LaNette F. Smith

Intraoperative ultrasound-guided breast biopsy

BACKGROUND Biopsy of nonpalpable lesions has increased during the last decade. Commonly these lesions are excised using preoperative wire localization. We describe a technique of intraoperative ultrasound-guided breast biopsy that allows easier excision and aids in obtaining surgical margins in breast cancer. METHODS Intraoperative ultrasound was performed on 81 lesions. Ultrasound was used in an attempt to approximate a 1 cm margin on malignant lesions. RESULTS All attempts to localize lesions with ultrasound in surgery were successful (81 of 81). Ultrasound-guided surgery was accurate in predicting margins in 24 of 25 malignant lesions. No complications resulted. CONCLUSION Ultrasound proved to be an effective technique for localizing and excising breast lesions. Benefits may include improving patient comfort, avoiding complications of needle localization breast biopsy, and simplifying the scheduling of surgical procedures. Additionally, this procedure may be used to obtain adequate surgical margins and thus reduce the recurrence rate of breast cancer.

Intraoperative touch preparation for sentinel lymph node biopsy: A 4-year experience

BackgroundThe optimal technique for intraoperative pathologic examination of sentinel lymph nodes (SLNs) is still controversial. Recent small series report sensitivity between 60% and 100% for various techniques. The aim of this study was to evaluate our long-term experience with touch preparation cytology (TPC) and frozen section (FS) in the intraoperative examination of SLNs for breast cancer.MethodsA total of 247 patients with operable breast cancer underwent an SLN biopsy for staging of the axilla. The SLN was identified by99mTc-labeled sulfur colloid unfiltered dye, blue dye, or both and dissected, and then intraoperative TPC or FS and permanent section, or both, were performed.ResultsA total of 479 SLNs were submitted for TPC and permanent hematoxylin and eosin. A total of 68 SLNs were positive by hematoxylin and eosin; 65 SLNs were positive by TPC, with a false-negative rate of 5.8%. The sensitivity for TPC was 94.2%, with a false-positive rate of 0.2%. A total of 165 SLNs were submitted for FS, with a sensitivity of 85.7% and a specificity of 98.6%. The false-positive rate was 1.4%, with a false-negative rate of 15.8%.ConclusionsIn a large series, TPC is as accurate as FS but is simpler and faster in the detection of intraoperative metastasis in SLNs for breast cancer.

Subareolar injection is a better technique for sentinel lymph node biopsy

BACKGROUND Numerous techniques and materials show accuracy in localizing the sentinel lymph node (SLN). We hypothesized that subareolar injection of material would localize the SLN as effectively as peritumoral injection. METHODS Thirty-eight patients were injected with technetium-99 sulfur colloid either peritumorally or subareolarly in addition to the injection of blue dye around the tumor. Radioactive SLNs were localized using a hand-held gamma probe. RESULTS Nineteen patients were included in each of the two groups, peritumoral and subareolar. SLNs were found in all patients injected subareolarly and in 18 of 19 injected peritumorally. The false-negative rate was 20% for peritumoral injection and 0% for subareolar injection. CONCLUSION The results suggest that subareolar injection was as accurate, if not more accurate, than peritumoral injection for localizing the SLN. This technique is simpler than peritumoral injection and does not require injection under image guidance for nonpalpable lesions.

Hematoma-Directed Ultrasound-Guided Breast Biopsy

Objective and Summary Background DataThe standard technique for removal of nonpalpable breast lesions is needle localization breast biopsy. Because traumatic hematomas can often be seen with ultrasound, the authors hypothesized that iatrogenically induced hematomas could be used to guide the excision of nonpalpable lesions using ultrasound. MethodsTwenty patients with nonpalpable breast lesions detected by magnetic resonance imaging only were enrolled in this single-institution trial, approved by the institutional review board. A hematoma consisting of 2 to 5 mL of the patient’s own blood was injected into the breast to target the nonpalpable lesion. Intraoperative ultrasound of the hematoma was used to direct the excisional biopsy. ResultsThe average age of women was 53.8 ± 10 years. Ninety-five percent of lesions detected by magnetic resonance imaging were localized by hematoma injection. All the hematomas used to recognize targeted lesions were identified at surgery by ultrasound and removed without complication. Eight (40%) of the lesions were malignant, with an average tumor size of 12 ± 6 mm (range 4–25). The remaining 12 lesions (60%) comprised papillomas, sclerosing adenosis, radial scar, fibroadenoma, and areas of atypical ductal hyperplasia. ConclusionThe results of this pilot study show the effectiveness of hematoma-directed ultrasound-guided breast biopsy for nonpalpable lesions seen by magnetic resonance imaging. This new procedure is potentially more comfortable for the patient because no wire or needle is left in the breast. It is technically faster and easier because ultrasound is used to visualize directly the location of the hematoma at surgery and to confirm lesion removal in the operating room by specimen ultrasound. The hematoma can be placed several days before biopsy, easing scheduling, and without fear of the migration that may occur with needle localization. This method may have ready application to mammographically detected lesions.

