Preoperative Needle Localization Research Articles

The incidence and risk factors of acute pain after preoperative needle localization of pulmonary nodules: a cross-sectional study.

BackgroundThe incidence, severity and associated risk factors of acute pain after preoperative needle localization of pulmonary nodules are poorly characterized. We therefore conducted a cross-sectional study to quantify the acute pain induced by preoperative needle localization of small pulmonary nodules before video-assisted thoracoscopic surgery (VATS).MethodsWe conducted this study at Shanghai Chest Hospital from September 2021 through December 2021. Eligible patients were between 18 and 75 years old and had small pulmonary nodules requiring preoperative CT-guided needle localization. The intensity of acute pain was assessed using the visual analogue scale (VAS) after preoperative needle localization. A VAS score ≥4 cm indicated moderate to severe pain. Patient demographics and CT-guided localization factors were collected to identify significant predictors associated with moderate to severe pain.ResultsA total of 300 patients were included in the final analysis, with a mean (SD) age of 51 (SD =12) years old; 63% were female. Moderate to severe pain occurred in 50.8% of patients during deep breathing and 45.7% of patients during movement. Multivariate logistic regression analysis showed that multiple localization needles [multiple needle localizations vs. single needle localization, odds ratio (OR): 2.363, 95% confidence interval (CI): 1.157–4.825, P=0.018] and the specific location of needle puncture on the chest wall were significant predictors of moderate to severe pain after CT-guided needle localization (lateral chest wall vs. anterior chest wall OR: 2.235, 95% CI: 1.106–4.518, P=0.025; posterior chest wall vs. anterior chest wall OR: 1.198, 95% CI: 0.611–2.349, P=0.599).ConclusionsIn adult patients receiving hookwire CT-guided localization, moderate to severe pain was common. Avoiding the localization route through lateral chest wall may be helpful and pharmacological medications or regional blockade is necessitated in high-risk population.

Techniques for overcoming a missing clip during pre-operative needle localization for lumpectomy: case report

: Breast conservation therapy (BCT) has become the standard of care for treating low-stage breast lesions. The principle of this therapy is to conserve as much normal breast tissue as allowable while still achieving a proper oncologic resection. These breast-sparing dissections would be difficult if not impossible without any intra-operative guidance. For this reason a wire is typically placed near the lesion pre-operatively to serve in directing the surgeon. To accurately place a wire, a lesion must be identifiable on imaging. This creates a potential dilemma as candidates for breast-conserving therapy typically have low-stage lesions which can be illusive at times. Thus, fiduciary markers such as clips have become integral in the treatment of low-stage breast lesions as they can serve as a reference point for identifying non-palpable breast lesions. In fact, cases in which a clip serves as the only identifiable landmark for an occult breast lesion are not uncommon. While undoubtedly useful, the heavy reliance we place on these markers creates a potential for significant dilemma when they cannot be visualized. We present a case that demonstrates one of the potential pitfalls that can occur when relying on a fiduciary marker, specifically, the inability to perform pre-operative wire-guided localization (WGL) for lumpectomy due to a lack of clip visualization. We discuss the potential causes for lost markers such as clip migration as well as several techniques available for attempting a “blind” lumpectomy with particular focus on intra-operative fluoroscopy. By utilizing this technique we were able to successfully complete an unexpected blind lumpectomy without any sacrifice in regards to oncologic margins or cosmesis.

CLO20-037: Time is On Our Side: Concomitant Needle Biopsy and Wire-Free Localization of Axillary Lymph Nodes May Decrease Redundant Preoperative Needle Localization in BI-RADS 5, 6 Breast Cancer Patients

CLO20-037: Time is On Our Side: Concomitant Needle Biopsy and Wire-Free Localization of Axillary Lymph Nodes May Decrease Redundant Preoperative Needle Localization in BI-RADS 5, 6 Breast Cancer Patients

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.

Cutting Healthcare Costs with Hematoma-Directed Ultrasound-Guided Breast Lumpectomy.

