to bilateral surgery in 396 (8·5 per cent). The risk of conversion decreased with the use of ioPTH monitoring (relative risk (RR) 0·77). Persistent hypercalcaemia was registered in 253 patients (4·3 per cent), and was less likely with the use of two (RR 0·55) or three (RR 0·44) localization procedures. In patients with a concordant localized single lesion, the rate of persistent hypercalcaemia was 2·5 per cent. The risk of persistent hypercalcaemia decreased with the use of ioPTH measurement, but was increased in patients with negative localization procedures and conversion to bilateral surgery. The use of ioPTH measurement decreased the risk of conversion and persistent hypercalcaemia. The use of two or three localization procedures decreased the risk of persistent hypercalcaemia; in patients with a concordant single lesion, the risk of persistent hypercalcaemia was low.

A Patient-Specific Mixed-Reality Visualization Tool for Thoracic Surgical Planning

Identifying small lung lesions during minimally invasive thoracic surgery can be challenging. We describe 3-dimensional mixed-reality visualization technology that may facilitate noninvasive nodule localization. A software application and medical image processing pipeline were developed for the Microsoft HoloLens to incorporate patient-specific data and provide a mixed-reality tool to explore and manipulate chest anatomy with a custom-designed user interface featuring gesture and voice recognition. A needs assessment between engineering and clinical disciplines identified the potential utility of mixed-reality technology in facilitating safe and effective resection of small lung nodules. Through an iterative process, we developed a prototype employing a wearable headset that allows the user to (1) view a patient's original preoperative imaging; (2) manipulate a 3-dimensional rendering of that patient's chest anatomy including the bronchial, osseus, and vascular structures; and (3) simulate lung deflation and surgical instrument placement. Mixed-reality visualization during surgical planning may facilitate accurate and rapid identification of small lung lesions during minimally invasive surgeries and reduce the need for additional invasive preoperative localization procedures.

Abstract OT3-01-01: Feasibility of carbon tattooing for targeted lymph node biopsy in breast cancer patients treated by primary systemic therapy (TATTOO trial)

Abstract Background: Selective removal of initially suspicious axillary lymph nodes in breast cancer patients downstaged by primary systemic therapy (PST) improves the accuracy of surgical staging and provides the opportunity for less extensive axillary surgery. Different techniques for this targeted lymph node biopsy (TLNB) have been evaluated. These are either prohibited for radiation safety reasons (radioactive seeds) in some countries, or revealed low identification rates for the target lymph node (TLN) in prospective feasibility trials (wire localization of clip-marked TLN). Therefore, an alternative TLN marking procedure avoiding radiation exposure, specialized intraoperative equipment, high costs and preoperative localization procedures is urgently needed. Tattooing TLNs with highly purified carbon suspension prior to PST and identifying the TLN intraoperatively by visual examination, is a method combining low costs with high patient comfort. Because of the data scarcity on the feasibility of TLNB by carbon tattooing, the TATTOO trial was initiated. Trial design: The Tattoo trial is a single-arm, multicentric, prospective feasibility trial. Before initiation of PST, ultrasound-guided fine needle aspiration or core needle biopsy of the most suspicious ipsilateral axillary lymph node (TLN) is performed and a highly purified carbon suspension then injected into the cortex of the sampled lymph node and the adjacent soft tissue. After completion of PST, TLNB and axillary lymph node dissection Level I/II is performed in all patients. In those with clinical and sonographical axillary down-staging, sentinel lymph node (SLN) biopsy is additionally performed. Eligibility criteria: Prior to tattooing, written informed consent is obtained. Female patients aged at least 18 years, with histologically confirmed invasive uni- or bilateral breast cancer with clinically or sonographically suspicious axillary lymph nodes and planned PST without signs of distant metastases are eligible. Specific aims: The primary outcome of the trial is the intraoperative identification rate (IR) of the carbon-labeled TLN after PST. Secondary outcomes are the concordance rate (CR) of sentinel lymph nodes (SLN) and TLN, the false negative rate (FNR) of targeted axillary dissection (TAD, i.e. SLNB biopsy + TLNB) and complications associated with the procedure. Statistical methods: IR is defined as the proportion of patients with intraoperatively visually detectable TLNs of all patients. CR is expressed as the proportion of patients in whom TLNB and SLN biopsy reveal the same lymph nodes. The proportion of patients with negative TLN and/or SLN but with metastatic axillary lymph nodes on ALND out of all patients with positive lymph nodes will be reported as FNR. Complications associated with tattooing (i.e. bleeding, pain, adverse tattoo effects) are reported. Statistical analyses will be carried out using IBM SPSS statistics version 25. Present and target accrual: Patient accrual was initiated in November 2017. Until now, 84 patients have been included by three sites in Germany and Sweden. The target enrollment of 100 patients is estimated to be reached by August 2019 and the final trial report is planned for 2020. Contact information Steffi Hartmann, MD (steffi.hartmann@kliniksued-rostock.de) Citation Format: Steffi Hartmann, Angrit Stachs, Thorsten Kühn, Antje Winckelmann, Jana de Boniface, Bernd Gerber, Toralf Reimer. Feasibility of carbon tattooing for targeted lymph node biopsy in breast cancer patients treated by primary systemic therapy (TATTOO trial) [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 OT3-01-01.

