Real‐time electromagnetic navigation for breast‐conserving surgery using NaviKnife technology: A matched case‐control study

Breast‐conserving surgery (BCS) is a mainstay in breast cancer treatment. For nonpalpable breast cancers, current strategies have limited accuracy, contributing to high positive margin rates. We developed NaviKnife, a surgical navigation system based on real‐time electromagnetic (EM) tracking. The goal of this study was to confirm the feasibility of intraoperative EM navigation in patients with nonpalpable breast cancer and to assess the potential value of surgical navigation. We recruited 40 patients with ultrasound visible, single, nonpalpable lesions, undergoing BCS. Feasibility was assessed by equipment functionality and sterility, acceptable duration of the operation, and surgeon feedback. Secondary outcomes included specimen volume, positive margin rate, and reoperation outcomes. Study patients were compared to a control group by a matched case‐control analysis. There was no equipment failure or breach of sterility. The median operative time was 66 (44‐119) minutes with NaviKnife vs 65 (34‐158) minutes for the control (P = .64). NaviKnife contouring time was 3.2 (1.6‐9) minutes. Surgeons rated navigation as easy to setup, easy to use, and useful in guiding nonpalpable tumor excision. The mean specimen volume was 95.4 ± 73.5 cm³ with NaviKnife and 140.7 ± 100.3 cm³ for the control (P = .01). The positive margin rate was 22.5% with NaviKnife and 28.7% for the control (P = .52). The re‐excision specimen contained residual disease in 14.3% for NaviKnife and 50% for the control (P = .28). Our results demonstrate that real‐time EM navigation is feasible in the operating room for BCS. Excisions performed with navigation result in the removal of less breast tissue without compromising postive margin rates.     

Prediction of pathological margin status using preoperative contrast‐enhanced MRI in patients with early breast cancer who underwent skin‐sparing mastectomy

Skin‐sparing mastectomy (SSM) with immediate reconstruction is standard surgical treatment for early breast cancer with widespread ductal carcinoma in situ (DCIS). The local recurrence rate after SSM is up to 7.0%. We investigated prediction of the pathological margin using contrast‐enhanced MRI, and evaluated the cut‐off point to obtain the safety margin. We performed SSM with immediate reconstruction in 216 early breast cancer patients with widespread DCIS and/or invasive cancer from January 2014 to December 2015. Forty cases were retrospectively reviewed after excluding those with >15 mm between skin and tumor, determined by preoperative contrast‐enhanced MRI, or involving reconstructive surgery for local recurrence, immeasurable lesion by preoperative contrast‐enhanced MRI, or neoadjuvant chemotherapy. We defined a positive pathological margin as <1 mm from the cancer nest. We reviewed the distance between skin and tumor by MRI and pathological examination. To identify the cut‐off for predicting a positive pathological margin, we performed sensitivity analysis using an ROC curve. The margin‐positive rate by pathological examination was 27.5% (n = 11/40), with a moderate correlation of MRI margin and pathological margin (r = 0.44). The best cut‐off point for margin positivity was 5 mm of MRI margin, with sensitivity and specificity of 54% and 86%, respectively (P = 0.009). This is the first prediction of pathological margin by preoperative contrast‐enhanced MRI in early breast cancer patients with SSM. Care is required for SSM if the MRI margin is less than 5 mm due to pathological margin positivity.     

MRI‐Guided Breast Needle Core Biopsies: Pathologic Features of Newly Diagnosed Malignancies

