Specimen Radiography Research Articles

Clipped Axillary Node as a Potential Surrogate for Overall Axillary Nodal Status in Inflammatory Breast Cancer Patients after Neoadjuvant Chemotherapy

BackgroundAxillary lymph node dissection is the current standard for management of the axilla in inflammatory breast cancer (IBC). The present study aims to determine whether the initially positive node identified by clip placement accurately represents the overall nodal status of axilla after neoadjuvant chemotherapy (NAC) in IBC.Patients and MethodsA retrospective study was conducted on patients with IBC who underwent operation (2014–2023). For patients with IBC who had clip placement in a positive axillary node at diagnosis, operative notes, specimen radiographs, and pathology reports were reviewed to confirm final pathologic status of clipped nodes.ResultsIn total, 92 patients with IBC (90 cN+) were identified (median age 54 years, 78% invasive ductal, 10% invasive lobular, and 12% mixed); 81 (90%) were biopsy-proven cN+, with a clip placed in the positive node for 62/81 (77%). All patients were treated with NAC and axillary surgery with median 19 (range 4–49) nodes removed. Among 28 (out of 56) patients with retrieved clipped nodes that were pathologically negative (ypN0), only 1 had an additional positive node with micrometastasis for a false negative rate of 4% (95% CI 1–19%). Conversely, 3/3 patients with isolated tumor cells (ITCs) only in the clipped node had additional axillary disease (ITCs in 1, macrometastasis in 2), and 20/23 (87%) of patients with pathologically positive clipped node (micrometastasis or greater) had additional positive nodes [19/20 (95%) with macrometastasis].ConclusionsThe clipped biopsy-positive axillary node in IBC accurately represented the post-NAC overall axillary nodal status. ITCs post-NAC should be considered positive as an indicator of additional nodes with metastasis.

Abstract PO1-23-07: The effect of intra-operative margin assessment during breast conserving surgery for breast cancer in a Dutch cohort

Abstract Background Pre-operative tumour localisation and intraoperative specimen radiography are necessary to perform adequate resection of non-palpable breast tumours. Intraoperative digital specimen mammography (IDSM), is an alternative to conventional specimen radiography (CSR) and has the benefit of providing immediate specimen evaluation and the potential of decreasing operation time. IDSM may also reduce positive margins and re-excision rates. IDSM was implemented in our hospital in 2018. The study objective was to evaluate the surgery time, radicality and re-excisions in IDSM and CSR. Methods A single centre retrospective cohort study with two cohorts: CSR (n=532) and IDSM (n=475). The primary outcome was duration of surgery. Secondary outcomes were margin status of the primary surgery, the perioperative cavity shave rate and the re-excision rate. Differences between cohorts were compared using univariate statistics and multiple regression to adjust for variables that were statistically significantly associated with duration of surgery. Results IDSM use was associated with 8 minutes shorter surgery time (B -8.242, p < 0.001). Treatment variables independently associated with the duration of surgery were use of IDSM, type of (axillary) surgery and the performance of cavity shaving. Cavity shaves were more often performed when IDSM was used (24% versus 14% in CSR group, p < 0.001), while the proportion of radical first surgeries (93% versus 96% respectively, p = 0.070) was comparable. Conclusion IDSM was associated with a modest reduction in duration of surgery. Surgeons performed more cavity shaves since IDSM but this was not reflected by a lower proportion of patients with positive margins. Table 1. Baseline characteristics of the CSR versus the IDSM cohort Table 2. Results of surgery in the CSR versus the IDSM cohort. Citation Format: Sophie Wooldrik, Elles van de Voort, Taco Klem, Thijs van Dalen, Cornelis Verhoef, Gerson Struik, Erwin Birnie. The effect of intra-operative margin assessment during breast conserving surgery for breast cancer in a Dutch cohort [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-23-07.

A novel method of assessing intraoperative surgical margins in patients with dermatofibrosarcoma protuberans: A specimen radiography system.

