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Intraoperative Ultrasound Facilitates Surgery for Early Breast Cancer

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... Se han sugerido y probado diversas alternativas a la localización por arpón. Algunos resultados utilizando US intraoperatorio han demostrado ser superiores en diferentes aspectos [3] [4], además se trata de una técnica precisa y económica. Lamentablemente, muchos tumores malignos visibles en mamogramas no son evidentes en la ecografía. ...
Conference Paper
La localización con arpón guiada por imagen de ultrasonido forma parte del protocolo estándar para la resección de tumores no palpables durante la cirugía de mama conservadora. Esta técnica facilita al cirujano localizar la lesión en el momento de la cirugía. Una alternativa para evitar el uso del arpón sería el empleo de imágenes multimodales y su visualización como herramienta de apoyo al cirujano. La fusión de estos estudios de imagen es especialmente compleja dada la naturaleza deformable de la mama y la diferente posición del paciente durante las distintas adquisiciones. En este trabajo se propone una solución para deformar la localización de la lesión identificada en la imagen de resonancia magnética adquirida en posición decúbito prono, de forma que pueda localizarse durante la cirugía que se realiza en posición decúbito supino. El algoritmo desarrollado se basa en la deformación laplaciana de mallas poligonales. Se presenta una validación empleando superficies obtenidas de estudios de resonancia magnética y tomografía computarizada en 6 casos reales, demostrando que es posible localizar el tumor con una precisión en la mayoría de los casos menor de 15 mm. Estos resultados se consiguen empleando únicamente la superficie de la piel del paciente y la localización del pezón como datos de referencia de la posición prona, lo cual facilita su aplicación como herramienta de apoyo en el guiado en este tipo de cirugías.
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Background Different techniques have been used for the guidance of nonpalpable breast cancer (NBC), but none of them has yet achieved perfect results. The aim of this study was to evaluate the feasibility of indocyanine green (ICG) fluorescence-guided nonpalpable breast cancer lesion excision (IFNLE), to introduce an alternative technique. Methods The data about 56 patients with preoperatively diagnosed NBCs operated with the help of intraoperative IFNLE between November of 2010 and September of 2014 were retrospectively analyzed. ResultsICG fluorescence localized all lesions at surgery. Re-excision due to positive resection margins was necessary in two patients (3.6 %; 2/56) with ductal carcinoma in situ (DCIS) at the surgical margins. Mastectomy was necessary in one patient (1.8 %; 1/56) due to multifocal invasive carcinoma. The mean volume of the excised tissue was 38.2 ± 16.5 cm3. ConclusionsIFNLE is a technically applicable and clinically acceptable procedure whenever a breast cancer needs image-guided excision.
Article
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Multiple recent reports have documented significant variability of reoperation rates after initial lumpectomy for breast cancer. To address this issue, a multidisciplinary consensus conference was convened during the American Society of Breast Surgeons 2015 annual meeting. The conference mission statement was to "reduce the national reoperation rate in patients undergoing breast conserving surgery for cancer, without increasing mastectomy rates or adversely affecting cosmetic outcome, thereby improving value of care." The goal was to develop a toolbox of recommendations to reduce the variability of reoperation rates and improve cosmetic outcomes. Conference participants included providers from multiple disciplines involved with breast cancer care, as well as a patient representative. Updated systematic reviews of the literature and invited presentations were sent to participants in advance. After topic presentations, voting occurred for choice of tools, level of evidence, and strength of recommendation. The following tools were recommended with varied levels of evidence and strength of recommendation: compliance with the SSO-ASTRO Margin Guideline; needle biopsy for diagnosis before surgical excision of breast cancer; full-field digital diagnostic mammography with ultrasound as needed; use of oncoplastic techniques; image-guided lesion localization; specimen imaging for nonpalpable cancers; use of specialized techniques for intraoperative management, including excisional cavity shave biopsies and intraoperative pathology assessment; formal pre- and postoperative planning strategies; and patient-reported outcome measurement. A practical approach to performance improvement was used by the American Society of Breast Surgeons to create a toolbox of options to reduce lumpectomy reoperations and improve cosmetic outcomes.
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The main goal of follow-up care after breast cancer treatment is the early detection of disease recurrence. In this review, we emphasize the multidisciplinary approach to this continuity of care from surgery, medical oncology, and radiology. Challenges within each setting are briefly addressed as a means of discussion for the future directions of an effective and efficient surveillance plan of post-treatment breast cancer care.