Magnetic resonance imaging (MRI) of the breast is used for select groups of patients. MRI‐guided breast core needle biopsies performed over a 3‐year period were retrospectively reviewed to determine the incidence and types of cancers found and to correlate the cancers with the MRI findings and the indication for the study. Patients were stratified based on indication for MRI examination including, evaluation of disease extent in patients with current ipsilateral carcinoma, surveillance for recurrence of prior ipsilateral carcinoma, as a problem‐solving method and for screening high‐risk patients. The high‐risk screening group included those with family history (with or without germline mutations), prior chest wall radiation, and contralateral breast carcinoma (current or prior). Four‐hundred and forty‐five biopsies were performed on 386 patients. The majority of biopsies (79%) were benign. Biopsies demonstrating ductal carcinoma in situ (DCIS) and invasive carcinoma were more likely to present as nonmass‐like and mass‐forming enhancements respectively, but with only 52% specificity. The highest rate of malignancy (44%) was seen in the least frequently biopsied patient group (n = 25), those with prior ipsilateral carcinoma. Conversely, the most frequently biopsied group (n = 283), the high‐risk screening group, demonstrated the lowest malignancy rate (16%). Within this group, most malignant cases were invasive carcinomas (n = 27), 67% of which were small (≤1 cm), well or moderately differentiated with a good prognostic receptor profile (estrogen receptor positive, human epidermal growth factor receptor 2 negative), and lacked nodal macrometastases. The remaining malignant cases in the high‐risk screening group were DCIS with or without microinvasion (n = 18), 78% of which demonstrated high nuclear grade. Overall, enhancement pattern did not correlate with the likelihood of or type of malignancy. The most common types of carcinomas identified by screening were small estrogen receptor positive invasive tumors and high grade DCIS.     

Utilization of multiple SAVI SCOUT surgical guidance system reflectors in the same breast: A single‐institution feasibility study

SAVI SCOUT Surgical Guidance System has been shown to be a reliable and safe alternative to wire localization in breast surgery. This study evaluated the feasibility of using multiple reflectors in the same breast. We performed an IRB‐approved, HIPAA‐compliant, single‐institution retrospective review of 183 patients who underwent breast lesion localization and excision using SAVI SCOUT Surgical Guidance System (Cianna Medical) between June 2015 and January 2017. We performed a subset analysis in 42 patients in whom more than one reflector was placed. Specimen radiography, pathology, distance between reflectors, target removal, margin positivity, and complications were evaluated. Among 183 patients, 42 patients had more than one reflector placed in the same breast to localize 68 lesions. Benign (n = 6, 8.8%), high‐risk (n = 23, 33.8%), and malignant (n = 39, 57.4%) lesions were included. Thirty‐six patients (85.7%) had a total of 2 reflectors placed and 6 patients had a total of 3 reflectors placed (14.3%). The indications for multiple reflector placement in the same breast included multiple separate lesions (n = 23) and bracketing of large lesions (n = 19). The mean distance between the reflectors was 42 mm (22‐93 mm). All lesions were successfully targeted and retrieved. Of 39 malignant lesions, 10.3% (n = 4) had positive margins and 10.3% (n = 4) had close (<1 mm) margins at surgery. All patients with positive margins underwent re‐excision. No complications occurred preoperatively, intra‐operatively, or postoperatively. The use of multiple SAVI SCOUT reflectors for localizing multiple lesions in the same breast or bracketing large lesions is feasible and safe.     

Acute toxicities after proton beam therapy following breast‐conserving surgery for breast cancer: Multi‐institutional prospective PCG registry analysis

We investigated adverse events (AEs) and clinical outcomes for proton beam therapy (PBT) after breast‐conserving surgery (BCS) for breast cancer. From 2012 to 2016, 82 patients received PBT in the prospective multi‐institutional Proton Collaborative Group registry. AEs were recorded prospectively at each institution. Median follow‐up was 8.1 months. Median dose was 50.4 Gy in 28 fractions. Most patients received a lumpectomy bed boost (90%) and regional nodal irradiation (RNI)(83%). Six patients (7.3%) experienced grade 3 AEs (5 with dermatitis, 5 with breast pain). Body mass index (BMI) was associated with grade 3 dermatitis (P = .015). Fifty‐eight patients (70.7%) experienced grade ≥2 dermatitis. PBT including RNI after BCS is well‐tolerated. Elevated BMI is associated with grade 3 dermatitis.     