Background Dermatofibrosarcoma protuberans (DFSP) is one of the most challenging cutaneous cancers in surgical clinic practice. Excision with negative margins is essential for effective disease control. However, wide surgical margins and maximal tissue conservation are mutually exclusive. Mohs micrographic surgery conserves tissue but is time-consuming. Thus, we developed a novel specimen radiography system that can be used intraoperatively. Aims To introduce a specimen radiography system for evaluating intraoperative surgical margins in patients with dermatofibrosarcoma protuberans. Methods Since September 2017, we have treated seven biopsy-proven cases of local DFSPs via local excision with surgical margins of 2-4 cm. During operations, the operative specimens were screened using the specimen radiography system. All surgical specimens were pathologically examined intraoperatively. Results Five patients were men and two were women, of median age 36 years. The mean radiographic screening time was 9.7 ± 2.3 min. Radiographically negative margins were confirmed intraoperatively. The minimal margin width ranged from 5.0 to 35.4 mm (mean width 16.9 ± 10.4 mm). The intraoperatively negative radiographic margins were consistent with those revealed by postoperative pathology. The minimal pathological margin width ranged from 4.0 to 34.5 mm (mean 16.6 ± 10.1 mm) and was not significantly different from the intraoperative data. Limitations The sample size was small and positive or negative predictive values were not calculated. Conclusions We introduce a novel method of intraoperative surgical margin assessment for DFSP patients. It may find broad clinical and research applications during oncoplastic surgery.

Programming for exposure chart modelling in conventional X-ray radiography

In radiography, an exposure chart is needed to determine the correct exposure. The creation of exposure chart so far requires a lot of film. To reduce the use of film, a program was created that utilizes the principles of radiographic exposure in the form of the relationship between tube current, tube voltage, exposure time, and geometry principles. The program was validated through curve fitting and Mean Absolute Percentage Error (MAPE) by comparing the density of the specimen radiograph image with the exposure chart generated by the program. The generated exposure chart is the exposure chart for steel with voltages of 120 kV, 130 kV, 140 kV, 150 kV, and 160 kV. The resulting exposure chart has a coefficient of determination of 0.97 and has high accuracy.

Retained Biopsy Site Markers After Breast Lesion Surgical Resection: Associations With Residual Malignancy.

BACKGROUND. Biopsy site markers (BSMs) placed during image-guided core needle biopsy (CNB) are typically targeted for surgical excision, along with the breast imaging abnormality. Retained BSMs raise concern of incomplete resection of the breast abnormality. OBJECTIVE. The purpose of our study was to assess the frequency of residual malignancy in patients with retained BSMs identified on the initial mammography performed after breast lesion surgical excision. METHODS. This retrospective study included 30 patients (median age, 59 years) who underwent surgical resection between August 2015 and April 2022 of a borderline, high-risk, or malignant breast lesion after CNB and technically adequate preoperative image-guided localization, in whom the initial postoperative mammography report described a retained nonmigrated BSM. EMR data were extracted. The index pathology from CNB and initial surgical resection was classified as malignant or nonmalignant. The presence of residual malignancy after initial surgical resection required pathologic confirmation from subsequent tissue sampling; the absence of residual malignancy required 2 years of benign imaging follow-up. RESULTS. Thirteen specimen radiographs were interpreted intraoperatively by a surgeon with later radiologist interpretation, and 17 underwent real-time radiologist interpretation. Eighteen patients had malignant index pathology from the initially resected lesion. The frequency of residual malignancy on subsequent follow-up after initial surgical resection was higher in patients with malignant than nonmalignant index pathology (39% [7/18] vs 0% [0/12], respectively; p = .02). Among patients with malignant index pathology, the frequency of residual malignancy was higher in those without, than with, malignancy in the initial surgical specimen (80% [4/5] vs 23% [3/13]; p = .047). Also in these patients, the frequency of a positive interpretation of the initial postoperative mammography (BI-RADS category 4 or 6) was not significantly different between those with and without residual malignancy (57% [4/7] vs 55% [6/11]; p > .99). CONCLUSION. Patients with retained BSMs associated with malignant index lesions are at substantial risk of having residual malignancy. Initial postoperative mammography is not sufficient for excluding residual malignancy. CLINICAL IMPACT. Retained BSMs associated with index malignancy should be considered suspicious for residual malignancy. In this scenario, timely additional tissue sampling targeting the retained BSM is warranted, given the greater-than-2% chance of malignancy. Active surveillance is a reasonable management strategy in patients with retained BSMs from nonmalignant index lesions.