Localization of nonpalpable breast lesions for breast-conserving surgery (BCS) remains highly variable and includes needle/wire localization (NL), radioactive seed localization, radar localization, and hematoma-directed ultrasound-guided (HUG) lumpectomy. The superiority of HUG lumpectomy over NL has been demonstrated repeatedly in terms of safety, accuracy, low positive margin rates, cosmesis, and patient satisfaction. In this study, we evaluate the cost effectiveness of HUG lumpectomy over NL for nonpalpable breast lesions. We performed a retrospective review of 569 patients who underwent lumpectomy at the University of Arkansas for Medical Sciences from May 2014 through December 2017. Lumpectomies were stratified by localization technique, i.e. NL versus HUG. A cost-savings estimate was determined for the HUG localization technique, and a total amount of dollars saved over the study period was calculated. Overall, 569 lumpectomies were performed: 501 (88.0%) via HUG and 68 (12.0%) via NL. Intraoperative ultrasound was used in 566 operations (99.5%). Of the lumpectomies performed by HUG, 190 lesions (33.4%) were visible only on mammogram or breast magnetic resonance imaging prior to diagnostic core needle biopsy (CNB). Cost estimates comparing HUG with NL demonstrated a cost savings of $497.00 per procedure, the cost of preoperative needle localization by a radiologist, and a total of $94,430.00 for the study period. In utilizing HUG lumpectomy, the initial CNB serves as the diagnostic and localization procedure, thus saving time and a painful second procedure on the day of operation. HUG lumpectomy is safe, accurate, reduces healthcare costs, and results in a better patient experience for the surgical removal of nonpalpable breast lesions.

Abstract P5-22-11: Enhanced intraoperative breast specimen assessment may reduce margin positivity and reoperation rates in breast cancer

Abstract Introduction: Partial mastectomy is the most commonly performed operation for breast cancer. Margin positivity throughout the nation ranges from 30-60%, of which 10-36% require reoperation. Data from the SHAVE trial showed that excising an additional 1 cm margin circumferentially can reduce margin positivity by 50%. We are concerned about the large volume of tissue that may be unnecessarily removed secondary to routine circumferential margin excision. We have practiced selective additional margin excision based on enhanced intraoperative margin assessment including gross specimen evaluation by pathology. We suggest that enhanced intraoperative specimen assessment may reduce margin positivity and reoperation rates. Methods: This is a retrospective review of a prospectively maintained, single surgeon database of patients undergoing partial mastectomy between Feburary 2014 – December 2016 at Medstar Union Memorial Hospital. One hundred consecutive patients diagnosed with DCIS or invasive carcinoma undergoing partial mastectomy with the intention of margin negativity were included. Information regarding preoperative planning and intraoperative specimen assessment were collected from clinical notes and operative records. These data points included preoperative imaging studies, use of preoperative needle localization, intraoperative ultrasound to guide surgery, use of intraoperative Faxitron, and gross pathologic consultation. The data is analyzed to calculate margin positivity and reoperation rates in comparison to reported experiences. Results: The average age was 62.3 years, ranging from 33-96 years. Of the 100 patients, 73 had invasive cancer, 19 had DCIS. The average lesion size was 14.17mm. There were 8/100 cases with a positive margin, of which 5 cases had re-excisions. An additional 3 cases had re-excision for positive cells <1mm from margin. Faxitron was used in 89% of cases and gross consultation in 100% of cases. The average number of additional margins taken was 1.2. 22/100 cases did not have additional margins taken during the index operation. Discussion: This is a hypothesis generating study that was prompted by our concern about the amount of tissue and the expense created by routine circumferential margin removal. The issue of variability among different institutions and the very high reoperation rates reported by many beg for an explanation. Many techniques have been proposed to reduce this unexplained variability but none has consistently shown the necessary improvement and many new technologies are costly. Our experience suggests that low margin positivity and reoperation rates may be achieved using inexpensive enhanced intraoperative specimen assessment. We can test this hypothesis by comparing information among the different hospitals in our system. A head to head prospective trial comparing routine shaves versus enhanced specimen assessment and selective additional margins would answer this question. Conclusion: Enhanced intraoperative margin assessment and selective margin excision may provide a good alternative to routine shave margin while removing less breast tissue. Uniform specimen assessment algorithms may also help achieve reduced margin positivity and reoperation rates. Citation Format: Tran H-T, Moore I, Patel N, Willey S, Farha M. Enhanced intraoperative breast specimen assessment may reduce margin positivity and reoperation rates in breast cancer [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 P5-22-11.

Operative bed recurrence of thyroid cancer: utility of a preoperative needle localization technique.

