Treatment Of Non-palpable Breast Cancer Research Articles

Intraoperative ultrasound-guided lumpectomy versus wire-guided excision for nonpalpable breast cancer.

ObjectiveThis study was designed to compare the margin clearance and re-excision rates of ultrasound (US)- and wire-guided excision in a large number of patients with nonpalpable breast cancer.MethodsIn total, 520 women who were histologically diagnosed with nonpalpable breast cancer were recruited in this study. All nonpalpable lesions were visible by US. The patients were randomly divided into two groups: those who underwent wire-guided breast-conserving surgery (BCS) and those who underwent US-guided BCS. Re-excision rates and positive surgical margins were recorded.ResultsA total of 262 patients underwent US-guided excision and 258 patients underwent wire-guided excision. No differences were found in tumor or patient characteristics. The positive margin rate was 4.6% in the US-guided group and 19.4% in the wire-guided group with a significant difference. Age, menopausal status, excision volume, histological grade, and tumor type significantly influenced the positive surgical margin rate. The intraoperative re-excision rate was significantly lower in the US-guided group than wire-guided group (11.1% vs. 24.0%, respectively).ConclusionsUS-guided BCS seems to be more effective than wire-guided BCS for treatment of nonpalpable breast cancers in terms of the margin clearance and re-excision rates. Patients can avoid the discomfort caused by preoperative wire placement.

Is there a role for a handheld gamma camera (TReCam) in the SNOLL breast cancer procedure?

Sentinel node and occult lesion localization (SNOLL) calls for a combination of two specific procedures: intraoperative detection of sentinel lymph node (SLN) and radio-guided occult lesion localization (ROLL). The safety and benefits of radio-guided localization in the surgical treatment of non-palpable breast cancer have been confirmed. The aim of this study was to evaluate the potential role for an intra-operative handheld tumor resection gamma camera (TReCam) in SNOLL procedures. Fifteen patients were enrolled. The SNOLL procedure was performed in all patients with conventional lymphoscintigraphy (LS). TReCam was used to obtain nuclear imaging in the operating theater. Concordance between LS and TReCam images, duration of use and assessment of difficulties in data acquisition with TReCam were reported. Concordance for tumor localization between single-detector gamma probe and TReCam was excellent (15/15). The number of radioactive SLNs visualized between LS and TReCam was equivalent in 53.3% of cases (8/15). TReCam was considered to be very easy-to-use (12/15) or easy-to-use (3/15). Average duration of acquisition with TReCam was 4 minutes and 45 seconds for the SLN procedure, and 2 minutes and 10 seconds for lumpectomy. This study suggests that TReCam is easy-to-use and does not increase operative time. Its exact role in radio-guided surgery needs to be clearly defined in a larger study. However, its usefulness and benefits in radio-guided breast surgery seem to be promising.

Systematic review and meta-analysis of radio-guided versus wire-guided localization in the treatment of non-palpable breast cancers

Background: One-third of breast cancers present as non-palpable lesions. The current gold standard surgical treatment for these cancers is wide local excision using wire-guided localization (WGL). WGL has drawbacks including technical and scheduling issues, which resulted in the development of alternative radio-guided techniques (RGL).

Magnetic sentinel lymph node biopsy and localization properties of a magnetic tracer in an in vivo porcine model