The Effect of Intraoperative Margin Assessment During Breast Conserving Surgery for Breast Cancer in a Dutch Cohort

IntroductionIntraoperative specimen radiography is a routinely used procedure to ensure adequate resection of non-palpable breast tumors. Intraoperative digital specimen mammography (IDSM) is an alternative to conventional specimen radiography (CSR) which provides immediate specimen evaluation and can potentially decrease operation time. IDSM may also result in lower positive margin and re-excision rates. IDSM was implemented in our hospital in 2018. The objective of this study was to evaluate the effect of using IDSM versus CSR on operation time, margin status and re-excision rates in breast conserving surgery. MethodsThe present study is a single-center retrospective cohort study with 2 patient cohorts: one which underwent CSR (n = 532) and one which underwent IDSM (n = 475). The primary outcome was the operation time. Secondary outcomes were the margin status of the primary surgery, the cavity shaving rate, and the re-excision rate. Differences between cohorts were compared using univariate statistics and multiple regression analyses to adjust for variables that were significantly different between the groups. ResultsIDSM use was associated with an 8-minute reduction in surgery time (B = -8.034, 95% CI [-11.6, -4.5]; P < .001). Treatment variables independently associated with the operation time included use of IDSM, type of surgery, and performance of cavity shaving. Cavity shaves were more often performed when IDSM was used (24% for IDSM vs. 14% for CSR, P < .001), while the proportion of negative margin rates (93% for IDSM vs. 96% for CSR, P = .070) was comparable. ConclusionIDSM was associated with a modest reduction in operation time. Surgeons performed more cavity shaves since the introduction of IDSM, but this increase was not reflected by difference in negative margin rates.

Surgeon and Radiologist Evaluation of Electromagnetic Chip Localization for Benign and Malignant Breast Lesions.

SmartClipTM is a food and drug administration-approved, electromagnetic chip (EMC) localization system that provides three-dimensional navigation for the excision of soft tissue lesions. The purpose of this study was to analyze the accuracy and feasibility of EMC radiologic and surgical localization for benign and malignant breast lesions. An institutional review board-approved, single institution, prospective study from October 2020 to September 2022 of 38 women undergoing breast conserving surgery with EMC localization of a single lesion > 5 mm on mammogram (MMG) or ultrasound (US) imaging. Surveys from performing breast radiologists and breast surgeons were collected after image-guided localization and surgical excision. Seventy-six survey responses from nine radiologists and four surgeons were received. The deployment needle and EMC were highly visible in 86.8% and 76.3% of procedures, respectively. There was no difficulty in deployment for 92.1% of procedures. The EMC was in the correct location on postdeployment MMG in 97.4% of cases. Three instances of EMC migration occurred, one 1 cm from target lesion. The targeted mass and EMC were within the surgical specimen in 97.4% of cases. On specimen radiograph, 39.5% of the EMCs were 0-1 mm from the center of the target lesion, 18.4% were within 2-4 mm, and 23.7% were within 5-10 mm. Mean operating room time for all cases was 65 min. One case required US to localize the target due to console malfunction. There was successful EMC deployment by radiologists with accurate visualization and successful surgical excision in most cases. The EnVisioTM SmartClipTM system is a reproducible and accurate localization method for benign and malignant breast lesions.

Radiomic and deep learning characterization of breast parenchyma on full field digital mammograms and specimen radiographs: a pilot study of a potential cancer field effect.

In women with biopsy-proven breast cancer, histologically normal areas of the parenchyma have shown molecular similarity to the tumor, supporting a potential cancer field effect. The purpose of this work was to investigate relationships of human-engineered radiomic and deep learning features between regions across the breast in mammographic parenchymal patterns and specimen radiographs. This study included mammograms from 74 patients with at least 1 identified malignant tumor, of whom 32 also possessed intraoperative radiographs of mastectomy specimens. Mammograms were acquired with a Hologic system and specimen radiographs were acquired with a Fujifilm imaging system. All images were retrospectively collected under an Institutional Review Board-approved protocol. Regions of interest (ROI) of were selected from three regions: within the identified tumor, near to the tumor, and far from the tumor. Radiographic texture analysis was used to extract 45 radiomic features and transfer learning was used to extract 20 deep learning features in each region. Kendall's Tau-b and Pearson correlation tests were performed to assess relationships between features in each region. Statistically significant correlations in select subgroups of features with tumor, near to the tumor, and far from the tumor ROI regions were identified in both mammograms and specimen radiographs. Intensity-based features were found to show significant correlations with ROI regions across both modalities. Results support our hypothesis of a potential cancer field effect, accessible radiographically, across tumor and non-tumor regions, thus indicating the potential for computerized analysis of mammographic parenchymal patterns to predict breast cancer risk.