Intraoperative inking is superior to suture marking for specimen orientation in breast cancer

Margin status is an important indicator of residual disease after breast‐conserving surgery (BCS). Intraoperatively, surgeons orient specimens to aid assessment of margins and guide re‐excision of positive margins. We performed a retrospective review of BCS cases from 2013 to 2017 to compare the two specimen orientation methods: suture marking and intraoperative inking. Patients with ductal carcinoma in situ, T1/T2 invasive cancer treated with BCS were included. Rates of positive margins and residual disease at re‐excision were evaluated. 189 patients underwent BCS; 83 had suture marking, 103 had intraoperative inking and 3 had un‐oriented specimens. The incidence of positive margins was 29% (24 patients) in the suture marked group and 20% (21 patients) in the intraoperative inked group (P = .18). Among the 45 patients with positive margins, 60% of tumors were stage T1, 76% were node negative, 36% were palpable with median tumor size of 1.5 cm. Residual disease was identified on re‐excision in 21% of the suture marked specimens and 57% of intraoperative inked specimens (P = .028). The incidence of residual cancer at re‐excision for positive margins was higher for intraoperatively inked versus suture marked specimens. This finding suggests that intraoperative inking is more effective at guiding re‐excision of positive margins.     

Safety of eribulin as third‐line chemotherapy in HER2‐negative,advanced breast cancer pre‐treated with taxanes and anthracycline: OnSITE study

Eribulin is active and safe in heavily pre‐treated metastatic breast cancer patients. Few safety data have been published in third line. We aimed to report the specific safety profile on third line beyond taxanes and anthracyclines in advanced breast cancer (ABC). A multicenter phase II, prospective study was conducted in anthracyclines and taxanes pre‐treated HER2‐negative ABC, programmed to receive eribulin as third‐line chemotherapy. Adverse events (AEs) were assessed and classified according to CTCAE. In addition, efficacy, in terms of overall survival (OS) and progression‐free survival (PFS), and the dynamics of circulating tumor cells (CTCs) during treatment were assessed. 59 patients fulfilled the criteria. All but one showed AEs with a cumulative number of 598 AEs. The most frequent grade 3/4 drug‐related AEs were neutropenia (1.7%), febrile neutropenia (0.5%), leukopenia (0.5%), alopecia (0.5%), asthenia (0.3%), elevated gamma glutamyl transferase levels (0.2%), and respiratory tract infection (0.2%). Median PFS was 4 months (95% CI 3.1‐5.9) and median OS was 13.6 months (11.8‐not reached). The mean number of CTCs in peripheral blood was significantly reduced from baseline to cycle 2 (16.8 vs 5.4 CTCs; P < 0.001). Median OS was significantly longer in <5 baseline CTC patients compared to ≥5 baseline CTC patients (13.1 months [95% CI: 11.8‐not reached] vs 12.5 months [95% CI: 7.6‐not reached]; P = 0.045). A significant correlation (P = 0.0129) was observed between CTC levels at cycle 2 and death when CTCs were analyzed using cox regression. Eribulin chemotherapy is effective and safe as third line in advanced HER2‐negative breast cancer. CTC levels correlate with overall survival.     

Oncological Safety and Quality of Life Associated with Mastectomy and Immediate Breast Reconstruction with a Latissimus Dorsi Myocutaneous Flap

Abstract: To determine the quality of life (QoL) of breast cancer patients who underwent mastectomy and immediate breast reconstruction with a latissimus dorsi myocutaneous flap (LD), and the oncological safety of the procedure. Between May 2001 and March 2007, 2,566 patients had breast cancer surgery at the National Cancer Center, Korea. Of the 2,566 patients, 1,699 had breast‐conserving surgery (BCS) and 120 had a mastectomy with an immediate LD. We retrospectively compared the oncologic safety of the two techniques. We also assessed the QoL using the EORTC QLQ BR‐23 and Zung’s self‐rating depression scale in 52 LD patients, 104 age‐ and stage‐matched patients who underwent BCS, and 104 age‐matched healthy women. The LD group had earlier stage disease than the BCS group at baseline, but following surgery, the groups did not differ in the rates of local recurrence or systemic metastases. Compared with the healthy group, the patient groups had poorer functioning and more depression (p < 0.001). Among the patient groups, the LD group reported lower scores for body image (p = 0.007) and future perspective (p = 0.023) than the BCS group. In the LD group, patients who received neoadjuvant chemotherapy reported lower scores for future perspective and higher scores for depression than those who did not receive neoadjuvant chemotherapy (p < 0.001). The BCS and LD groups did not differ in oncological outcome, and the QoL of patients in the LD group was not always good. Mastectomy with immediate reconstruction should be considered carefully and tailored to the patient’s needs and characteristics.     