Surgical management of recurrent disease after total thyroidectomy and/or neck dissection for thyroid carcinoma remains a challenging clinical problem. Reoperation is associated with a significant increase in morbidity. Preoperative needle localization technique for non-palpable breast tumors has recently been extrapolated to head and neck surgery. We report on the use of preoperative ultrasound-guided needle localization for non-palpable recurrent operative bed disease as an intraoperative aid in resection. Patients with thyroid carcinoma were identified from a retrospective database at a tertiary care center from 2011-2014. Inclusion criteria were history of thyroidectomy and/or neck dissection, non-palpable recurrent disease in the resection bed on surveillance, and ultrasound-guided needle localization of recurrent disease before resection. Perioperative data and outcomes were analyzed. Seventeen patients were identified using the inclusion criteria listed above. Median patient age was 46 years (53% male, 47% female). A total of 23 masses in the previous operative bed were needle-localized successfully with no major long-term sequelae from this technique. The recurrent laryngeal nerve was involved with tumor in six patients. Two patients, in whom the tumor surrounded the nerve circumferentially, experienced recurrent laryngeal nerve injuries. No patients experienced postoperative hypocalcemia. With a routine surveillance and a median follow-up of 558 days, sixteen of the patients remain with no evidence of disease. Preoperative ultrasound-guided needle localization of non-palpable recurrent operative bed disease after thyroidectomy and/or neck dissection is a potentially safe method to aid in resection and cure.

In Memoriam: Gerald D. Dodd, Jr., MD (1922-2015): Champion of Screening Mammography

Screening mammography has been one of the greatest scientific advancements of our time. Numerous randomized trials and service screening studies conducted in Europe have shown that periodic screening can reduce deaths from breast cancer in women aged 40 years and older by as much as 50%. A greater than 30% reduction in the breast cancer death rate in the United States since 1980 has been largely due to the widespread application of high-quality mammographic technique and interpretation. For this accomplishment, women in our country can be grateful to Gerald D. Dodd, Jr., MD, who passed away in Houston, Texas, on September 25, 2015, at age 92. Through his leadership in organizations such as the American Cancer Society (ACS), the American College of Radiology (ACR), the American Board of Radiology (ABR), and the National Council on Radiation Protection and Measurements, Dodd played an indispensable role in the adoption of technical quality requirements by the ACR and the U.S. Food and Drug Administration, the Mammography Quality Standards Act (MQSA), the development of interpretive descriptors used in the ACR Breast ImagingReporting and Data System (ACR BI-RADS), the incorporation of breast imaging on ABR examinations, and the initiation of ACS screening mammography guidelines. During much of his remarkably productive career, Dodd was chairman of the Division of Diagnostic Imaging at The University of Texas MD Anderson Cancer Center in Houston, Texas. He was the imaging editor for Breast Diseases: A YEAR BOOK Quarterly from its inception in 1990 until 2005, when at age 82, he recommended to S. Eva Singletary, MD, then editor-in-chief, that I assume his position. To me, Gerry Dodd was a long-time friend, a trusted mentor, and an inspiration. Dodd was born in Oaklyn, New Jersey, on November 18, 1922. He attended Blair Academy preparatory school, participating with distinction in football, wrestling, and boxing. He received a football scholarship to Cornell University but chose Lafayette College instead, intending to pursue a career in medicine. World War II interrupted his studies, and he joined the U.S. Navy as a hospital corpsman. His commanding officer recommended him to the Officer Training Program through Swarthmore College in suburban Philadelphia, and he was commissioned with the rank of ensign. After the war, he returned to Lafayette, graduating in 1945. In 1946, he married his beloved wife of 68 years, Helen Glenzing. He received his medical degree from Thomas Jefferson Medical College in Philadelphia, Pennsylvania, in 1947 and was elected to the Alpha Omega Alpha Honor Medical Society. (Many years later, he was selected for the prestigious Thomas Jefferson University Alumni Achievement Award.) In 1948, he interned at Fitzgerald Mercy Hospital in Darby, Pennsylvania. His ensuing residency in radiology at Thomas Jefferson Medical College, under Dr. Paul Swenson as chairman, ran from 1948 to 1950. During the Korean War, he joined the U.S. Air Force, rising to the rank of captain, while serving as the chief of radiology at Mitchell Air Force Base in New York. Dodd began his highly productive career as an assistant professor at Thomas Jefferson Medical College (1952-1955). He then relocated to MD Anderson, where he served as section head of diagnostic imaging from 1955 to 1961. During that time, Dodd assigned Robert L. Egan, then a resident in radiology, the task of developing a mammographic technique for the staging of breast cancer. Egan’s landmark accomplishment demonstrated that mammography can reduce errors in preoperative diagnosis and reveal unsuspected lesions. Disappointed by the lack of support for diagnostic radiology at MD Anderson at that time, Dodd returned to Jefferson in the spring of 1961 as chief of diagnosis and director of residency training. Under the leadership of Dodd and Dr. Philip J. Hodes, chairman of radiology, the department experienced a dramatic growth in the resident program. During the 1950s and 1960s, Philadelphia was a leading center for clinical studies in the emerging field of breast imaging. Dr. Jacob Gershon-Cohen at Albert Einstein Medical Center was developing improved mammographic techniques, correlating the mammographic, pathologic, and clinical findings of breast diseases, and investigating the value of mammography for screening. At Jefferson, Dodd coauthored a cooperative study of mammography at 7 Philadelphia teaching hospitals, initiated byDr. Eugene P. Pendergrass, chairman of radiology at the University of Pennsylvania. Their results confirmed that mammography could detect clinically unsuspected breast cancer. While at Jefferson, Dodd was the first in the country to develop a preoperative needle localization technique for nonpalpable breast lesions. This major technical innovation increased the accuracy of excisional biopsy while decreasing postoperative deformity. In 1964, Dodd and John D. Wallace, a medical physicist at Jefferson, began to assess the relationship between breast tumors and mammographic vascularity. Their studies led them to evaluate thermography, a technique that depicts the infrared radiation emitted by the superficial vasculature of the breast, as a potential screening modality.