Hook-wire localization versus lipiodol localization for patients with pulmonary lesions having ground-glass opacity

ObjectivesAccurate and safe preoperative localization is useful for video-assisted thoracic surgery of small pulmonary lesions with ground-glass opacity (GGO). However, the optimal localization method is unclear. The aim of this study was to compare the usefulness and safety of the lipiodol and hook-wire localization techniques for video-assisted thoracic surgery of GGO lesions. MethodsThis prospective, non-randomized comparative study was conducted between April 2014 and December 2016 at 8 qualifying university teaching hospitals. Two-hundred-fifty patients with pulmonary lesions having GGO were included. Patients were assigned in a 1:1 ratio to either the lipiodol (n = 125, 4 hospitals) or hook-wire group (n = 125, 4 hospitals) for preoperative localization procedures. Participants underwent preoperative localization via the lipiodol or hook-wire technique followed by thoracoscopic surgery. The primary endpoint was the procedure success rate. ResultsThe procedure success rates (hook-wire vs lipiodol group) were 94.40% versus 99.16% (P = .08). Localization-related complications occurred in 53.60% versus 48.33% of patients (P = .49). Hemorrhage rates were significantly greater in the hook-wire group than in the lipiodol group (21.6% vs 5.83%, P < .001). The lipiodol procedure time was significantly longer than that of the hook-wire technique (20.69 ± 9.34 vs 17.15 ± 7.91 minutes, P = .001). The initially positive surgical resection margin was significantly greater in the hook-wire group than in the lipiodol group (10.89% vs 2.38%, P = .02). ConclusionsThere was no significant difference in success rate between the hook-wire and lipiodol methods. However, the hemorrhage rate was significantly greater in the hook-wire group, whereas the hook-wire group showed greater initially positive surgical resection margins.

The Wire and Beyond: Recent Advances in Breast Imaging Preoperative Needle Localization.

Many patients with breast cancer are candidates for breast conservation therapy. This group includes individuals with small nonpalpable tumors detected at screening mammography and those with sufficient tumor shrinkage after neoadjuvant chemotherapy. Breast conservation surgery often requires the use of an imaging-guided preoperative localization procedure, during which a device is placed within or adjacent to the target lesion to guide the surgeon intraoperatively. For decades, wire localization has been the standard for preoperative localization in breast imaging. With this method, a wire is placed in the breast percutaneously, with the distal wire segment positioned adjacent to the abnormality and the proximal wire segment remaining outside the breast. Because of the external component of the wire, the patient must be compliant, and care must be taken to not disturb the wire's position before surgery. Scheduling flexibility is also limited because the wire localization must be performed on the same day as the subsequent surgery. More recently, the available options for performing preoperative localization have expanded greatly and now include the use of nonwire devices such as radioactive and magnetic seeds, radar reflectors, and radiofrequency identification tags. Nonwire localization devices can be placed days in advance of the surgery, at the patient's convenience, to avoid wire-related challenges and complications. They are placed percutaneously within or adjacent to the target breast lesion and detected intraoperatively by using a probe outside the breast.©RSNA, 2019.

Importance of localization of insulinomas: a systematic analysis.

Procedures suitable for preoperative localization of insulinomas are widely used but it is unclear whether they determine surgical success. We wanted to clarify whether preoperative localization or intraoperative ultrasound determines the success of surgically identifying and removing insulinomas. We performed a systematic literature search (PubMed) yielding 100 publications with patient-level data on preoperative localization procedures, intraoperative ultrasound, success of surgical identification and removal or single, benign insulinomas (published until 31 December 2016). The consequences of successful preoperative localization and intraoperative ultrasound for surgical identification and removal of an insulinoma could be analyzed for 863 and 529 patients with single benign insulinomas, respectively. Sensitivities of commonly employed methods to localize biochemically proven insulinomas were calculated for single benign (1,153 patients), multiple benign, and malignant insulinomas, also in relation to diameter and intra-pancreatic location. The success of surgery (identification and removal of single benign insulinomas) in patients with a biochemically proven insulinoma was high (approximately 98%) even in the absence of preoperative localization. However, successful preoperative localization or intraoperative ultrasonography slightly, but significantly, increased the probability of surgically identifying/removing single benign insulinomas (by 1.4% and 2.0%, P=0.012 and 0.0032, respectively). Diagnostic sensitivities of localization procedures varied widely, with GLP-1 receptor scintigraphy achieving the highest sensitivity despite its non-invasive nature. The probability of surgically identifying and removing a single, benign insulinoma is high even in the absence of successful preoperative localization or intraoperative ultrasound. However, both approaches slightly, but significantly, improve the outcome to near 100%.