The standard for the treatment of early non-palpable breast cancers is wide local excision directed by wire-guided localization and sentinel lymph node biopsy (SLNB). This has drawbacks technically and due to reliance upon radioisotopes. We evaluated the use of a magnetic tracer for its localization capabilities and concurrent performance of SLNB using a handheld magnetometer in a porcine model as a novel alternative to the current standard. Ethical approval by the IRCAD Ethics Review Board, Strasbourg (France) was received. A magnetic tracer was injected in varying volumes (0.1-5 mL) subcutaneously into the areolar of the left and right 3rd inguinal mammary glands in 16 mini-pigs. After 4 h magnetometer counts were taken at the injection sites and in the groins. The magnetometer was used to localize any in vivo signal from the draining inguinal lymph nodes. Magnetic SLNB followed by excision of the injection site was performed. The iron content of sentinel lymph nodes (SLNs) were graded and quantified. All excised specimens were weighed and volumes were calculated. Univariate analyses were performed to evaluate correlation. Magnetic SLNB was successful in all mini-pigs. There was a significant correlation (r = 0.86; p < 0.01) between magnetometer counts and iron content of SLNs. Grading of SLNs on both H&E and Perl's staining correlated significantly with the iron content (p = 0.001; p = 0.003) and magnetometer counts (p < 0.001; p = 0.004). The peak counts corresponded to the original magnetic tracer injection sites 4 h after injection in all cases. The mean volume and weight of excised injection site specimens was 2.9 cm(3) (SD 0.81) and 3.1 g (SD 0.85), respectively. Injection of ≥0.5 mL magnetic tracer was associated with significantly greater volume (p = 0.05) and weight of excision specimens (p = 0.01). SLNB and localization can be performed in vivo using a magnetic tracer. This could provide a viable alternative for lesion localization and concurrent SLNB in the treatment of non-palpable breast cancer.

Intra-operative ultrasound versus wire-guided localization in the surgical management of non-palpable breast cancers: systematic review and meta-analysis

The current standard of treatment for non-palpable breast cancers is wire-guided localization (WGL). WGL has its drawbacks and alternatives such as radio-guided surgery (RGL) and intra-operative ultrasound (IOUS) have been developed. The clinical effectiveness of all forms of RGL has been assessed against WGL in previous systematic reviews and meta-analyses. We performed the first systematic review and meta-analysis of IOUS in the management of non-palpable breast cancers. Studies were considered eligible for inclusion in this systematic review if they (1) assessed the role of surgeon-performed IOUS for the treatment of non-palpable breast cancers and ductal carcinoma in situ (DCIS) and (2) specified surgical margin excision status. Those studies, which were randomized controlled trials (RCTs) or cohort studies with comparison WGL groups were included in the meta-analysis. For those studies included in the meta-analysis, pooled odds ratios (ORs) and 95 % confidence intervals (CIs) were estimated using fixed-effects analyses and random-effects analyses in case of statistically significant heterogeneity (p < 0.05). Eighteen studies reported data on IOUS in 1,328 patients with non-palpable breast cancer and DCIS. Nine cohort studies with control WGL groups and one RCT were included in the meta-analysis. Successful localization rates varied between 95 and 100 % in all studies and there was a statistically significant difference in the rates of involved surgical margins in favour of IOUS with pooled OR 0.52 (95 % CI 0.38-0.71). Compared with WGL, IOUS reduces involved surgical margin rates. Adequately powered RCTs are required to validate these findings.

Systematic review of radioguided versus wire-guided localization in the treatment of non-palpable breast cancers

One-third of breast cancers present as non-palpable lesions. The current gold standard treatment for these cancers is localized wide local excision using wire-guided localization (WGL). WGL has drawbacks including technical and scheduling issues resulting in the development of alternative radioguided techniques (RGL). A systematic review was performed to identify studies comparing RGL and WGL. The outcomes of surgical margin status, re-operation rates, surgical operative time, volume and excised specimen weight and successful sentinel lymph node biopsy (SLNB) rates were evaluated. Pooled odds ratios (ORs) and 95% confidence intervals were estimated using fixed-effects analyses and random-effects analyses in case of statistically significant heterogeneity (p<0.05). Seven randomized controlled trials (RCTs) matching the inclusion criteria were identified. The pooled ORs for involved surgical margin status were 0.78 (95% CI, 0.52-1.17); for re-operations 0.74 (95% CI, 0.49-1.11) and for successful SLNB 1.29 (95% CI, 0.66-2.53). There was a significant difference in surgical operating time in favour of RGL (mean difference (MD), -2.95; 95% CI, -4.43, -1.47) and a significant difference in excised specimen volume, favouring WGL (MD, 6.79; 95% CI, 0.03, 13.56). The MD for a specimen weight of -3.00 (95% CI, -15.15, 9.15) showed no significant difference between RGL and WGL. RGL has a reduced operating time, but larger volume excisions compared to WGL. There is insufficient evidence to support the uptake of RGL over WGL, and larger, adequately powered, multi-centre RCTs are required.