Annotated catalogue of the type specimens of salmon, cod and cottoid fishes described by Dmitry Taliev

The article provides a brief biography of the ichthyologist Dmitry Nikolayevich Taliev (1908–1952), as well as information and illustrations for 24 taxa described by him from the White Sea (Gadidae – one subspecies), the coast of the Sea of Okhotsk (Salmonidae – one subspecies), Lake Baikal (Cottidae – 2 species and 4 subspecies; Abyssocottidae – 6 species and 8 subspecies), and Lake Baunt (Cottidae – 1 subspecies; Abyssocottidae – 1 species). For 19 taxa, photographs and radiographs of type specimens kept in the collection of the Zoological Institute of the Russian Academy of Sciences (Saint Petersburg, Russia) are presented for the first time. Type specimens of three species and two subspecies from the families Cottidae and Abyssocottidae found in the collection are examined and catalogued. It was revealed that Cottus kessleri bauntovi Taliev, 1946 and Limnocottus kozovi Taliev, 1946 are morphologically similar to Cottus sibiricus, a species widely distributed in Siberia, including Lake Baunt. According to modern fish taxonomy, Taliev’s 12 taxa are valid. Findings of type specimens in the historical collection are extremely important for the scientific community.

Conventional specimen radiography in breast-conserving therapy: a useful tool for intraoperative margin assessment after neoadjuvant therapy?

PurposeA previous study in our breast unit showed that the diagnostic accuracy of intraoperative specimen radiography and its potential to reduce second surgeries in a cohort of patients treated with neoadjuvant chemotherapy were low, which questions the routine use of Conventional specimen radiography (CSR) in this patient group. This is a follow-up study in a larger cohort to further evaluate these findings.MethodsThis retrospective study included 376 cases receiving breast-conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) of primary breast cancer. CSR was performed to assess potential margin infiltration and recommend an intraoperative re-excision of any radiologically positive margin. The histological workup of the specimen served as gold standard for the evaluation of the accuracy of CSR and the potential reduction of second surgeries by CSR-guided re-excisions.Results362 patients with 2172 margins were assessed. The prevalence of positive margins was 102/2172 (4.7%). CSR had a sensitivity of 37.3%, a specificity of 85.6%, a positive predictive value (PPV) of 11.3%, and a negative predictive value (NPV) of 96.5%. The rate of secondary procedures was reduced from 75 to 37 with a number needed to treat (NNT) of CSR-guided intraoperative re-excisions of 10.In the subgroup of patients with clinical complete response (cCR), the prevalence of positive margins was 38/1002 (3.8%), PPV was 6.5% and the NNT was 34.ConclusionThis study confirms our previous finding that the rate of secondary surgeries cannot be significantly reduced by CSR-guided intraoperative re-excisions in cases with cCR after NACT. The routine use CSR after NACT is questionable, and alternative tools of intraoperative margin assessment should be evaluated.

O077 Accuracy of intraoperative techniques for margin assessment in breast cancer surgery

Abstract Introduction There are a wide variety of intraoperative techniques available in breast surgery to achieve low rates for positive margins of excision. The objective of this systematic review was to determine the diagnostic accuracy of intraoperative breast margin assessment techniques, establishing a benchmark against which novel techniques may be compared. Methods A systematic search of the literature was conducted to identify studies assessing the diagnostic accuracy of intraoperative margin assessment (IOMA) techniques. Only clinical studies with raw diagnostic accuracy data as compared with final permanent section histopathology were included in the meta-analysis. A bivariate model for diagnostic meta-analysis was used to determine overall pooled sensitivity and specificity for each technique. Results Sixty-two studies were included for meta-analysis. The majority of studies evaluated specimen radiography (n= 20), frozen section (n= 14) and cytology (n= 13). Other techniques such as intraoperative ultrasound (n= 7), optical spectroscopy (n= 5), margin probe (n= 3) and micro-CT (n= 3) were less commonly evaluated. Frozen section, optical spectroscopy and cytology had the greatest diagnostic accuracy with sensitivities of 80%, 89% and 88%, respectively, and specificities of 97%, 94% and 93%, respectively. Conclusion Pooled data indicate that optical spectroscopy, cytology and frozen section have the greatest diagnostic accuracy of currently available IOMA techniques. However, long turnaround time for results and their resource intensive nature has prevented widespread adoption of these methods. The aim of emerging technologies is to challenge the diagnostic accuracy of these established techniques, while improving speed, cost and usability.

