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Radioactive Seed Localization of Breast Lesions: an Adequate Localization Method Without Seed Migration

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Radioactive Seed Localization of Breast Lesions: an Adequate Localization Method Without Seed Migration ORIGINAL ARTICLE Radioactive Seed Localization of Breast Lesions: An Adequate Localization Method without Seed Migration Tanja Alderliesten, PhD,* Claudette E. Loo, MD,* Kenneth E. Pengel, MSc,* Emiel J. Th. Rutgers, MD, PhD, Kenneth G. A. Gilhuijs, PhD,* and Marie-Jeanne T. F. D. Vrancken Peeters, MD, PhD *Department of Radiology; and Department of Surgery, The Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital (NKI-AVL), Amsterdam, The Netherlands n Abstract: Preoperative localization is important to optimize the surgical treatment of breast lesions, especially in nonpal- pable lesions. Radioactive seed localization (RSL) using iodine-125 is a relatively new approach. To provide accurate guid- ance to surgery, it is important that the seeds do not migrate after placement. The aim of this study was to assess short-term and long-term seed migration after RSL of breast lesions. In 45 patients, 48 RSL procedures were performed under ultrasound or stereotactic guidance. In the first 12 patients, the lesion was localized with two markers: an iodine-125 seed and a refer- ence marker. In 33 patients, 36 RSL procedures were performed using a single iodine-125 seed. All patients received control mammograms after seed placement and prior to surgery. In the patients with two markers, migration was defined as the differ- ence in the largest distance between the markers observed in the mammograms. For single-marked lesions, migration was assessed by comparing distances between anatomical landmarks in the mammograms. RSL was successful in all patients. Seeds were in-situ for 59.5 days on average (3–136 days). The detection rate during surgery was 100%. Overall, an average seed migration of 0.9 mm (standard deviation 1.0 mm) was observed. Neither differences in lesion type, nor days in situ, type of surgery or radiologic localization method were found to have impact on seed migration. RSL is an accurate preoperative localization method for breast lesions with negligible seed migration, independent of time in-situ. n Key words: breast-conserving surgery, image-guided localization, iodine-125, migration, radioactive seed localization reast cancer is the most common type of cancer (a) patients with nonpalpable ductal carcinoma in situ Bin women. More than one million women world- (DCIS); (b) patients with small invasive lesions; and wide are newly diagnosed with breast cancer each (c) patients who have a (near) complete response to year. neoadjuvant chemotherapy. All three patient groups Currently, breast-conserving surgery (BCS) is pre- are increasing, partly because of the aging population ferred to mastectomy when feasible. Because incom- combined with improved breast-cancer screening tech- plete excision of the lesion is a significant risk factor nology and partly because of the more wide-spread for local recurrence and local recurrence is associated use of neoadjuvant chemotherapy. with higher mortality (1,2), it is important to mini- For the excision of nonpalpable lesions, a preopera- mize incomplete surgery. Especially nonpalpable tive localization by the radiologist is essential. Preop- breast cancer poses, however, major challenges to BCS erative localization of breast cancer is typically in this respect. The incidence of incomplete excision performed using wire-guided localization (WGL) or of nonpalpable breast cancer is higher than that of using the radioguided occult lesion localization palpable breast cancer (3,4). There are three groups of (ROLL) technique (5–12). In WGL, one or multiple patients in whom nonpalpable lesions are found: wires are placed in or surrounding the lesion to serve as a guiding tool for the surgeon. ROLL is based on 99m Address correspondence and reprint requests to: Marie-Jeanne T. F. D. an intra-lesional injection of technetium-99m ( Tc) Vrancken Peeters, The Netherlands Cancer Institute - Antoni van Leeuwen- labeled nanocolloid. Excision of the lesion is per- hoek Hospital, Department of Surgery, P.O. Box 90203, 1006 BE Amster- formed with the aid of a gamma probe that registers dam, The Netherlands, or e-mail: [email protected]. the radioactivity of the injected nanocolloid. DOI: 10.1111/j.1524-4741.2011.01155.x More recently, radioactive seed localization (RSL) Ó 2011 Wiley Periodicals, Inc., 1075-122X/11 The Breast Journal, Volume 17 Number 6, 2011 594–601 has been proposed (13). RSL involves implanting RSL of Breast Lesions: No Seed Migration • 595 radioactive iodine-125 seeds into the lesion prior to ‘‘double-marked’’ group. The remaining patients were surgery. Similar to the ROLL procedure, a gamma assigned to the ‘‘single-marked’’ group. probe provides intra-operative guidance to locate and excise the lesion with the radioactive seed. A potential RSL & Radiologic Localization advantage of RSL over ROLL is that the seed provides Mammography and ultrasound of the breast were