Surgery of nonpalpable breast cancer: First step to a virtual per-operative localization? First step to virtual breast cancer localization.

Preoperative localization procedures of occult breast cancer (radioisotopic and wire localization) are invasive and uncomfortable. We have evaluated a novel technique which allows a virtual localization. Our retrospective study focused on patients treated for occult and unifocal breast cancer from September 2016 to June 2017. All patients had radioisotopic preoperative localization. We included patients who had a preoperative prone Magnetic Resonance Imaging (MRI) and an intraoperative 3D optical scan. During surgery, the surgeon localized the tumor thanks to a gamma detection probe and marked the localization on the skin with a black marker. The breast was then optically scanned. MRI was adjusted to the optical surface to match the exact breast position in the Operating Room. The virtual localization provided by the 3D breast modeling tool was retrospectively compared with the radioisotopic localization, defined as the pen mark visible in the optical scan. Nine patients were included in this feasibility study. Tumors were successfully localized in the respective breast quadrant. The mean cutaneous distance between virtual and radioisotopic localization was 1.4cm in patients with low breast volume (5/9) and 2.8cm in those with large breast volume (4/9). We developed a research prototype which enables virtual preoperative localization of nonpalpable breast lesions using MRI images and intraoperative optical scanning. Parameter optimization is required and will lead to a precise and noninvasive tool. By adding augmented reality, it will be possible to initiate a prospective study to compare this tool with the traditional localizations.

Neck Exploration Versus Imaging Localization of Parathyroid in Secondary Hyperparathyroidism

The aim of this study is to evaluate the effectiveness of preoperative imaging localization of hyper functioning parathyroid glands and comparing it with operative neck exploration in secondary hyperparathyroidism. This study was performed in Minia University Hospital between January 2017 and May 2018. Twenty patients with secondary hyperparathyroidism were included in this study. Ultrasonography was done for all patients, and then we classify our patients into two groups: in group 1 patients, Technetium-99 m sestamibi scan and computed tomography were done preoperatively while in group 2, patients underwent operation with neck exploration directly without other preoperative localization procedures. Mean age in our cases was 45.2 ± 9.46, while the most affected age group was (40–49) years by (35%), then (30–39) years by (30%), then (50–59) years by (25%), and then (≥ 60) years by (10%), while females were more affected than male by (75%) of cases. CT sensitivity in detection of parathyroid disease was 70%, and sestamibi detects 80% while neck exploration detection sensitivity was 100%. Neck exploration is the only reliable localization procedure in the cases of secondary hyperparathyroidism.

Better performance of four-dimension computed tomography as a localization procedure in normocalcemic primary hyperparathyroidism.

The multi-phase or four-dimensional computed tomography (4D CT) has emerged as a promising technique for preoperative localization of parathyroid lesions in patients with primary hyperparathyroidism (PHPT), but little is known about its accuracy in patients with normocalcemic primary hyperparathyroidism (NPHPT). A total of 18 patients diagnosed with PHPT underwent three methods of preoperative localization (4D CT, TC-99-Sestamibi scintigraphy and ultrasonography). After surgery, the results of imaging were compared with operative findings, pathological and biochemical data to evaluate the sensitivity and of each localization procedure. In NPHPT the sensitivity for identifying the parathyroid lesion, according to presentation of PHPT (hypercalcemic or normocalcemic), was better with 4DCT in comparison to USG and scintigraphy. In these patients, the sensitivity for lateralization was as follows: USG: 22% (95% CI 0-44.9), scintigraphy: 11.1% (95% CI 0-31.6), 4DCT: 55.6% (95% CI 23.1-88). In hypercalcemic patients the results were as follows: USG: 58.3% (95% CI 30.4-86.2), scintigraphy: 75% (95% CI 50.5-99.5), 4DCT: 75% (95% CI 50.5-99.5). There was a poor agreement between the three procedures in the identification of the parathyroid lesions, with Kappa coeficients of 0.292 and 0.01 for scintigraphy and 4DCT, respectively, in comparison to USG. Our data showed that 4DCT had a better performance as a preoperative localization procedure of the parathyroid lesion in patients with NPHPT.

Localization for Breast Surgery: The Next Generation.