Breast-Conserving Surgery Margin Guidance Using Micro-Computed Tomography: Challenges When Imaging Radiodense Resection Specimens.

Breast-conserving surgery (BCS) is an integral component of early-stage breast cancer treatment, but costly reexcision procedures are common due to the high prevalence of cancer-positive margins on primary resections. A need exists to develop and evaluate improved methods of margin assessment to detect positive margins intraoperatively. A prospective trial was conducted through which micro-computed tomography (micro-CT) with radiological interpretation by three independent readers was evaluated for BCS margin assessment. Results were compared to standard-of-care intraoperative margin assessment (i.e., specimen palpation and radiography [abbreviated SIA]) for detecting cancer-positive margins. Six hundred margins from 100 patients were analyzed. Twenty-one margins in 14 patients were pathologically positive. On analysis at the specimen-level, SIA yielded a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 42.9%, 76.7%, 23.1%, and 89.2%, respectively. SIA correctly identified six of 14 margin-positive cases with a 23.5% falsepositive rate (FPR). Micro-CT readers achieved sensitivity, specificity, PPV, and NPV ranges of 35.7-50.0%, 55.8-68.6%, 15.6-15.8%, and 86.8-87.3%, respectively. Micro-CT readers correctly identified five to seven of 14 margin-positive cases with an FPR range of 31.4-44.2%. If micro-CT scanning had been combined with SIA, up to three additional margin-positive specimens would have been identified. Micro-CT identified a similar proportion of margin-positive cases as standard specimen palpation and radiography, but due to difficulty distinguishing between radiodense fibroglandular tissue and cancer, resulted in a higher proportion of falsepositive margin assessments.

Abstract P2-14-19: Targeted Axillary Lymph Node Dissections Using Radar Reflector Localization Can Reduce Unnecessary Axillary Lymph Node Dissections in Node Positive Patients Treated with Neoadjuvant Chemotherapy

Abstract Background Targeted axillary dissection (TAD) is a surgical strategy that involves staging the axilla through sentinel lymph node biopsy (SLNB) combined with the removal of a biopsy-proven positive lymph node identified by a clip. TAD reduces the false negative rate of SLNB alone in patients with clinically detected nodal metastasis who receive neoadjuvant chemotherapy (NAC) while avoiding axillary lymph node dissections (ALND). Radar reflector-localization (RRL) can be used to identify previously positive nodes and safely and effectively guide dissection. Methods We performed an institutional retrospective chart review of breast cancer patients with clinical stage T1-3 and N1-3 disease treated with NAC from 2015 to 2020 who had a biopsy proven positive node and underwent TAD using RRL. The primary outcome was the retrieval of clipped node as documented by gross visualization or specimen radiography. Secondary outcomes included pathologic complete response rates and completion axillary lymph node dissections (cALND). Results 79 patients were identified who fulfilled inclusion criteria. 32 (40.5%) had RRL markers placed prior to chemotherapy (mean 187 days prior to surgery) and 47 (59.5%) had RRL markers placed following the completion of chemotherapy (mean 7 days prior to surgery). The clipped node was retrieved in 77 patients (97.5%). 32 of the 34 ypN0 (i+) patients avoided an ALND; 1 patient had a cALND for failure to localize the RRL and 1 patient had a cALND for a false-positive on frozen section. There was no significant difference in clip recovery rates in the pre vs post NAC RRL groups (p=1.00). Conclusion RRL systems are an effective way to guide TAD with a high success rate in identifying and removing previously biopsied nodes. These markers can be placed prior to NAC without migration or deactivation. This strategy allows surgeons to avoid unnecessary cALND. Citation Format: Lilia Lunt, Alison Coogan, Andrea Madrigrano, Cristina O’Donoghue. Targeted Axillary Lymph Node Dissections Using Radar Reflector Localization Can Reduce Unnecessary Axillary Lymph Node Dissections in Node Positive Patients Treated with Neoadjuvant Chemotherapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-14-19.

