Radioguided Occult Lesion Localization Research Articles

A rare association of synchronous intraductal carcinoma of the breast and invasive carcinoma of ectopic breast tissue of the vulva: case report and literature review

Only 17 cases of breast carcinoma arising in vulvar ectopic mammary tissue have been reported. We present a unique case of synchronous pure intraductal carcinoma of the breast (DCIS) and invasive carcinoma of ectopic breast tissue of the vulva. A 53-year-old woman presented with a 2-cm nodule in left labium major of the vulva. A surgical biopsy revealed an invasive carcinoma of ectopic mammary tissue. The mammography showed irregular microcalcifications of the right breast. The patient underwent left hemivulvectomy, bilateral inguinal sentinel lymph node biopsy, and radioguided breast resection (radioguided occult lesion localization) of the microcalcifications. The definitive histology revealed negative inguinal sentinel nodes, no further residual tumor in the vulva, and a high-grade (grade 3) DCIS in the breast. The synchronous occurrence of primary breast carcinoma and ectopic breast tissue carcinoma in the vulva is an extremely rare finding, only once previously being reported and leading to unsolved problems of differential diagnosis. The presence of a pure DCIS of the breast makes this case really unique, definitively confirming the independent primary origin of both mammary tumors. The inguinal sentinel node biopsy avoided a bilateral inguinal dissection.

Radioguided surgery for breast cancer: preliminary experience in Piaui

Intraoperatory detection and excision of sentinel lymph node (SLN), radioguided occult lesion localization (ROLL) and lesional resection, or a combination of these two procedures at one time in a same patient (SNOLL), are techniques that represent, at the moment, a significant advance in breast cancer surgery, procedures in clinical practice being established, as can be seen from the medical literature, as well as in this institution. Thirty-one patients with breast cancer were initially treated with the aid of radioguided surgery. Of those, 20 patients were submitted to sentinel lymph node biopsy, six have undergone only ROLL and five were submitted to a combination of the two techniques.

391 PUBLICATION Extended role of radioguided occult lesion localization in early stage breast cancer

391 PUBLICATION Extended role of radioguided occult lesion localization in early stage breast cancer

Occult breast lesions: A comparison between radioguided occult lesion localisation (ROLL) vs. wire-guided lumpectomy (WGL)

Mammographic screening increases the number of impalpable breast cancers requiring surgical excision. It is important to optimise the localisation technique to remove the smallest amount of tissue, still adequately excising the lesion. The last 65 wire-guided lumpectomies (WGLs) were compared vs. the first 65 radioguided occult lesion localisations (ROLLs) performed for impalpable breast cancers. Data collection included patient's age, radiological abnormality, pre-operative core biopsy, type of primary surgery, length of localisation and excision, hospital stay, cancer size, weight and volume of the excised specimen, clearance margins. All patients were successfully localised with ROLL and WGL. Localisation time was reduced with ROLL (P<0.001). Clear margins were achieved in 83% ROLLs and 57% WGLs (P=0.001). Pathological cancer size and specimen weight were similar in both groups, although the specimen volume was slightly smaller for ROLL. A total of 74% ROLLs had excellent cosmetic outcomes and 26% good, vs. 55% excellent and 45% good in WGLs. A larger amount of normal breast tissue was excised with WGL, without achieving any better cancer clearance. ROLL provides a feasible alternative to WGL. This quick and simple technique achieves an improved rate of clear margins.

Radioguided occult lesion localisation (ROLL) in surgery of impalpable breast tumours

With advanced detection methods now allowing cancers to be found at earlier and earlier stages, new treatment methods to deal with these early stage cancers are also emerging. Radioguided occult lesion localisation (ROLL), a technique pioneered in 1996, is a useful method for localisation of impalpable breast tumours with results superior to those obtained by wire localisation and comparable to those achieved by surgery of palpable lesions. ROLL allows for the precise localisation necessary to optimise the cosmetic outcome in breast conserving surgery without jeopardising sufficient free tissue margins. ROLL can also be used in conjunction with sentinel node biopsy (SNB) using either the same or different radioactive tracer. For all these reasons, ROLL is an important development in breast cancer treatment.