Improving the Accuracy of Axillary Lymph Node Surgery in Breast Cancer with Ultrasound-Guided Wire Localization of Biopsy Proven Metastatic Lymph Nodes.

This study aimed to evaluate whether the use of preoperative ultrasound (US)-guided wire localization of metastatic axillary lymph nodes (LN) assessed previously by core needle biopsy (CNB) and clip placement in breast cancer patients improves successful surgical removal. A retrospective review examined breast cancer patients who underwent US-guided CNB of an axillary LN and biopsy clip placement as well as axillary lymph node dissection (ALND) or sentinel node lymph node biopsy (SLNB) from 1 January 2010 to 30 September 2013. Preoperative needle localization status, neoadjuvant chemotherapy, and type of axillary LN surgery were reviewed. Confirmation that the metastatic LN had been surgically removed was determined on the specimen image, by pathologic report confirmation, or by pre-radiation therapy computed tomography (CT) scan. Preoperative US-guided needle localization was performed for 68.2 % (73/107) of the patients, with 97.3 % (n = 71) demonstrating confirmation of biopsy clip and LN removal versus 79.4 % (n = 27) of the 34 patients showing no performance of needle localization (p = 0.0043). Subgroup analysis showed a significant difference in removal of metastatic LN between the patients who received neoadjuvant chemotherapy [97 % of LNs removed with wire localization (n = 65/67) vs. 83.3 % of LNs removed without wire localization (n = 20/24; p = 0.04)] and the patients who had ALND, [96.3 % of LNs removed with wire localization (n = 52/54) vs. 77.8 % of LNs removed without wire localization (n = 21/27; p = 0.015)]. US-guided wire localization of metastatic axillary LNs that have had biopsy with clip placement significantly improves the success rate of surgical removal, allowing more accurate staging and decreasing the false-negative rates of SLNB after neoadjuvant therapy.

Effect of Introducing Hematoma Ultrasound-Guided Lumpectomy in a Surgical Practice

Preoperative needle localization (NL) is the gold standard for lumpectomy of nonpalpable breast cancer. Hematoma ultrasound-guided (HUG) lumpectomy can offer several advantages. The purpose of this study was to compare the use of HUG with NL lumpectomy in a single surgical practice. Patients with nonpalpable lesions who underwent NL or HUG lumpectomy from January 2007 to December 2009 by a single surgeon were identified from a breast surgery database. Ease of scheduling, volume excised, re-excision rates, operating room time, and health care charges were the main outcomes variables. Univariate and multivariate analyses were performed to compare the 2 groups. Lumpectomy was performed in 110 patients, 55 underwent HUG and 55 underwent NL. Hematoma ultrasound-guided lumpectomy was associated with a nearly 3-fold increase in the odds ratio of additional tissue being submitted to pathology (p = 0.039), but neither the total amount of breast tissue removed, nor the need for second procedure were statistically different between the 2 groups. Duration of the surgical procedure did not vary between the 2 groups; however, the time from biopsy to surgery was shorter for HUG by an expected 9.7 days (p = 0.019), implying greater ease of scheduling. Mean charges averaged $250 less for HUG than for NL, but this difference was not statistically significant. Hematoma ultrasound-guided is equivalent to NL with regard to volume of tissue excised, need for operative re-excision, and operating room time. Adoption of HUG in our practice allowed for more timely surgical care.