Abstract P3-04-09: 3-dimensional intraoperative analysis of screen-detected breast cancers reduce re-excision rates

Abstract Introduction: Breast conserving therapy, has generally been accepted as treatment of choice for early invasive breast cancer. However adequate local control depends on obtaining negative margins and receipt of radiation In 20-30 % of patients with breast conserving surgery a second re-excision procedure is due to tumor-positive margins at histopathology. Margins re-excision rate are variable across the countries. Mean re-excision rate of 17.2% across units in UK. Intraoperative specimen radiography,used to evaluate partial mastectomy specimens ensure that the lesion is adequately removed. Objective: to determine whether 3D-intraoperative imaging better predicts margin status and reduces the re-excision rate than conventional 2D imaging. Methods: Retrospective study comparing two cohorts of patients 360 screen-detected breast cancer (2D cohort). April 2015 to March 2018 300 screen-detected breast cancer (3D cohort) April 2018 to March 2021 Royal Cornwall Hospital (RCHT) introduced a 3D intraoperative system for all cases in April 2018 Prior to the introduction of 3D intraoperative imaging at RCHT the re-excision rate was stable at approximately 15%. All patient had undergone preoperative digital mammogram and ultrasound. All patients had core biopsy diagnosis All malignancies were localised with ROLL (Radio-guided occult lesion localization) techniques. All wide local excision were performed by 5 fully trained oncoplastic breast surgeons (similar distribution within the two cohort) Specimen radiograph was performed intraoperatively using: 2D x-ray device (Faxitron system; Trident Hologic, Marlborough, MA) or 3D tomosynthesis (Mozart system; Kubtec Medical imaging, Stratford,CT). For both methods of assessment,specimen was placed in the device and auto exposed without any compression of tissue. All specimens were marked with orienting sutures and clips according to local protocol. All specimens were painted in theatre by the operating surgeon. All specimens were examined by the same pathologists. No change in margin protocol for 12 years(already compliant to ABS guidelines) • A clear margin for invasive cancer was defined as tumour found within 1mm of margin. For ductal carcinoma in situ (DCIS), a margin was classified as positive if ink on tumour, was classified as close ink is found in under 2 mm from tumour and as negative if more or equal to 2 mm, in accordance with NICE guidelines. (22) Statistical Analysis: • The study compares patient demographics, histology, and re-excision rates between 2D and 3D • Descriptive and comparative statistics are be calculated for all collected data TABLE 1: 3D/2D RR 0.59 (P:0.01), CI 0,3369-09068, Z -2.3473, P 0.0189 Conclusions: The use of intraoperative 3D specimen X-ray reduced the relative risk of re-excision rate by 41% (P=0.01) without any negative impact on other parameters. Table 1: Results 3D intraoperative imaging versus 2D intraoperative imaging Citation Format: Jo Mondani, Hamza Arabiyat, Stavroula Kastora, Mona Sulieman, Imran Abbas, Polly King, Rachel English, Iain Brown, Miklos Barta, Nicola Jackson, Philip Drew. 3-dimensional intraoperative analysis of screen-detected breast cancers reduce re-excision rates [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-04-09.

Imaging of lumpectomy surface with large field-of-view confocal laser scanning microscopy ‘Histolog® scanner’ for breast margin assessment in comparison with conventional specimen radiography

PurposeThe Histolog® Scanner (SamanTree Medical SA, Lausanne, Switzerland) is a large field-of-view confocal laser scanning microscope designed to allow intraoperative margin assessment by the production of histological images ready for assessment in the operating room. We evaluated the feasibility and the performance of the Histolog® Scanner (HS) to correctly identify infiltrated margins in clinical practice of lumpectomy specimens. It was extrapolated if the utilization of the HS has the potential to reduce infiltrated margins and therefore reduce re-operation rates in patients undergoing breast conserving surgery (BCS) due to a primarily diagnosed breast cancer including ductal carcinoma in situ. MethodsThis is a single-center, prospective, non-interventional, diagnostic pilot study including 50 consecutive patients receiving BCS. The complete surface of the specimen was scanned using the HS intraoperatively. The surgery and the intraoperative margin assessment of the specimen was performed according to the clinical routine consisting of conventional specimen radiography as well as the clinical impression of the surgeon. Three surgeons and an experienced pathologist assessed the scans produced by the HS for cancer cells on the surface. The potential of the HS to correctly identify involved margins was compared to the results of the conventional specimen radiography alone as well as the clinical routine. The histopathological report served as the gold standard. Results50 specimens corresponding to 300 surfaces were scanned by the HS. The mean sensitivity of the surgeons to identify involved margins with the HS was 37.5% ± 5.6%, the specificity was 75.2% ± 13.0%. The assessment of resection margins by the pathologist resulted in a sensitivity of 37.5% and a specificity of 81.0%, while the local clinical routine resulted in a sensitivity of 37.5% and a specificity of 78.2%. ConclusionAcquisition of high-resolution histological images using the HS was feasible in clinical practice. Sensitivity and specificity were comparable to clinical routine. With more specific training and experience on image interpretation and acquisition, the HS may have the potential to enable more accuracy in the margin assessment of BCS specimens.