Radioguided occult lesion localisation (ROLL) is available in the UK for impalpable breast lesions

To test the feasibility and reliability of ROLL in a district general hospital (DGH) dealing with screening detected breast lesions. [(99m) Tc]-labelled colloidal human serum albumin was injected in the core of the breast lesion under ultrasound or stereotactic guidance 2-4 h prior to surgery. At operation, the radioactivity is localised using a gamma-probe. This allows optimal placement of the skin incision and subsequent WLE of the abnormal area. ROLL was utilised on 36 patients (median age, 61 years; range, 43-75 years); of these, 33 B5 lesions had a therapeutic one-step procedure (lumpectomy and axillary dissection) and 3 B4 patients had the lesion excised for diagnostic purposes. Localisation lasted a median of 8 min (range, 5-15 min), ROLL-guided wide tumour excision lasted 20 min (range, 15-30 min), and median postoperative hospital stay was 2 days (range, 1-3 days). Median cancer diameter was 12 mm (range, 6-40 mm). Margins were clear in 29 patients, while 7 patients with DCIS had involved margins. Median minimal clearance was 5 mm (range, < 1-10 mm). Patients had either excellent (24/36) or good (12/36) cosmetic results. ROLL successfully localised all lesions; this technique can be implemented in any DGH with a Nuclear Medicine Department. The learning curve is short, cost effectiveness is proven, and cosmetic results are highly rewarding. ROLL could rapidly become the standard localisation technique in the UK.

Radiolocalización de lesiones mamarias no palpables combinada con la biopsia del ganglio centinela en mujeres con cáncer de mama

The practice of intratumoral radiocolloid injection for sentinel node biopsy (SNB) allows localization of nonpalpable breast tumors in the same surgical intervention, using the technique known as radio-guided occult lesion localization (ROLL). We present our experience with the combined use of both techniques (SNB and ROLL). A total of 233 patients were retrospectively analyzed: 65 patients underwent ROLL and 168 patients underwent wire-guided localization (control group) as the excision modality. Both groups had comparable pathologic and radiologic features. Complete excision of the lesion was achieved at the first attempt in only 169 patients. There were no significant differences among groups in surgical margin status (margins were adequate in 80% of ROLL patients vs 69.9% of non-ROLL patients) or in maximum specimen diameter (6.85 cm vs 6.52 cm, respectively). We conclude that ROLL is an acceptable alternative to wire-guided localization in patients with nonpalpable breast tumors undergoing SNB, leading to easier lesion excision and greater patient comfort.

Radioguided occult lesion localisation (ROLL) and sentinel node biopsy for impalpable invasive breast cancer

Radioguided occult lesion localisation (ROLL) and sentinel node biopsy for impalpable invasive breast cancer

Radioguided occult lesion localisation (ROLL) and sentinel node biopsy for impalpable invasive breast cancer

Aim The aim of this study was to simplify the technique of ROLL and sentinel node biopsy without compromising tumour excision and sentinel node biopsy. Methods Twenty patients with impalpable primary invasive breast carcinoma underwent an injection of 99mTc-nanocolloid mixed with radiographic contrast medium Iohexol into the centre of the lesion under ultrasound or stereotactic guidance pre-operatively. No guidewire localisation was performed. Under general anaesthesia, a periareolar intradermal/subcutaneous injection of patent blue-V dye was performed. The sentinel node was identified by blue-stained lymphatics and node and a hot spot on the gamma probe. Surgical excision of the primary tumour was then carried out using the gamma probe. Results In eight of 20 cases an immediate re-excision was carried out and on histological assessment, all 20 patients were clear of invasive disease at the margins. In two patients, in situ disease was present at the margins and a further re-excision was therefore performed. The sentinel node was identified in all cases. In all, five of 20 patients were node positive on routine HE staining. In a further two patients, tumour cells were identified by immunohistochemistry with CAM5.2 antibody. Completion axillary clearance in six patients confirmed that the sentinel node was the only positive node. Conclusions This modification of the previously described ROLL technique is feasible and safe and does not compromise tumour excision or sentinel node detection.

Combined radioguided occult lesion and sentinel node localization for breast cancer.

The incidence of non-palpable breast lesions requiring intraoperative localization has greatly increased, particularly because of the widespread use of mammographic screening. These lesions have previously been localized preoperatively using hook-wire or carbon track techniques. In the era of increasing acceptance of sentinel node biopsy (SNB) a separate procedure would be required for sentinel node localization (SNL). The present study describes an experience with ultrasound guided radionucleotide occult lesion localization (ROLL) as a reliable alternative that enables SNL synchronously. Twenty-two patients with proven breast malignancy on core biopsy were enrolled in the present study. Preoperatively, technetium-99m was injected around the lesion under radiological guidance. A gamma-probe was then used to locate the lesion and guide its surgical removal. Complete excision was then confirmed immediately by verifying minimal residual radioactivity in the cavity wall tissue. Appropriate SNB then proceeded. The primary breast lesion was identified in all cases except in one, where the radiotracer was injected into the wrong site, giving a miss rate of 1/22 (4.5%). The average size of the tumour was 13 mm (range 6-22 mm) and the closest margins ranged from 0 (1 patient) to 22 mm (mean 7 mm). Two patients had inadequate margins and required further excision giving a re-excision rate of 2/21 (9.5%). SNB specimens included a median of 3.7 nodes/patient. Radionucleotide occult lesion localization/SNL is a simple, accurate and reliable method of combining localization of impalpable breast lesions with the localization required for SNB. The miss and re-excision rates compare favourably with the needle-wire systems and carbon tracking techniques. There are significant resource efficiency and time advantages.