A plea for the biopsy marker: how, why and why not clipping after breast biopsy?

In the last decade, percutaneous breast biopsies have become a standard for the management of breast diseases. Biopsy clips allow for precise lesion localization, thus minimizing the volume of breast to be resected at the time of surgery. With the development of many imaging techniques (including mammography, sonography, and breast magnetic resonance imaging), one of the challenges of the multidisciplinary became to synthesize all informations obtained from the various imaging procedures. The use of biopsy markers after percutaneous biopsy is one of the keys for optimal patient management, helping the radiologist to deal with multiple lesions, to insure correlation across different imaging modalities and to follow-up benign lesions, helping the oncologist by marking a tumor prior to neoadjuvant chemotherapy, helping the surgeon by facilitating preoperative needle localization, to precisely mark the margins of extensive disease and to guide intraoperative tumor resection, and helping the pathologist to insure the lesion of interest has been removed and to identify the region of interest in a mastectomy specimen. We believe biopsy clip markers should be deployed after all percutaneous interventions and present in this review the arguments to support this statement. Minimal indications for clip deployment will also be detailed.

Freehand MRI‐guided preoperative needle localization of breast lesions after MRI‐guided vacuum‐assisted core needle biopsy without marker placement

To evaluate the feasibility of magnetic resonance imaging (MRI)-guided preoperative needle localization (PNL) of breast lesions previously sampled by MRI-guided vacuum-assisted core needle biopsy (VACNB) without marker placement. We reviewed 15 women with 16 breast lesions undergoing MRI-guided VACNB without marker placement who subsequently underwent MRI-guided PNL, both on an open 0.5T magnet using freehand techniques. Mammograms and specimen radiographs were rated for lesion visibility; MRI images were rated for lesion visibility and hematoma formation. Imaging findings were correlated with pathology. The average prebiopsy lesion size was 16 mm (range 4-50 mm) with 13/16 lesions located in mammographically dense breasts. Eight hematomas formed during VACNB (average size 13 mm, range 8-19 mm). PNL was performed for VACNB pathologies of cancer (5), high-risk lesions (5), or benign but discordant findings (6) at 2-78 days following VACNB. PNL targeted the lesion (2), hematoma (4), or surrounding breast architecture (10). Wire placement was successful in all 16 lesions. Final pathology showed six cancers, five high-risk lesions, and five benign findings. MRI-guided PNL is successful in removing lesions that have previously undergone VACNB without marker placement by targeting the residual lesion, hematoma, or surrounding breast architecture, even in mammographically dense breasts.

TU-C-210A-05: Enhancement Characteristics of Cancer On MRI of the Breast and Biopsy Techniques

MRI of the breast is a highly sensitive technique for finding breast cancer. Suspicious findings include masses with an early rapid enhancement and a late plateau or washout. When suspicious findings are found on MRI, breast biopsy is done with vacuum‐assisted core devices or preoperative needle localization. This presentation will review state‐of‐the‐art findings diagnostic of cancer and review MRI‐guided biopsy techniques. Learning Objectives: 1. To learn MRI features of cancer. 2. To identify methods of MRI‐guided biopsy. 3. To learn limitations of MRI for finding cancer.

Who Wants a Blind Breast Surgeon?