Contrast-enhanced Mammography-guided Biopsy: Initial Trial and Experience.

Evaluate lesion visibility and radiologist confidence during contrast-enhanced mammography (CEM)-guided biopsy. Women with BI-RADS ≥4A enhancing breast lesions were prospectively recruited for 9-g vacuum-assisted CEM-guided biopsy. Breast density, background parenchymal enhancement (BPE), lesion characteristics (enhancement and conspicuity), radiologist confidence (scale 1-5), and acquisition times were collected. Signal intensities in specimens were analyzed. Patient surveys were collected. A cohort of 28 women aged 40-81 years (average 57) had 28 enhancing lesions (7/28, 25% malignant). Breast tissue was scattered (10/28, 36%) or heterogeneously dense (18/28, 64%) with minimal (12/28, 43%), mild (7/28, 25%), or moderate (9/28, 32%) BPE on CEM. Twelve non-mass enhancements, 11 masses, 3 architectural distortions, and 2 calcification groups demonstrated weak (12/28, 43%), moderate (14/28, 50%), or strong (2/28, 7%) enhancement. Specimen radiography demonstrated lesion enhancement in 27/28 (96%). Radiologists reported complete lesion removal on specimen radiography in 8/28 (29%). Average time from contrast injection to specimen radiography was 18 minutes (SD = 5) and, to post-procedure mammogram (PPM), 34 minutes (SD = 10). Contrast-enhanced mammography PPM was performed in 27/28 cases; 13/19 (68%) of incompletely removed lesions on specimen radiography showed residual enhancement; 6/19 (32%) did not. Across all time points, average confidence was 2.2 (SD = 1.2). Signal intensities of enhancing lesions were similar to iodine. Patients had an overall positive assessment. Lesion enhancement persisted through PPM and was visible on low energy specimen radiography, with an average "confident" score. Contrast-enhanced mammography-guided breast biopsy is easily implemented clinically. Its availability will encourage adoption of CEM.

Breast excisional specimen radiograph: a single centre experience from a regional laboratory

Breast excisional specimen radiograph: a single centre experience from a regional laboratory

Abstract B021: Use of wide field optical coherence tomography (WF-OCT) in margin assessment during breast conserving surgery (BCS) for ductal carcinoma in situ (DCIS)