Radioguided occult lesion localization: better delineation of the injection site with a high-resolution collimator

Aim: Radioguided Occult Lesion Localization (ROLL) is a method for guiding the excision of occult breast lesions. A radiotracer is injected preoperatively in the tumor. The surgeon can locate the lesion with a gamma probe. It has been recommended that the tissue is resected where the activity falls rapidly. But this cut-off level can fluctuate depending on the user. The aim of this study was to compare the accuracy of two different types of collimation.Materials and methods: To simulate the detection of a radioactive “lesion”, 0.2ml of a solution of 99mTc labeled colloids (4MBq) were deposited at 3cm depth in a chunk of cow muscle. Detection was performed with a gamma probe (GammaSup, Clerad, F) equipped either with a regular or with an additional high-resolution collimator. The response curve was drawn moving laterally the probe on the chunk of cow by 5mm steps. Edges of resection were determined with different cut-off levels (from 5 to 50% of maximum counts by 5% steps).Results: Without additional collimator, the mean distance between injection point and resection edge was 18mm, standard deviation 7.8mm with a range between 11 and 18mm. With additional collimator, the mean distance decreased to 10mm (−44%), standard deviation 4.2mm (−46%) with a range between 6 and 10mm.Conclusion: The results demonstrate that the additional collimator provides more precise and reproductive delineation of the injection site. It should be optimal for the ROLL technique.

Radio-guided occult lesion localization in patients undergoing breast-conserving surgery and sentinel node biopsy

Background The objective of the study was to evaluate the feasibility of radio-guided occult lesion localization (ROLL) in breast-conserving surgery for nonpalpable breast cancer. Methods Altogether 215 breast cancer patients were included in a prospective study. Ultrasonographically guided intratumoral injection of radioactive tracer was used for tumor localization in 64 patients with nonpalpable tumors, visible in breast ultrasonography (the ROLL group). Nonpalpable tumors, visible only in mammography, were localized with a help of a guidewire in 14 patients (the WGR group). The remaining 137 patients had palpable tumors. Results The proportion of specimens with close or involved margins (0 to 3 mm) was the same in the ROLL group (6%) and among cases with palpable tumors (5%). In addition the median length of the closest margin did not differ significantly between the groups. Conclusions The results of ROLL for nonpalpable breast cancer are comparable with those for resection of palpable tumors.

Radio-guided occult lesion localization in patients undergoing breast-conserving surgery and sentinel node biopsy

Background The objective of the study was to evaluate the feasibility of radio-guided occult lesion localization (ROLL) in breast-conserving surgery for nonpalpable breast cancer. Methods Altogether 215 breast cancer patients were included in a prospective study. Ultrasonographically guided intratumoral injection of radioactive tracer was used for tumor localization in 64 patients with nonpalpable tumors, visible in breast ultrasonography (the ROLL group). Nonpalpable tumors, visible only in mammography, were localized with a help of a guidewire in 14 patients (the WGR group). The remaining 137 patients had palpable tumors. Results The proportion of specimens with close or involved margins (0 to 3 mm) was the same in the ROLL group (6%) and among cases with palpable tumors (5%). In addition the median length of the closest margin did not differ significantly between the groups. Conclusions The results of ROLL for nonpalpable breast cancer are comparable with those for resection of palpable tumors.