Mammary ductoscopy was introduced by Japanese surgeons in the early 1990s for the direct visualization of the source of bloody nipple discharge. As techniques and equipment have evolved in the last 15 years, we now have several relatively simple submillimeter endoscopes that can be used to look within saline-distended larger ductal segments within the breast. Valdes et al. demonstrate in their early experience with ductoscopy the ability to find and visualize intraductal lesions for excision. As with prior studies, they were impressed with the ability to identify histologically significant lesions that were relatively distant from the nipple, such as an 8-cmdeep ductal carcinoma-in-situ. They clearly have increased the number of breast cancers identified before traditional radiographical imaging or clinical examination alone. From their study and others, it is not a giant leap to conclude that intraluminal abnormalities in the ductal system have just as much need to undergo biopsy as the average palpable lump or radiographical (mammographic, ultrasound, or magnetic resonance imaging) lesion. But this relatively narrow view misses the greatest power of this new technology. We do not have mammogram and magnetic resonance imaging machines in our operating rooms to direct our surgical procedures. The best we can do is preoperative needle localization and postexcision specimen imaging. Despite this, most breast surgery operations today are performed with the same intraoperative imaging tool that Halsted used: the surgeon’s palpation alone. The last decade has seen a rapid increase in intraoperative ultrasonography use by dedicated breast surgeons to assist in better and more accurate excisions of small invasive cancers. Improving our intraoperative mapping of the suspicious lesions—especially if these are potentially ductal carcinoma-in-situ—can only further enhance our success at getting truly clear margins. We understand that many cancers are years in evolution. We should not be waiting to treat them until they are invasive and have the potential to spread from the breast. Finding cancers earlier and intervening sooner has been the mantra that has led to the dramatic decreases in breast cancer death rates in the last several years. Over the last decade, we have learned the importance of ellictable fluid from the nipple, especially in high-risk individuals. If we know someone is high risk and she is having breast surgery, should we not be certain that any intraductal lesions, related or unrelated to the target of the surgical procedure, are also adequately sampled? Can we perform a more accurate lumpectomy by actually mapping out the extent of the involved ductal system and either excising it all or excising the lesion and all associated intraluminal defects? When vascular surgeons are sewing on small blood vessels, is there any argument about putting on loops to make a better and smoother suture line closure? Although there are many unanswered questions about when and how best to use our new ability to see submillimeter disease with the new ductoscopes, there is no reason for surgeons to continue to blindly operate on the breast if their vision of the extent of intraluminal ductal lesions can be improved. My personal series of using ductoscopy to direct lumpectomy margins has consistently shown a marked decrease in positive margins at first excision. Although we are still following these patients up for Received January 26, 2006; accepted February 1, 2006; published online July 8, 2008. Address correspondence and reprint requests to: William C. Dooley, MD; E-mail: william-dooley@ouhsc.edu.

Pathologic Evaluation of Cryoprobe-Assisted Lumpectomy for Breast Cancer

Cryoprobe-assisted lumpectomy is a relatively new technique that converts nonpalpable carcinomas into well-defined, palpable ones by creating an ice ball under ultrasonographic guidance, thus eliminating the need for preoperative needle localization. We evaluated the effect of cryoprobe-induced freezing on tumor tissue, peritumoral tissue, and margin status in 6 cases of cryoprobe-assisted lumpectomy performed for infiltrating ductal carcinoma. Immunohistochemical stains for estrogen and progesterone receptors and the proliferation marker Ki-67 were performed on 4 cases and results compared with those of the pretreatment biopsy specimens. Although it was possible to recognize the tumor as infiltrating carcinoma in all cases, the alteration in tumor morphology interfered with tumor grading, distinguishing in situ and invasive components, and assessment of mitoses and lymphovascular invasion. The expression of estrogen and progesterone receptors was greatly reduced, whereas the Ki-67 staining was not significantly different when compared with pretreatment biopsy specimens. The "cryoprobe effect" did not interfere with evaluation of the margins and surrounding breast tissue.

Intra-operative Sonography: A Valuable Aid During Breast-Conserving Surgery for Occult Breast Cancer

Breast cancer is increasingly detected during an early non-palpable stage. Together with pre-operative marking of the mass, intra-operative imaging provides invaluable clues. This study was designed to evaluate the usefulness of intra-operative sonography in the hands of the surgeon. Between July 2001 and October 2006, 567 patients underwent treatment for operable breast cancer at the landeskrankenhaus (LHK) Feldkirch. Three hundred and sixty lesions were not palpable. Two hundred and ninety-nine patients with poorly definable or non-definable lesions well seen by ultrasound imaging underwent intra-operative sonography (group 1), while 61 patients with non-palpable lesions only seen on mammography (group 2) were subjected to pre-operative needle localization. The study was non-randomized with prospective data acquisition All lesions were identified by both sonography and pre-operative needle localization. In the ultrasound group (group 1) 81% of the lesions were successfully removed by primary intention without metachronous secondary surgery versus 62% in group 2 (p < 0.00228). Eighty-eight percent of the lesions in group 1 were eligible for breast-conserving surgery versus 75% in group 2. The mean clear margin in group 1 was substantially smaller (4.8 mm) than in group 2 (7.2 mm) (p < 0.0001). Intra-operative sonography proved to be a reliable and helpful tool in the hands of the surgeon, not only for tumor localization, but also for orientation during tumor excision. It simplifies organizational work and spares the patient the discomfort of pre-operative needle localization.