ROLL versus RSL: toss of a coin?

The safety and benefits of radio-guided localization (RGL) versus wire-guided localization (WGL) surgery in the treatment of non-palpable breast cancers have been confirmed through several meta-analyses. RGL has become the standard of care in several institutions, although overall uptake has been slow. In view of this evidence supporting RGL, we believe that the future discussion is not of RGL versus WGL, but rather of what form of RGL will constitute best practice of care going forward. We therefore discuss the case for radio-guided occult lesion localization versus radioactive seed localization in the treatment of non-palpable breast cancers, is it really a toss of a coin?

Radio guided occult lesion localization (ROLL) for non‐palpable invasive breast cancer

Wire guided localization (WGL) for non-palpable breast cancer is technically difficult and patient unfriendly. Radio guided occult lesion localization (ROLL) takes advantage of the possibility to detect the tumor through the nuclear tracer that is injected directly into the tumor for the sentinel node procedure. Forty patients with 41 invasive breast carcinomas were treated using ROLL. Patients received a dose of 120 Mbq 99mTc Nanocolloid intra-tumorally on the day of surgery or a dose of 370 Mbq 99mTc Nanocolloïd intra-tumorally the prior day. The sentinel node (SN) was located using patent blue and a gamma ray detection probe that was also employed to guide the tumor excision. In 31 patients (78%) the invasive tumor was adequately excised. In two cases (5%) a re-excision was required due to inadequately excised carcinoma in situ and in three patients (7.5%) both the invasive and the in situ tumor were inadequately excised. In 35 patients (88%) the SN was found and removed. The ROLL procedure seems to be an alternative to WGL in patients with non-palpable breast carcinoma. To determine the place of ROLL versus WGL in the treatment of non-palpable breast cancer, a randomized clinical trial is needed.

Shift in the surgical treatment of non-palpable breast cancer: tactile to visual

Increasing number of small, early-staged breast cancers are detected by screening mammography. Diagnosis and determination of the prognostic factors may be made by either ultrasound (US) or stereotactically guided needle biopsy. Approximately 2000 stereotactic tables are installed at various medical centers throughout the United States and a significant number in other countries where breast cancer is common. Many surgeons and interventional radiologists are trained in the use of this technology for diagnostic purposes. Employing the same technology, these physicians may be trained to treat selected breast cancers with laser energy percutaneously. Experimental and clinical reports to-date indicate the technique to be safe. High-resolution imaging modalities including grayscale and color Doppler US, magnetic resonance imaging, mammography and needle biopsy, when necessary, will confirm the tumor kill. Newer imaging modalities such as magnetic resonance spectroscopy may also provide additional confirmation for total tumor ablation.

Ultrasound-guided lumpectomy of nonpalpable breast cancer versus wire-guided resection: A randomized clinical trial

The wire-guided excision of nonpalpable breast cancer often results in tumor resections with inadequate margins. This prospective, randomized trial was undertaken to investigate whether intraoperative ultrasound (US) guidance enables a better margin clearance than the wire-guided technique in the breast-conserving treatment of nonpalpable breast cancers. Patients with a preoperative histological diagnosis of nonpalpable breast cancer that could be visualized both with US and mammography were included. Patients were randomized to undergo either a wire-guided or a US-guided excision. Adequate margins were defined as >or=1 mm. Of 49 included patients, 23 were assigned to undergo wire-guided excision and 26 to undergo US-guided excision. One patient crossed over to US-guided excision after inadvertent wire displacement. Mean tumor diameter, specimen weight, and operating time were similar in both groups. The excision was adequate in 24 (89%) of 27 US-guided excisions and 12 (55%) of 22 wire-guide excisions (P =.007). US-guided excision seems to be superior to wire-guided excision with respect to margin clearance of mammographically detected and US-visible nonpalpable breast cancers. Patients do not have to undergo the unpleasant wire placement before surgery.

Critical analysis of the treatment of non-palpable breast cancer: toward a less invasive future?