Radiation effect on late cardiopulmonary toxicity: An analysis comparing supine DIBH versus prone techniques for breast treatment

Two commonly used whole breast irradiation (WBI) techniques, deep inspiration breath hold (DIBH) and prone positioning, are compared with regard to dosimetry and estimated late cardiac morbidity and secondary lung cancer mortality using published models. Forty patients with left‐sided DCIS or breast cancer who underwent lumpectomy and required adjuvant WBI were enrolled on a prospective trial comparing supine DIBH (S‐DIBH) with prone free breathing (P‐FB) planning. Patients underwent CT simulation in both positions; two plans were generated for each patient. Comparative dosimetry was available for 34 patients. Mean cardiac and lung doses were calculated. Risk of death from ischemic heart disease (IHD), risk of at least one acute coronary event (ACE), and lung cancer mortality were estimated from published data. Difference between S‐DIBH and P‐FB plans was compared using paired two‐tailed t test. Estimated mean risk of death from IHD by age 80 was 0.1% (range 0.0%‐0.2%) for both plans (P = 1.0). Mean risk of at least one ACE was 0.3% (range 0.1%‐0.6%) for both plans (P = .6). Mean lung cancer mortality risk was 1.4% (range 0.5%‐15.4%) for S‐DIBH and 1.0% (range 0.4%‐9.8%) for P‐FB (P = .008). Excess lung cancer mortality due to radiation was 0.5% (range 0.1%‐6.0%) with S‐DIBH and 0.0% (range 0.0%‐0.4%) with P‐FB (P = .008). Both S‐DIBH and P‐FB provide excellent cardiac sparing. Prone positioning results in lower lung dose than S‐DIBH and leads to an absolute decrease of 0.5% in excess lung cancer mortality for patients receiving WBI.     

Malignant Phyllodes Tumor of the Breast: Treatment and Prognosis

Surgery remains the mainstay of the treatment in patients with malignant phyllodes tumor of the breast (MPTB); however, the extent of surgery (breast conserving surgery [BCS] versus mastectomy) and the role of adjuvant radiotherapy have been controversial. We report a single institution's experience with MPTB. We discuss controversial therapeutic aspects of this rare tumor. Seventy patients with MPTB treated primarily with surgery were evaluated. The mean age was 50 years (21–76), and the mean size of the tumor was 6 cm. Thirty‐four (48.6%) patients were treated with total mastectomy, and 36 (51.4%) were treated with BCS (lumpectomy or wide local excision). Microscopic surgical margins were free of tumor in all cases. In 64 (91.4%) patients, margins were ≥1 cm. Remaining 6 (8.6%) patients treated with BCS margins were <1 cm and subsequently radiotherapy was performed. Among 70 patients, 58 (82.9%) had no evidence of disease (NED) after 5 years. The extent of surgery was not significantly related to the 5‐year NED survival rates (82.4% in patients who underwent mastectomy and 83.3% in patients who underwent BCS only or BCS with adjuvant irradiation). The 5‐year NED survival rates in BCS (tumor‐free margin ≥1 cm) and BCS with irradiation (tumor‐free margin <1 cm) groups were identical (83.3%). Our data support the potential use of BCS in patients with MPTB. Mastectomy is indicated only if tumor‐free margins cannot be obtained by BCS. Adjuvant radiotherapy may be considered if tumor‐free margins are <1 cm.     

Variability of Preoperative Breast MRI Utilization among Older Women with Newly Diagnosed Early‐stage Breast Cancer