a small point source of radioactivity enabling accurate performed in all patients. Patients in whom the lesion guidance during surgery. RSL has been compared with was visible at ultrasonography underwent an ultra- WGL and was strongly favored over WGL (14,15). In sound-guided RSL. For this procedure, a Philips iU22 these studies, RSL was performed up to 5 days prior (Philips Healthcare, Eindhoven, The Netherlands) or a to surgery. Seed migration was not the focus of these GE ⁄ Kretz Volusion 730 (GE Medical Systems, Zipf, studies. As a result, little is known about the ability of Austria) ultrasonography unit was used. In the the seeds to migrate over longer periods of time remaining patients, stereotactic RSL was performed (5 months), e.g., when RSL is applied prior to neo- guided by X-ray mammography (XM) (Model adjuvant chemotherapy. Also, little is known which ASY-00072; Lorad Medical Systems, Danbury, CT). procedures during treatment are more likely to cause Single-packed iodine-125 seeds were used for the seed migration. Knowledge of these factors may aid to RSL procedures (Figs. 1 and 2). At the time of place- optimize the surgical margins in BCS. ment, the seeds contained on average 0.13 mCi The aim of this study is to prospectively evaluate (range: 0.03–0.21 mCi) of iodine-125. After occluding seed migration after RSL for surgery of nonpalpable the tip of a 10 cm long 18 gauge needle (item no. breast lesions, taking multivariate factors into account 15810020, Bard Peripheral Vascular – Biopsy, Tempe, including time in-situ of the iodine-125 seed. AZ) with sterile bone wax (knochenwachs W30; Johnson & Johnson, Ethicon GmbH, Germany), the radioactive seed was placed into the needle with twee- MATERIALS AND METHODS zers. Confirmation of placement of the seed in the tip of the needle was obtained via measurement with a Patient Data scintillation detector (Type 540, Mini Instruments; Between January 2008 and February 2009, 45 Stratec Services BV, Houten, The Netherlands). patients received surgery after implantation of iodine- For patient comfort, we applied local anesthesia. 125 seeds (STM1251; Bard Brachytherapy, Carol Subsequently, the radiologist placed the tip of the Stream, IL). All procedures were performed according needle in the center of the lesion. This was performed to accepted clinical indications. The radioactive seeds under ultrasound or stereotactic mammography guid- were placed for different clinical indications: prior to ance. When imaging confirmed that the tip of the neoadjuvant chemotherapy (n = 22), prior to wide needle (with iodine-125 seed and loosely placed stylet) local excision (WLE) for nonpalpable DCIS or infil- was in the center of the lesion, the seed was deployed trating ductal carcinoma (IDC) (n = 20), a diagnostic by fully advancing the stylet. After withdrawal of the excision biopsy (n = 2), and re-excision (n = 1) for needle, both the needle and the breast were residual DCIS. Patients who demonstrated favorable investigated with a scintillation detector to confirm response to neoadjuvant chemotherapy, resulting in that the seed was placed in the breast. residual lesion smaller than 3 cm, received BCS. Oth- ers underwent mastectomy. In the first 12 patients, lesions were localized with both an iodine-125 seed and a standard O-twist-mar- ker (OTM3.OS, [diameter of ring: 3 mm, needle length: 13.7 cm, 18 gauge], Bard Peripheral Vascular – Biopsy, Tempe, AZ) to exclude potential unexpected large shifts. The markers were inserted during the same radiologic examination. In the following 33 patients, the breast lesion was localized by an iodine- Figure 1. Photograph of three iodine-125 seeds (STM1251) man- 125 seed only. All patients in whom the lesion was ufactured by Bard Brachytherapy, (Carol Stream, IL). Copyright CR localized with two markers were assigned to the Bard. 596 • alderliesten et al. Figure 2. Product design of an iodine-125 seed. The seed has a nominal length of 4.5 mm and a nominal width of 0.8 mm. The copper layer is coated with iodine-125. The seed has a gold core and is encased in titanium. The seed has flat ends. Copyright CR Bard. To confirm correct placement and to monitor the distance between the two markers after placement potential seed migration, all patients received and after surgery. Patients in whom the initial distance mammograms (MLO and CC view) at two different between the two markers exceeded 10 mm were trans- times: (a) directly after RSL; (b) prior to surgery ferred to the group of single-marked lesions. In these (either on the day before surgery or on the day of sur- patients, differences in distance between the markers gery). For patients in the double-marked group, addi- could not be reliably attributed to seed migration tional X-ray images were acquired of the excision alone, but could also be caused by deformation of the specimen (in two orthogonal directions) after surgery. tissue in between due to differences in breast compres- sion during mammography. This threshold was empir- Surgery ically derived based on the observations of the During surgery a handheld gamma detector radiologists.
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