Clip Migration Within 15 Days of 11-Gauge Vacuum-Assisted Stereotactic Breast Biopsy

Parikh J(AQ 1) fter a percutaneous vacuum-assisted breast biopsy, a metallic clip is frequently placed at the biopsy site by interventional breast radiologists [1, 2]. The clip acts as a landmark for future reference when the mammographic abnormality (mass or calcifications) is removed during stereotactic biopsy. If histology is benign, the clip denotes the site of biopsy on future mammograms. If atypical or malignant histology is found at the core biopsy, the clip helps to identify and localize the area as needed for future surgery. With neoadjuvant therapy, a malignant area can become progressively and mammographically imperceptible, with the clip remaining as the only mammographic evidence of the initial site of the malignancy. Initial clip misplacement at the time of stereotactic breast biopsy is known to occur [3] and is typically identified immediately after the procedure. Three reports of migration of the MicroMark clip (Ethicon Endo-Surgery) within 5 weeks [4], 10 months [5], and 1 year [6] of accurate initial placement have been reported. Two cases of migration of the Gel Mark clip (SenoRx) within 8 days [7] and 10 weeks [4] of initial accurate placement have been reported [6]. To my knowledge, I am reporting the first case of Gel Mark clip migration, which occured within 15 days of initial accurate placement that was confirmed by mammographic imaging, that led to inaccurate preoperative needle localization, using digital stereotactic guidance. Consultation with the institutional review board revealed neither their approval nor informed patient consent was required for this case report.

Determinants of surgical site infection after breast biopsy

Surgical site infections (SSI) following clean and clean-contaminated ambulatory surgery at Bon Secours Cottage Health Services are monitored utilizing a postdischarge surveillance form in addition to traditional surveillance. From January 2000 to December 2002, the clean procedure SSI rate was 0.73% (31/4266) versus 1.58% (15/950) for breast biopsy, P = .04. A case-control study was performed to identify risk factors for infection. A case patient was identified as any patient having an ambulatory breast biopsy from January 2000 to December 2002 with SSI identified by the Centers for Disease Control and Prevention (CDC) definition of nosocomial infection. For each case patient, 3 randomly selected control patients were matched by date and procedure. Factors significantly associated with the development of SSI were duration of surgery (case mean, 71.7 minutes vs control mean, 34.7 minutes, P < .01) and presence of surgical drains (26.7% of cases vs 6.7% of controls, P = .04). Factors determined not to be associated with SSI were obesity (P = .88) and preoperative needle localization (P = .88). We conclude that there is a significant difference between the breast biopsy infection rate and the clean procedure infection rate in ambulatory surgery. Duration of surgery and presence of surgical drains were associated with increased infection rate.

The Use of Additional Skin Markings During Preoperative Needle Localization to Improve Initial Surgical Excision Margins

The Use of Additional Skin Markings During Preoperative Needle Localization to Improve Initial Surgical Excision Margins

Comparison of Full-Field Digital Mammography to Screen-Film Mammography with Respect to Diagnostic Accuracy of Lesion Characterization in Breast Tissue Biopsy Specimens

Rationale and Objectives This study was performed to investigate whether full-field digital mammography (FFDM) is at least as accurate as screen-film mammography with respect to breast lesion characterization. Materials and Methods Seventy-nine breast surgical specimens were obtained by means of preoperative needle localization with surgical excision from 79 patients. The specimens were imaged with both screen-film mammography and FFDM. Six radiologists specialized in breast imaging analyzed both sets of images and characterized the visualized lesions on a five-point scale: 1, definitely not malignant; 2, probably not malignant; 3, possibly malignant; 4, probably malignant; and 5, definitely malignant. Receiver operating characteristic curve analysis of the data was then performed to assess for differences between modalities in the radiologists' ability to predict breast malignancy. Results The areas under the receiver operating characteristic curves for the prediction of breast malignancy in surgical biopsy specimens were not statistically significantly different for FFDM and screen-film mammography. Conclusion The results demonstrate that with breast surgical specimens, FFDM is similar in diagnostic accuracy to screen-film mammography.