While magnetic resonance imaging (MRI) is frequently used following breast cancer diagnosis, routine use of breast MRI for preoperative evaluation remains contentious. We identified factors associated with preoperative breast MRI utilization and investigated the variation among physicians. We used the surveillance, epidemiology, and end Results (SEER)‐Medicare linked database to analyze the preoperative breast MRI utilization among patients with stage 0, I, or II breast cancer diagnosed between 2002 and 2007. Multilevel logistic regression models were used to identify patient‐ and physician‐level predictors of preoperative MRI utilization. Of 56,743 women with early‐stage breast cancer who were treated with surgery and evaluated by a preoperative mammogram and/or ultrasound during the study period, 8.7% (n = 4,913) received preoperative breast MRI. While patient and tumor characteristics did predict preoperative breast MRI utilization, they explained only 15.4% of the variation in utilization rates. Differences in preoperative breast MRI utilization across physicians were large, after controlling patient‐level factors and physicians' volumes. Accounting for clustering of patients within individual physicians (n = 3,144), the multilevel logistic regression models explained 36.4% of variation. The median odds ratio of 3.2, corresponding with the median value of the relative odds of receiving preoperative breast MRI between two randomly chosen physicians, indicated a large individual physician effect. Our study found that preoperative breast MRI has been adopted rapidly and variably. Although patient characteristics were associated with preoperative breast MRI utilization, physician practice was a major determinant of whether women received preoperative breast MRI. Future studies should evaluate whether routine use of preoperative breast MRI in newly diagnosed early‐stage breast cancer improves clinical outcomes.     

Simple oncoplastic breast defect closure improves long-term cosmetic outcome of breast conserving surgery for breast cancer: A randomised controlled trial

IntroductionBreast conserving surgery (BCS) is associated with unsatisfactory cosmetic outcomes in up to 30% of patients, carrying psychological and quality-of-life implications. This study compares long-term cosmetic outcomes after BCS for breast cancer with v without simple oncoplastic defect closure.MethodsA randomised controlled trial was performed, recruiting patients who underwent BCS over four years and randomising to the “reshaping” group (closure of excision defect with mobilised breast tissue; n = 124) and to the “control” group (no attempt at defect closure; n = 109). The estimated excision volume (EEV) was <20% of breast volume (BV) in both groups. Photography and breast retraction assessment (BRA) were recorded preoperatively. Cosmetic outcomes were blindly assessed annually for five years by BRA, panel assessment of patients, and body image questionnaire (BIQ).ResultsThere were no significant differences between the reshaping and control groups in mean age (52.4 v 53.0; p = 0.63), body mass index (27.8 v 27.7; p = 0.80), margin re-excision (9 v 9; p = 0.78), mean BV (562.5 v 590.3 cc; p = 0.56), mean EEV (54.6 v 60.1 cc; p = 0.14), mean EEV/BV ratio (11.2 v 11.0; p = 0.84), or mean specimen weight (52.1 v 57.7 g; p = 0.24). Reshaping group patients had significantly better outcomes compared to control group patients in terms of mean BRA (0.9 v 2.8; p < 0.0001), achieving a score of “good” or “excellent” by panel assessment at 5 years (75.8% v 48%, p < 0.0001), body image questionnaire top score at 5 years (66.9% v 35.8%; p = 0.0001).ConclusionsSimple oncoplastic closure of defects after breast-conserving surgery improves long-term objective and subjective cosmetic outcomes.     

Long‐Term Impact of Young Age at Diagnosis on Treatment Outcome and Patterns of Failure in Patients with Ductal Carcinoma In Situ Treated with Breast‐Conserving Therapy

We reviewed our institution's long‐term experience treating patients diagnosed with ductal carcinoma in situ (DCIS) of the breast with breast‐conserving therapy (BCT) to determine the impact of patient age on outcome over time. All DCIS cases receiving BCT between 1980 and 1993 were reviewed. Patient demographics (including age <45) and pathologic factors were analyzed for effect on outcomes including ipsilateral breast tumor recurrence (IBTR) and survival. BCT included limited surgery (excisional biopsy or lumpectomy) followed by radiotherapy to the whole breast (median whole‐breast dose: 50 Gy, median tumor bed dose: 60.4 Gy). One hundred and forty‐five cases were evaluated; the median follow‐up was 19.3 years. Twenty‐five patients developed an IBTR, for 5‐, 10‐, 15‐, and 20‐year actuarial rates of 9.9%, 12.2%, 13.7%, and 17.5%, respectively. The 10‐year ipsilateral rate of recurrence was 23.3% (<45 years) versus 9.1% (≥45 years) (p = 0.05). Younger patients more frequently developed invasive recurrences (20‐year actuarial rates: 20.4% versus 12.8%, p = 0.22) and true recurrences/marginal misses of the index lesion (23.3% versus 9.7%, p = 0.04) with lower rates of contralateral breast cancer (0.0% and 0.0% versus 12.0% and 20.5%, p = < 0.01, at 10 and 20 years, respectively). Young women under the age of 45 diagnosed with DCIS have a greater risk of local recurrence with different patterns of failure following BCT, which is most notable within 10 years of diagnosis.     