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Purpose: The aim of this study was to investigate the value of intraoperative ultrasound in breast-conserving operations and to compare it with standard procedures. Methods: For this purpose 307 women with palpable breast cancers and 116 patients with non-palpable breast cancers were compared retrospectively. In the group with palpable breast cancers 177 patients were treated by US-guided operations and 130 patients underwent palpation-guided breast-conserving operations. As primary outcomes, the resection margins and the rate of re-operations were evaluated. Results: With regard to disease-free resection margins, intraoperative ultrasound was significantly superior to palpation alone. In the group of patients in whom the tumours were extirpated with the help of palpation, R1 resections were observed almost twice as often (16.9 %) as in the US-guided group (8.5 %). In the group with non-palpable breast cancers, intraoperative ultrasound was employed in 61 patients. As a control, 43 cases were evaluated in whom the breast-conserving operation was performed after wire marking. In this group US-guided tumour removal proved to be superior to that after wire marking for tumours that did not exhibit any intraductal components. Otherwise the redo resection rate was reduced by use of ultrasound. Furthermore, the surgeon was able by means of intraoperative ultrasound to identify "problematic" margins and to excise them in the same sitting. Conclusions: The US-guided, breast-conserving operations led to a lower rate of R1 resections and redo operations in comparison to operations with palpation alone or those after wire marking.
Article
Wire localization for excision of nonpalpable breast cancer is an inefficient and inexact technique. A total of 18 women with palpable invasive breast cancers underwent preoperative prone and supine magnetic resonance imaging (MRI). Intraoperatively, the edges of the tumor were palpated and marked on the skin surface. The breast was optically scanned, and the supine MRI was adjusted to match the actual breast position at the time of surgery. Image-defined tumor edges were marked on the surface of the breast. The main outcome measure was the distance between the image-defined and palpation-defined edges of the tumor. No significant difference was found between the mean maximal tumor diameter as measured by histopathology (29.6 ± 14.3 mm), supine MRI (25.3 ± 9.7 mm), prone MRI (27.6 ± 13 mm), or palpation (30.5 ± 9.3 mm). The distance from the tumor to the chest wall was markedly different in prone versus supine MRI (56.4 ± 38 vs 19.5 ± 20 mm, p = .002). The average distance between the palpated and supine MRI image-defined tumor edge locations was 7.2 mm (range, 0-19 mm). Accuracy improved over time; the average difference in edge locations in the last 7 patients was 4.0 mm. All 4 image-defined edge locations in the last 5 patients were ≤1 cm away from the palpated locations. We have developed a method of breast tumor localization using preoperative supine MRI and intraoperative optical scanning that defines tumor size and position as accurately as palpation.
Article
Image-guided wire localization is the current standard of care for the excision of non-palpable carcinomas during breast conserving surgeries (BCS). The efficacy of this technique depends upon the accuracy of wire placement, maintenance of the fixed wire position (despite patient movement), and the surgeon's understanding of the spatial relationship between the wire and tumor. Notably, breast shape can vary significantly between the imaging and surgical positions. Despite this method of localization, re-excision is needed in approximately 30% of patients due to the proximity of cancer to the specimen margins. These limitations make wire localization an inefficient and imprecise procedure. Alternatively, we investigate a method of image registration and finite element (FE) deformation which correlates preoperative supine MRIs with 3D optical scans of the breast surface. MRI of the breast can accurately define the extents of very small cancers. Furthermore, supine breast MR reduces the amount of tissue deformation between the imaging and surgical positions. At the time of surgery, the surface contour of the breast may be imaged using a handheld 3D laser scanner. With the MR images segmented by tissue type, the two scans are approximately registered using fiducial markers present in both acquisitions. The segmented MRI breast volume is then deformed to match the optical surface using a FE mechanical model of breast tissue. The resulting images provide the surgeon with 3D views and measurements of the tumor shape, volume, and position within the breast as it appears during surgery which may improve surgical guidance and obviate the need for wire localization.