Results and experience with the treatment of non-palpable breast cancer are reported and related to the future of less invasive treatment of small breast cancers. The retrospective study included 102 patients treated between 1980 and 1993 at the University Hospital of Nijmegen. Most cancers were screen-detected. Tumor sizes on pathological examination proved 3 mm (SD 7.7 mm) larger than on mammography (p = 0.0029). pT1 tumors were encountered in 77 patients (75%); pT2 tumors in 17 patients (17%). Seventy-five patients were free of lymph node metastases, 26 patients showed stage pN1 (25%). Most patients had invasive ductal cancers. Only two patients died of breast cancer. A 10-year disease-free survival of 94% was calculated, after excluding four patients with known systemic disease (M1) at diagnosis. T1a, T1b, and T1c had a 10-year survival of 100%, 96%, and 96%, respectively. Early detection and multimodality treatment of breast cancer have significantly improved survival. Inpatients with small breast cancer tumors future developments in treatment must be aimed at the use of less invasive techniques, reducing morbidity while maintaining high levels of disease-free survival.

Impact of stereotactic large-core needle biopsy on diagnosis and surgical treatment of non-palpable breast cancer

Introduction Stereotactic large-core needle biopsy is increasingly replacing needle-localized breast biopsy for the diagnosis of nonpalpable breast disease. In this prospective study, the impact of the introduction of this technique on diagnosis and surgical treatment of nonpalpable breast cancer was assessed in two hospitals in The Netherlands. Patients and methods A total of 84 patients with nonpalpable breast cancer, diagnosed by means of stereotactic large-core needle biopsy (needle biopsy group) were compared with 80 patients diagnosed with nonpalpable breast cancer before the introduction of large-core needle biopsy. These patients were diagnosed by means of needle-localized open breast biopsy (control group). Clinical outcome measures evaluated included: duration of diagnostic and therapeutic intervals and number of surgical procedures required for complete surgical treatment. Subgroup analysis was performed for the category of microcalcifications without tissue distortion.Results For the needle biopsy group, the median interval between initial referral to the surgeon and the availability of histological diagnosis was 9 days and the interval between initial referral and complete surgical treatment was 31 days. These intervals were significantly longer for the control group (19 days and 44 days respectively); 75% of patients in the needle biopsy group were treated in a single step surgical procedure compared to 16% of the patients in the control group (67vs 25% respectively for the subgroup). The mean number of surgical procedures required to complete surgical treatment was 1.31 for needle biopsy group vs 1.91 for the open biopsy group (1.46 vs 1.84 for the subgroup).Conclusion Introduction of stereotactic large-core needle biopsy leads to a reduction of the time to diagnosis and the time to complete surgical treatment of nonpalpable breast cancer. It also reduces the number of surgical procedures required for complete surgical treatment of nonpalpable breast cancer. The benefits of large-core needle biopsy may also be anticipated for patients with microcalcifications without tissue distortion.

Surgeon variability in treating nonpalpable breast cancer: surgical oncology as a value-added specialty

Background: Several studies have demonstrated a relatively low rate of breast conservation surgery (BCS) in the United States. Few have analyzed the impact of individual surgeon variability on the outcome of the procedure, and none have contrasted surgical oncologists versus general surgeons in the treatment of nonpalpable breast cancer. Methods: A blinded review was done of 409 excisions for nonpalpable breast cancer performed by 11 board-certified general surgeons (GS, n=221) and one surgical oncologist (SO, n=185) in a teaching institution. We compared surgical margins, need for reexcision, and breast conservation rates. Results: Although there were no significant differences in patient and tumor characteristics, there were surprising differences between the GS and SO, especially related to surgical margins and final treatment. The SO has a significantly higher rate of frozen section compared to GS (81% vs. 64%,P<0.01) and a lower rate of positive margin at the time of original biopsy (25% vs. 41%,P<0.01). These differences translated into lower necessity for reexcision of tumor (18% vs. 48%,P<0.01) and higher rate of BCS (88% vs. 70%,P<0.01). Conclusion: This study demonstrates marked differences among trained general surgeons. The additional experience of a surgical oncologist is valuable, because fewer positive margins lead to a higher likelihood of breast preservation and decreased costs related to fewer additional operative procedures.