Abstract Purpose: To assess the utility of a novel imaging technology for intraoperative margin assessment in breast conserving surgery (BCS) for ductal carcinoma in situ (DCIS). Background: The multi-focal nature of DCIS presents a challenge to ensuring negative margins during BCS. Routine methods for intraoperative margin assessment, such as specimen radiography, ultrasound, cavity margins, and touch prep cytology each have specific limitations, including operator skill, time delay, probe position, and specimen completeness. A more recent method, wide field optical coherence tomography (WF-OCT), enables real-time tissue visualization at up to 2 mm of depth with the ability to use image-based machine learning to identify regions of interest suspicious for residual malignancy. Methods: Two adult females with biopsy-proven DCIS and one with invasive carcinoma underwent BCS following routine surveillance mammography and were prospectively evaluated. Primary lesions were imaged intraoperatively with specimen radiography and a WF-OCT imaging device (OTIS, Perimeter Medical AI, Toronto, Canada); images from both modalities were read to identify potential residual malignancy, and additional tissue was excised as indicated. Permanent histopathology was compared to imaging results. Results: The first patient (76 y/o, BI-RADS 4B, 1.6 cm) underwent BCS and the excised sample was 4 x 3.7 x 3.2 cm. By radiography, the biopsy clip and localization reflector were within the specimen and margins appeared satisfactory; WF-OCT demonstrated residual disease at the inferior margin and additional tissue was excised. Permanent histology showed DCIS involvement of inferior primary margin; additional margin excision contained DCIS and was negative. The second patient (64 y/o, BI-RADS 4B, 1 cm) underwent BCS and the excised sample was 4 x 3.5 x 3.5. By radiography, the biopsy clip and reflector were within the specimen and margins appeared satisfactory; WF-OCT showed residual disease at the inferior and posterior margins and additional tissue was excised. Permanent histology demonstrated DCIS within 1 mm and pleomorphic lobular carcinoma in situ (LCIS) microns from primary inferior margin; the additional inferior sample was margin negative, and posterior sample contained pleomorphic LCIS and was margin negative. The last patient (76 y/o, BI-RADS 5, 1.9 x 1.9 x 1.7 cm) underwent BCS and the excised sample was 6.5 x 5.3 x 4.2 cm. By radiography, the biopsy clip and localization reflector were within the specimen and margins appeared satisfactory; WF-OCT showed residual disease at the lateral margin and also revealed occult DCIS not found on biopsy. Additional tissue was taken until margin clearance by WF-OCT. Permanent histology demonstrated DCIS to &amp;lt;1 mm of primary lateral margin; the additional excision contained DCIS and was margin negative. Conclusions: In this case series of 3 adult females undergoing BCS for breast carcinoma, WF-OCT was a beneficial adjunctive imaging modality to specimen radiography for margin assessment. Citation Format: Amelia B. Tower, Andrew Berkeley. Use of wide field optical coherence tomography (WF-OCT) in margin assessment during breast conserving surgery (BCS) for ductal carcinoma in situ (DCIS) [abstract]. In: Proceedings of the AACR Special Conference on Rethinking DCIS: An Opportunity for Prevention?; 2022 Sep 8-11; Philadelphia, PA. Philadelphia (PA): AACR; Can Prev Res 2022;15(12 Suppl_1): Abstract nr B021.

2022 Canadian Surgery Forum Sept. 15–17, 202201. Operative classification of ventral abdominal hernias: new and practical classification02. Watchful waiting for large primary splenic cysts03. Transversus abdominis plane (TAP) blocks with and without dexamethasone in colorectal surgery04. What factors determine publication of resident research day projects?05. Characterization of near-infrared imaging and indocyanine green use amongst general surgeons06. Variation in opioid prescribing

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

Ultrasonographic Detection and Surgical Retrieval of a Nonmetallic Twinkle Marker in Breast Cancer: Pilot Study.

Purpose To evaluate the short-term safety of a nonmetallic twinkle marker and compare its conspicuity at color Doppler US with that of standard breast biopsy clips and radioactive seeds by using B-mode US in axillary lymph nodes. Materials and Methods This prospective study (November 2020-July 2021) of participants with node-positive breast cancer who completed chemotherapy involved placing a twinkle marker at the time of preoperative radioactive seed localization. A five-point scoring system (1 = easiest, 5 = most difficult) was used to rate the ease of identifying the clip, seed, and twinkle marker on postlocalization sonograms, mammograms, specimen radiographs, and gross pathologic specimens. Descriptive statistics were used. Results Eight women (mean age, 57 years ± 16 [SD]) were enrolled. The median scores for US conspicuity of each device were 3.9 (range, 3.7-5.0) for the radioactive seed, 2.4 (range, 1.0-5.0) for the clip, and 2.0 (range, 1.0-4.3) for the twinkle marker. In six of eight participants, the twinkle marker was the most identifiable at US. The seeds, clips, and twinkle markers were scored "very easy" to identify on seven of eight postlocalization mammograms. The surgeon retrieved all eight twinkle markers 1-3 days after localization. In all 16 interpretations, the seeds, clips, and twinkle markers were rated as very easy to identify on specimen radiographs. The clip was the most difficult device to identify at pathologic examination in all participants, and the twinkle marker was the easiest to identify in seven of eight participants. Conclusion This pilot study demonstrates that the safety and ease of US detection of a twinkling tissue marker may be comparable to a biopsy clip. Keywords: Ultrasonography, US-Doppler, Breast, Localization, Surgery Clinical trial registration no. NCT04674852 © RSNA, 2022.