Article
The aim of this study was to determine the efficacy of ultrasonography (US)-guided excision of palpable breast cancer and to compare it with the standard palpation-guided breast-conserving surgery (BCS). For this purpose, 335 women with palpable breast cancer who underwent BCS were retrospectively studied. The positive surgical margins and re-excision rates were investigated. Of the total cohort, 137 patients were treated with palpation-guided BCS and 198 underwent US-guided tumor excision. The tumor and patient characteristics were similar in both groups. Patient age, postmenopausal status, tumor size, histological grade, intraductal tumor component, lobular histology, and palpation-guided tumor excision were associated with increased risk of positive margins. The shave margins were re-excised at the time of original operation more often by palpation-guided localization (28.5%) than by the US-guided procedure (11.1%) (P < .0001). A surgeon was able to correctly identify the "problematic" margin in 81.1% of cases via intraoperative US and in only 17.9% via palpation (P < .0001). The re-excision rate during a second operation was significantly reduced by US-guided tumorectomy (P = .004). Of 198 patients in the US-guided group, 23 (11.6%) underwent a second operation, as did 33 of 137 patients in the palpation group (24.1%). The sensitivity and specificity of US-guided excisions were 52.7% and 97.5%, respectively, whereas the sensitivity and the specificity of palpation-guided tumor excisions were 15.5% and 65.9%, respectively. US-guided BCS is superior to palpation-guided excision in predicting the closest margins, obtaining clear surgical margins, and reducing re-operations.
Article
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Intraoperative ultrasound (IOUS) can be used in the operation theatre for localization of non-palpable breast cancers. In this prospective cohort study, we compared the yield of IOUS to guidewire localization (GWL). A total of 258 consecutive patients with non-palpable invasive breast cancer underwent breast conserving surgery between 1999 and 2010. GWL was performed in 138 (54 %) and IOUS in 120 (46 %) patients. Tumor dimensions, resection volume, margin status and re-excision rates were compared by means of multivariate regression analysis. The groups were similar in terms of age, histological subtype and presence of DCIS. Lesions in the IOUS group were larger (1.24 vs. 0.98 cm, P < 0.001), while microcalcifications were more common in the GWL group (19 vs. 3 %, P < 0.001). Even after stratification for tumor diameter, presence of DCIS and findings on mammography, resection volumes were similar in both groups. Tumor-free resection margins were obtained in >93 % of patients (93.5 % with GWL vs. 93.3 % with IOUS, P = 0.958) and re-excision was performed in 11 % of patients undergoing GWL and 12.5 % of patients undergoing IOUS (P = 0.684). For localization of non-palpable breast cancer, IOUS is a reliable alternative to GWL, as it achieves similar results in terms of complete tumor removal, re-excision rate and excised volume.
Article
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The use of intraoperative ultrasonography (US) to localize and guide excision of nonpalpable breast lesions has advantages over other techniques. It avoids the need for additional resources and minimizes patient morbidity. The technique of surgeon-performed US-guided excision as described in this report is straightforward and safe, easily reproducible, and suitable for teaching. The US-guided breast excision technique is predictable and accurate, minimizes costs, and is advocated as an appropriate method for US-visible lesions requiring surgical excision. With appropriate training, breast surgeons can easily acquire the necessary skills to incorporate the use of US in their surgical practice.
Article
Stereotactic and ultrasonography-guided large core needle biopsy has replaced wire localization biopsy as the diagnostic method of choice. Lumpectomy alternatives are being sought to eliminate the need for preoperative wire localization, to facilitate easier and more accurate resection, and to decrease positive margin rates. Cryoprobe-assisted lumpectomy (CAL) was investigated as an alternative. Patients with ultrasonographically visible breast cancers that otherwise would have required wire localization participated. Before lumpectomy, a cryoprobe (Visica; Sanarus, Pleasanton, CA) was inserted through a 3-mm skin incision and directed by ultrasonography through the center of the tumor. An ice ball was created that enveloped the tumor plus an adjacent 5-10 mm of sonographically normal breast tissue. Twenty-four CAL procedures were performed and all lesions were successfully localized. Mean (+/-SD) tumor size was 1.2 +/-.4 cm (range,.7-2.0 cm). Mean dimensions of the ice ball before excision were 3.9 +/-.3 cm by 2.5 +/-.5 cm, and the ice margin around the tumor was 8 +/- 2 mm. The size of the ice ball was controlled to the millimeter, and the ice ball itself provided a precise template around which to dissect. The margin re-excision rate was 5.6% among patients with an ice margin greater than 6 mm. CAL is a superior alternative to wire localization. Ultrasonographic visualization of the ice ball allows the size of the margin and tissue resected to be individually tailored and accurate within millimeters. The created template allows a precise lumpectomy, adding a dimension of control not previously realized with any other technology.