Feasibility Study of Safe Breast Conservation in Large and Locally Advanced Cancers with Use of Radiopaque Markers to Mark Pre-Neoadjuvant Chemotherapy Tumor Margins

Background  The lack of objective documentation of pre-neoadjuvant chemotherapy (NACT) margins after chemotherapy is a major constraint in performing safe breast-conserving surgery (BCS) in patients with locally advanced breast cancer (LABC). Using a novel method of marking pre-NACT tumor margins with indigenous silver wire markers, this prospective pilot study attempted to assess the feasibility of safe BCS in LABC patients by performing excision wide of the marked pre-NACT margins. Methods  LABC patients had sterile silver wire markers placed at all tumor margins percutaneously. Patients were then treated with NACT followed by wide local excision (WLE) incorporating pre-NACT margins (ex vivo on mastectomy specimen or in vivo in patients opting for BCS). The histology of the margins wide of the post-WLE cavity (pre-NACT) and post-NACT tumor was used to assess adequate disease clearance and safety of BCS. Results  Altogether, 40 stage III breast cancer patients (mean tumor size 7.9 cm) were studied; none had marker-related complications. Following NACT, the tumor size assessed by markers showed average regression by 1.5 cm. The pre-NACT margins were histologically negative in 95% of the surgical specimens. In 2 (5%) patients both pre-NACT and post-NACT margins were positive; post-NACT margins were infiltrated in 14 (35%). Conclusions  The post-NACT WLE that is wide of the marked pre-NACT margins can achieve uninfiltrated margins in 95% of cases. If post-NACT margins are used to guide the WLE, 35% patients would have infiltrated margins, some of which would remain undetected, putting patients at high risk of local recurrence. This novel indigenous method of identifying tumor margins with sterile silver wire markers is safe, inexpensive, practical, and effective; and it may help perform safe BCS in a large proportion of LABC patients. Drs. Vivek Aggarwal and Gaurav Agarwal have contributed equally to this study, and so are joint first authors.     

False‐positive Extra‐Mammary Findings in Breast MRI: Another Cause for Concern

Breast magnetic resonance imaging (MRI) has been repeatedly shown to have a high false‐positive rate for additional findings in the breast resulting in additional breast imaging and biopsies. We hypothesize that breast MRI is also associated with a high rate of false‐positive findings outside of the breast requiring additional evaluation, interventions, and delays in treatment. We performed a retrospective review of all breast MRIs performed on breast cancer patients in 2010 at a single institution. MRI reports were analyzed for extra‐mammary findings. The timing and yield of the additional procedures was also analyzed. Three hundred and twenty‐seven breast cancer patients (average age = 53.53 ± 11.08 years) had a breast MRI. Incidental, extra‐mammary findings were reported in 35/327 patients (10.7%) with a total of 38 incidental findings. The extra‐mammary findings were located in the liver (n = 21, 60.0%), thoracic cavity (n = 12, 34.3%), kidneys (n = 1, 2.9%), musculoskeletal system (n = 3, 8.6%), and neck (n = 1, 2.9%). Eighteen of the 35 patients (51.4%) received additional radiographic imaging, 3 (8.6%) received additional laboratory testing, 2 (5.7%) received additional physician referrals and 2 (5.7%) received a biopsy of the finding. The average time to additional procedures in these patients was 14.5 days. None of the incidental, extra‐mammary findings were associated with breast cancer or other malignancy. Breast MRI was associated with a high rate (10.7%) of extra‐mammary findings, which led to costly additional imaging studies, referrals, and tests. These findings were not associated with breast cancer or other malignancies. Extra‐mammary findings highlight an unrecognized adverse consequence of breast MRI.     

Screening vs staging magnetic resonance imaging‐guided core needle breast biopsies: Does MRI indication impact upgrade rate?