Intraoperative localization after stereotactic breast biopsy without a needle

BACKGROUND Needle localization breast biopsy (NLBB) is the standard for the removal of breast lesions after vacuum-assisted breast biopsy (VABB). Disadvantages include a miss rate of 0% to 22%, risk of vasovagal reactions, and scheduling difficulties. We hypothesized that the hematoma resulting from VABB could be used to localize the VABB site with intraoperative ultrasonography (US) for excision. METHODS Twenty patients had VABB followed by intraoperative US-guided excision. RESULTS The previous VABB site in 19 patients was successfully visualized with intraoperative US and excised at surgery. One patient had successful removal of the targeted area under US guidance, but failed to show removal of the clip on initial specimen mammogram. CONCLUSION This study demonstrates the effectiveness of US in identifying hematomas after VABB for excision. This technique, which can be performed weeks after VABB, improves patient comfort and allows easier scheduling.

Magnetic resonance imaging-guided core needle biopsy and needle localized excision of occult breast lesions.

BACKGROUND Breast magnetic resonance imaging (MRI) has been reported to be twice as sensitive and three times more specific in detecting breast cancer. We report a series of MRI-guided stereotactic breast biopsies (SCNBB) and needle localized breast biopsies (NLBB) to evaluate MRI as a localization tool. METHODS Forty-one breast lesions were identified in 39 patients who subsequently had SCNBB or NLBB. Suspicious areas of enhancement were stereotactically biopsied with 16-G core biopsy needles or localized with 22-G wires for excision under laser guidance. RESULTS Forty-one breast lesions were identified from 1,292 breast MRIs. SCNBB identified three malignancies and two areas of atypia. Two additional cancers were found after NLBB. In patients having NLBB alone, five cancers and two areas of atypia were identified. CONCLUSIONS In this initial series, breast MRI-guided SCNBB and NLBB were valuable tools in the management of patients with suspicious abnormalities seen only on MRI.

Is Scintimammography Really the Most Valuable Preoperative Assessment Tool

Over the last few years, scintimammography (SMM), the use of radiopharmaceuticals to image the breast, has evolved as an adjunct technique in breast imagery.1 Several different radiopharmaceutical agents have been used for scintimammography. Currently, however, 99mTcsestamibi (MIBI) is the only agent approved by the FDA for use in breast cancer.1 Other agents include thalium201, technetium-99m tetrofosmin, and technetium-99m MDP. However, there are relatively few studies using these other agents, and any advantage over MIBI remains to be seen. 99mTc-sestamibi was first introduced as a myocardial perfusion agent and subsequently as a tumor imaging agent.2 It has been used most commonly in the evaluation of lung carcinoma, brain malignancies, and osteosarcomas. The modality has also proven useful in the imaging of benign lesions of the thyroid and parathyroid.3 More recently, it has been proposed as a complement to mammography to increase sensitivity and specificity in breast cancer detection. 99mTc-sestamibi is a lipophilic cationic complex that has been proposed as a valuable tumor-seeking agent. The exact mechanism of action is not fully understood, but it has been linked to several variables including regional blood flow, plasma and mitochondrial membrane potential, angiogenesis, and possibly tissue metabolism.1,4 Several investigators feel the mechanism may be related more to the degree of desmoplastic activity and cellular proliferation than neovascularity and mitochondrial density.1 The tracer is taken into the mitochondria at a rate 4 to 9 times greater in malignant cells than in benign cells.5 Also, the size of the tumor may influence uptake of MIBI. Numerous authors report poor uptake in lesions 1 centimeter.6 In this issue of the Annals of Surgical Oncology, Lumachi et al.7 and other advocates of SMM claim it may be valuable in surgical planning by improving the sensitivity and specificity of mammography and thereby decreasing the number of unnecessary breast biopsies.6–8 Other suggested uses of SMM include the assessment of women with inadequate mammograms because of altered or dense breasts, the identification of multicentric disease, and possibly the use in the evaluation of the response to chemotherapy. MIBI has also been suggested for preoperative assessment of lymph node status. However, SMM seems to add little to mammography and ultrasound evaluation of the breast and is currently felt to be inadequate for staging of the axilla.1,9,10 Perhaps future studies may compare it to sentinel lymph node biopsy. Furthermore, SMM is postulated to identify breast cancers that may be unresponsive to chemotherapy because MIBI is taken up by tumor cells with a multidrug resistance (MDR) phenotype and rapidly cleared by P-glycoprotein. Tumors that express high levels of P-glycoprotein and then show rapid clearance of MIBI may correlate with the MDR phenotype.1 The study by Lumachi et al.7 proposes to evaluate the usefulness of 99mTc-sestamibi with mammography and fine-needle aspiration (FNA) in detection of early stage breast cancer. This study included 64 patients, the majority of whom had palpable masses (82.8%). Multiple authors have found much better results, by using SMM, with palpable masses than with nonpalpable lesions.11–14 A 420 patient 3-center study evaluated SMM and found a much lower sensitivity of 62% for nonpalpable lesions when compared with a sensitivity of 98% for palpable lesions.6 Sixty-nine percent of the undetected tumors by SMM in Lumachi’s study were of nonpalpable lesions.7 Clearly, with increased emphasis on breast cancer Received July 15, 1999; accepted July 16, 1999. From the Department of Surgery, Division of Surgical Oncology, Breast Section, University of Arkansas for Medical Sciences, Little Rock, Arkansas. Address correspondence to: V. Suzanne Klimberg, MD, Department of Surgery, Division of Surgical Oncology, University of Arkansas for Medical Sciences, Slot 725, Little Rock, AR 72205; Fax: 501-6867861. Annals of Surgical Oncology, 6(6):525–527 Published by Lippincott Williams & Wilkins