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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.
Article
Positive margins after breast conservation surgery occur frequently and negatively influence local control rates. Preoperative breast ultrasonography reduces the incidence of positive margins during breast conservation surgery. Case-control analysis. Patients and One hundred twenty-two consecutive patients with invasive breast cancer were studied. Palpation or needle-wire-guided breast conservation surgery was used in the first 61 patients (group 1). Preoperative breast ultrasonography was added to the protocol in the last 61 patients (group 2). Incidence of positive margins, distance to closest margin. There was a 3.7-fold reduction in positive margins (P =.04, 95% confidence interval, 1.06-16.73) and improved resection margins (P =.04, 95% confidence interval, 0.14-3.88) when breast ultrasonography was used. Reexcision of margins was done in 11% (7 of 61 patients) in group 1 and 3% (2 of 61 patients) in group 2 (P =.17). Preoperative breast ultrasonography improves the margins of resection and decreases the incidence of positive margins during breast conservation surgery.
Article
Preoperative hookwire localizations have been used for some years to guide excision of subclinical breast lesions. With the availability of ultrasonography in the operating theatre, these localizations can be done intraoperatively. One hundred and thirty lesions in 112 consecutive patients with impalpable breast lesions were intraoperatively localized and excised, obviating the need for preoperative localizations. All 130 lesions were detected intraoperatively and excised. Forty-four patients elected to have their benign lesions excised and there were 32 cancers removed. Ultrasonography was used to ensure complete local excisions in the majority of the cancers. Intraoperative breast ultrasound is a reliable, rapid and cost-effective adjunct in the management of both benign and malignant breast lesions.
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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.
Article
The introduction of portable ultrasound equipment enables surgeons to perform ultrasound examinations in a clinic setting. This study was undertaken to evaluate surgeon-performed ultrasound (SP-US) in patients with primary hyperparathyroidism (PHPT). Between July 2003 and March 2004, 65 patients with PHPT were evaluated with SP-US and 48 of these patients underwent parathyroid surgery. Among this group of 48 evaluable patients, 47 had preoperative imaging with technetium-99m sestamibi scanning (MIBI), and 12 had an additional ultrasound examination at an external radiology department (RP-US). All patients were cured of PHPT and the operative findings were used to determine the true status of the parathyroid glands of each patient. Twenty-four (50%) patients had concomitant thyroid nodules which were identified by SP-US, and 4 (8.3%) patients had simultaneous thyroid operations, 2 of which were for thyroid cancer. Considering data for all patients, SP-US had significantly higher sensitivity than MIBI or RP-US (60% vs. 46%, P = 0.013, and 60% vs. 11%, P = 0.004 respectively). Among the patients with a single adenoma, SP-US, MIBI, and RP-US had sensitivities of 83%, 63%, and 13% respectively. The specificities of all three imaging techniques were uniformly high and were not significantly different from each other. Surgeon-performed ultrasound is an accurate modality for localizing abnormal parathyroid glands in patients with PHPT, with results that compare favorably with other parathyroid imaging modalities.
Article
Specimen mammography during image guided breast surgery is a daily occurrence. The process of specimen travel, imaging and reporting may take 20-30 minutes. An intraoperative method to obtain digital specimen mammograms may expedite the process. We compared intraoperative digital specimen mammography (IDSM) as well as standard specimen mammography (SSM) on 121 consecutive image guided lumpectomies. Each lumpectomy specimen had IDSM obtained followed by travel to radiology for SSM. Surgical decisions were based on all imaging obtained. Data included 1) the ability of each imaging method to identify the target lesion, 2) degree of concordance of surgical interpretation of IDSM compared to radiologist interpretation of SSM, 3) the time required from lumpectomy to surgical review of images from each method, and 4) potential operative time savings. Intraoperative digital specimen mammography (IDSM) was equally as accurate as standard x-ray film specimen mammography. There was no significant difference between 1) the frequency of identification of the target lesion by surgeon or radiologist, 2) lack of identification of any lesion, or 3) frequency of involved margins using imaging criteria. However, there was a marked difference in 1) the time needed to obtain images ready to read, 2) the ability to re-excise tissue promptly, and 3) the overall operating room time with an average decrease of 19 minutes. Intraoperative digital specimen mammography (IDSM) was equally accurate as SSM obtained in this study. Use of this new technology allows surgeons to quickly view specimen images which translate into shorter more efficient operations.
Article
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.
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