Adjunct magnetic resonance imaging (MRI) for both screening high‐risk patients and staging for patients with newly diagnosed breast cancer leads to an increased number of biopsies and increased detection of atypical lesions. We assessed whether the malignancy upgrade frequency for high‐risk atypia identified via MRI‐guided biopsies varied based on indication: high‐risk screening vs staging for malignancy. Among 399 MRI‐guided biopsies, 46 (11.5%) high‐risk lesions (ADH, ALH, and LCIS) were identified. Surgical excision was performed on 37% of 46%, and 24.3% were upgraded to invasive malignancy or DCIS. Of lesions identified by staging MRI, a slightly higher percentage, 28.5%, were upgraded (P = .36). Our data suggest that surgeons should carefully consider excisional biopsy for atypia identified on MRI regardless of indication.     

Outcomes of single‐port gasless laparoscopic breast‐conserving surgery for breast cancer: An observational study

To compare the clinical efficacy and aesthetic perspectives between single‐port gasless laparoscopic breast‐conserving surgery (SGL‐BCS) and traditional breast‐conserving surgery (T‐BCS) in early‐stage breast cancer. A total of 70 patients who were diagnosed with stage I or stage II breast cancer participated in this study, which 35 patients underwent SGL‐BCS, while others underwent T‐BCS. There were no death or severe intraoperative complications, and none of the patients exhibited regional recurrence, distant metastases, or any critical complications after 2 years follow‐up. SGL‐BCS is feasible and safe surgery, and has advantages in terms of a single, shorter, hidden incision, high‐satisficed aesthetic outcome and less intraoperative blood loss.     

Shock wave lithotripsy for distal ureteric stones: supin or prone

Shock Wave Lithotripsy (SWL) has become the preferred first-line approach to most patients with symptomatic urolithiasis. The purpose of this study is to assess the ideal patient position during SWL for the treatment of distal ureter stones. A total of 342 patients included in this retrospective study. 148 (108 men, 40 women) patients were included in the first group and were treated in supine position. The remaining 194 (143 men, 51 women) patients were included to second group and were treated in prone position. This study designed retrospectively. The procedure was accepted as a success if the patient was stone free or had only clinically insignificant fragments (≤3 mm) for 3 months or more after the last SWL session. Before SWL, the mean is one area in the first group was 61.32 mm² while the mean stone area in the second group was 59.04 mm² (p = 0.208). Mean energy, Mean energy maximum and mean number of applied shock waves of the first group was 4.65, 3.19 and 3,960, respectively. The same parameters in second group were 4.26, 3.03 and 2,953, respectively. These results show that there are statistically significant differences between two groups with respect to mean energy, mean energy maximum and mean number of applied shock waves (p = 0.003, p = 0.010, p = 0.000, respectively). Success rate was 85.1% in group 1 and 72.7% in group 2 (p = 0.006). Our results suggest that supine position is effective and better than prone position for SWL in patients with distal ureteric stones.     

Intraoperative Radiotherapy of Early Breast Cancer Using Low‐Kilovoltage X‐Rays‐Reasons for Omission of Planned Intraoperative Irradiation

The purpose of this study is to investigate reasons for omission of a planned intraoperative radiotherapy (IORT) during breast‐conserving surgery (BCS). Between 2002 and 2009, in 297 women an IORT during BCS was planned. In 55 women this irradiation was finally not performed. We retrospectively analyzed pre‐, peri‐, and postoperative data of these 55 women. Main reasons for omission of an IORT were insufficient tumor–skin distance (n = 20, 35.1%), an oversized wound cavity (n = 14, 24.6%), and a combination of both (n = 8, 14%). Further reasons (n = 12, 21.1%) were temporal shortage, unplanned maintenance work of the Intrabeam^® device, unsuitable anatomicosurgical conditions, and ineligible histologic findings. Apart from suitable anatomic conditions, a precise preoperative ultrasonography as well as a strict interdisciplinary preoperative management is important for successful application of IORT.     

Supine Breast MRI and 3D Optical Scanning: A Novel Approach to Improve Tumor Localization for Breast Conserving Surgery

Background

Wire localization for excision of nonpalpable breast cancer is an inefficient and inexact technique.

Methods

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.

Results

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.

Conclusions

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.