- Preoperative localization of nonpalpable breast lesions using image-guided wire placement has been a standard of breast imaging, diagnosis, and treatment since its development in the 1970s. With this technique, coordinated, same-day wire placement by the radiologist and surgery are required, which can lead to significant inefficiencies in workflow. Other disadvantages of wire localization (WL) include limitations in surgical incision and dissection route and protruding wires that can be both bothersome for the patient and have risk of displacement. - To outline several recently developed techniques that could replace traditional WL and eliminate its disadvantages. The first developed was radioactive seed localization (RSL) using I-125, a technique adopted by many institutions during the last few years. The challenge to this method, however, is the strict nuclear regulatory requirements, which can be a significant burden and limitation. The disadvantages of WL and RSL have provided incentive for the development of other types of preoperative localization procedures. Two of these are recently US Food and Drug Administration-cleared, nonradioactive, non-wire location technologies emerging as alternatives to WL and RSL; SAVI SCOUT (Cianna Medical Inc, Aliso Viejo, California), which uses infrared light and a microimpulse radar reflector, and Magseed (Endomagnetics Inc, Austin, Texas), which uses a magnetic seed for localization. - We review the published literature on non-wire location technologies for breast tissue resection. - Non-wire location techniques are beneficial, allowing image-guided placement before the day of surgery and resulting in improved workflows. These techniques also eliminate bothersome protruding wires, risk of dislodging, and allow the incision site to be independent from the localization site.

Localizating and Extracting Small Peripheral Nodules of Lung with Simulating Radiaotherapy Combining Methylene Blue Staining

背景与目的随着肺癌早期筛查的广泛开展及高分辨率计算机断层扫描（comouted tomography, CT）的普及，临床上微小结节型肺癌在可手术的肺癌中所占的比例大幅增加。如何在术中快速而准确地找到病灶是近年来胸外科医生经常面临的问题。为此我们开展此项研究，旨在探索利用放射治疗计划系统模拟引导穿刺染色定位外周肺部微小结节，并评估这一新方法的定位效率和临床应用价值。方法2012年2月-2015年1月我们对97例患者共100枚直径1 cm内的肺部周围型微小病灶，术前利用放射治疗计划系统，对病灶进行CT模拟定位，患者麻醉后依据术前放疗计划标记的穿刺位点、角度和深度，向病灶注射亚甲蓝，继而手术，在胸腔镜下根据染色标记楔形切除病灶区域肺组织。剖视标本并快速病理检查。统计穿刺注射亚甲蓝的时间、染料注射完毕至剖胸寻视到染色斑的时间、色斑中心点与病灶边缘的距离、定位成功率和并发症率等数据。结果100枚病灶共完成定位96枚，成功率为96%。麻醉后皮肤定位点穿刺注射亚甲蓝的时间为（4.85±1.25）min；染料注射结束至入胸寻找到染色斑的时间为（16.36±2.36）min；色斑中心点与病灶边缘的距离为（4.78±2.34）mm；所有患者无并发症。结论放疗计划系统模拟定位引导穿刺亚甲蓝注射法对肺部周围型微小结节的定位成功率较高，无相关并发症。此方法可避免患者清醒状态下穿刺定位的恐惧和疼痛，并可明显减少患者的辐射危害。

Risk factors for treatment failure in surgery for primary hyperparathyroidism: the impact of change in surgical strategy and training procedures.

Surgery for primary hyperparathyroidism (pHPT) has a high cure-rate and few complications. Preoperative localization procedures have permitted a dramatic shift from routine bilateral exploration to focused, minimally invasive procedures. At Odense University Hospital, Denmark, the introduction of focused surgery was combined with training of new surgeons. The objective of this study was to identify possible risk factors for treatment failure with special focus on surgical strategy and training of new surgeons. A 6-year prospective and consecutive series of 567 pHPT patients operated at Odense University hospital, Denmark, was analyzed. A shift in strategy was made in 2006 and at the same time new surgeons started training in parathyroid surgery. Biochemical-, clinical- and follow-up data were analyzed. Overall cure-rate was 90.7%. Complication rates were 1.1% for hemorrhage, 1.1% for wound infection and 0.9% for recurrent nerve paralysis. The only significant predictor of treatment failure at 6months was histology of hyperplasia (OR 4.3). Neither the introduction of minimal invasive surgical strategy nor the training of new surgeons had a significant influence on the rate of treatment failures. Hyperplasia is a significant predictor of treatment failure in pHPT surgery. A shift towards systematic preoperative localization with focused surgery as well as training of new surgeons can be done without negative impact on treatment results. Identification of the hyperplasia and multigland patients in need of bilateral cervical exploration is crucial to avoid failures and raise cure rates.