Surgical outcomes for clinically occult breast lesions: comparing radioguided occult lesion localisation (ROLL) vs. wire guided lumpectomy (WGL)

Background: Management of clinically occult breast lesions is still a major point of debate. Several techniques (eg, skin projection, guidewire localization) have been proposed, but all of them have technical limitations.Study Design: The aim of this study was to assess the efficacy of a new method to locate occult breast lesions using technetium-99m (99mTc)-labeled colloid particles of human serum albumin (radioguided occult lesion localization). We studied 647 consecutive patients (mean age 51.3 years; range 25 to 77 years) with nonpalpable breast lesions detected mammographically or by ultrasonography. Within 24 hours before operation, 3.7 MBq (0.1 mCi) of 99mTc-labeled colloid was injected directly into the center of the lesion using stereotactic mammographic guidance (when only microcalcifications were present) or ultrasonographic guidance (for opacities). Excision biopsy was performed with a gamma-detecting probe. After excision, the area was checked for residual radioactivity and the specimen was radiographed to verify complete removal of the lesion. The material was then sent for pathologic examination. The absorbed dose to the inoculated area and the external irradiation to staff were also determined.Results: In all 647 patients, the “hot spot” was located easily and quickly. X-ray and scintigraphy of the specimen verified the presence and centricity of the lesion in all patients but three (99.5%). Pathologic examination revealed 340 cancer lesions (52.6%). Of these patients, 339 (99.7%) were treated by breast-conserving operations and one (0.3%) received a modified radical mastectomy. No major surgical or postoperative complications were encountered. No recurrences were documented during follow-up. The absorbed dose to the breast and other tissue was negligible (0.03 ± 0.02 mGy/MBq), as was the dose to the surgeon’s hands (7.5 ± 5.0 μSv/h). The latter dose represents 0.015% and 0.002% of the recommended limits of the European Community for the general population and for exposed workers, respectively.Conclusions: Radioguided occult lesion localization seems to offer a simple and reliable method to locate occult breast lesions with a gamma-detecting probe, allowing complete removal of the lesion in 99.5% of patients. Because of the small quantity of radioactivity, the procedure is safe for both patients and medical staff.

Radioguided occult lesion localisation (ROLL) and sentinel node biopsy for impalpable invasive breast cancer

Radioguided occult lesion localisation (ROLL) and sentinel node biopsy for impalpable invasive breast cancer

Emprego concomitante da localização radioguiada da lesão e do estudo do linfonodo sentinela para o carcinoma invasor de mama não palpável

OBJETIVO: analisar o emprego concomitante da localização radioguiada de lesão não palpável e do estudo do linfonodo sentinela (LS) em mulheres com câncer de mama. MÉTODO: estudo prospectivo de 45 pacientes com carcinoma não palpável de mama. O radiofármaco utilizado foi o dextram marcado pelo 99mTc. Realizou-se injeção no sítio peritumoral, sob orientação ultra-sonográfica ou estereotáxica, com auxílio de agulha de raquianestesia de gauge 18. A linfocintilografia, para visualização pré-operatória do local da lesão e do LS, foi feita em gama câmera convencional, com abdução de 90º do membro superior ipsilateral. A exérese da lesão primária e a do LS foram realizadas com auxílio de sonda de detecção de radiação gama. RESULTADOS: quanto à remoção do tumor primário, obteve-se taxa de sucesso em todos os casos. Houve necessidade de ampliação de margem cirúrgica em cinco pacientes. Em relação ao LS houve falha em quatro casos, com índice de localização de 93%. Não foram observadas complicações. CONCLUSÃO: os resultados obtidos parecem demonstrar que a utilização simultânea dos dois procedimentos constitui estratégia eficaz para o tratamento do câncer inicial de mama em uma única sessão

An original approach in the diagnosis of early breast cancer: use of the same radiopharmaceutical for both non-palpable lesions and sentinel node localisation.

A modern approach to the surgical treatment of early breast carcinoma requires intraoperative localisation of non-palpable lesions and assessment of the lymph node status. Localisation of breast lesions can be achieved by intratumoural injection of a small amount of radiotracer and intraoperative use of a gamma probe (i.e. radioguided occult lesion localisation, or ROLL). Assessment of the lymph node status is possible by means of the sentinel node approach. To date, two different radiopharmaceuticals have been used for localisation of tumour and sentinel node. We now propose the use of a single nanocolloidal tracer (Nanocoll, with a particle size of less than 80 nm) which is labelled with technetium-99m for simultaneous performance of ROLL and sentinel node identification. The aim of this study was to evaluate the feasibility of this approach, which should be easier and more practical than the dual-tracer injection method. We have employed this new technique in 73 patients with non-palpable, cytologically diagnosed breast cancer and non-palpable axillary lymph nodes. In all patients the radiocolloid, in a total volume of 0.3-0.4 cc, was injected under sonographic or stereotactic guidance. Half of the dose was injected intratumourally and half superficially, but very close to the tumour. Because of the slow lymphatic flow in the breast, Nanocoll must be injected some time before surgery in order to enable adequate migration to the axilla. We injected colloid in the afternoon before surgery (16-23 h before the start of the operation, with an average interval of 18 h). An average dose of 130 MBq (range 110-150) was injected in order to have about 10 MBq of radioactivity when surgery commenced. Lymphoscintigraphy was performed after 15-19 h, with an average interval of 17 h. The procedure was always successful in permitting the localisation of occult breast lesions. Lesions were always localised at the first attempt, and were always contained within the surgical margins. Histological examination revealed all 73 resected lesions to be malignant: there were 64 cases of infiltrating carcinoma and nine of intraductal carcinoma. All breast lesions were therefore confirmed to be early breast cancer. We achieved sentinel node localisation in 71 out of 73, either at scintigraphy or with the intraoperative probe; in two patients, radiopharmaceutical migration was absent. Lymphoscintigraphy showed only axillary drainage in 52 cases, only internal mammary chain (IMC) drainage in nine cases, and combined axillary and IMC drainage in eight cases. In two cases, lymphoscintigraphy suggested the sentinel node was located inside the same breast (intramammary lymph node). All the visualised sentinel nodes were biopsied except for four that were localised in the IMC. Histological examination of the nodes showed metastases in 20 cases: in 15 cases there were micrometastases, and in five, macrometastases. In conclusion, this study has demonstrated the feasibility of the proposed procedure. Simultaneous performance of ROLL and sentinel node localisation using a single tracer represents a useful and practicable choice in the management of early breast cancer.

Use of technetium-99m–labeled colloid albumin for preoperative and intraoperative localization of nonpalpable breast lesions

Background: Management of clinically occult breast lesions is still a major point of debate. Several techniques (eg, skin projection, guidewire localization) have been proposed, but all of them have technical limitations. Study Design: The aim of this study was to assess the efficacy of a new method to locate occult breast lesions using technetium-99m ( 99mTc)-labeled colloid particles of human serum albumin (radioguided occult lesion localization). We studied 647 consecutive patients (mean age 51.3 years; range 25 to 77 years) with nonpalpable breast lesions detected mammographically or by ultrasonography. Within 24 hours before operation, 3.7 MBq (0.1 mCi) of 99mTc-labeled colloid was injected directly into the center of the lesion using stereotactic mammographic guidance (when only microcalcifications were present) or ultrasonographic guidance (for opacities). Excision biopsy was performed with a gamma-detecting probe. After excision, the area was checked for residual radioactivity and the specimen was radiographed to verify complete removal of the lesion. The material was then sent for pathologic examination. The absorbed dose to the inoculated area and the external irradiation to staff were also determined. Results: In all 647 patients, the “hot spot” was located easily and quickly. X-ray and scintigraphy of the specimen verified the presence and centricity of the lesion in all patients but three (99.5%). Pathologic examination revealed 340 cancer lesions (52.6%). Of these patients, 339 (99.7%) were treated by breast-conserving operations and one (0.3%) received a modified radical mastectomy. No major surgical or postoperative complications were encountered. No recurrences were documented during follow-up. The absorbed dose to the breast and other tissue was negligible (0.03 ± 0.02 mGy/MBq), as was the dose to the surgeon’s hands (7.5 ± 5.0 μSv/h). The latter dose represents 0.015% and 0.002% of the recommended limits of the European Community for the general population and for exposed workers, respectively. Conclusions: Radioguided occult lesion localization seems to offer a simple and reliable method to locate occult breast lesions with a gamma-detecting probe, allowing complete removal of the lesion in 99.5% of patients. Because of the small quantity of radioactivity, the procedure is safe for both patients and medical staff.

Radioguided localization of occult breast lesions

Abstract Clinically occult breast lesions are found with increasing frequency by breast screening, and several methods have been used to locate suspicious occult lesions prior to excision. We have developed a new localization technique called ROLL (radioguided occult lesion localization) in which a small quantity of 99m Tc-labelled colloidal serum albumin is injected into the lesion during mammographic or ultrasonic examination. Correct positioning is checked by scintigraphy. A gamma detecting probe is then used to locate the lesion and guide its surgical removal. We report on the first 225 patients in whom we have employed this technique; all had non-palpable breast lesions identified by mammography or ultrasound as clusters of microcalcifications or small opacities. Pathology revealed 134 cancers, 133 of which were treated by breast-conserving surgery. In all but 2 cases (99%), radiolabelling coincided with the lesion site. X-radiography verified that the specimen removed contained all of the lesion. Removal of clinically occult breast lesions is greatly facilitated by the gamma probe, which locates the skin projection accurately, allowing choice of the most appropriate incision, and which can be employed continuously during surgery.