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Surgery: Initial Experiences

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Surgery: Initial Experiences Digital tomosynthesis for surgical margin assessment in breast-conserving surgery: Initial Experiences N. Merchant1, L. Richmond1, M. Skarpathiotakis1, B. Curpen1, R. Jong1, C. Betel1, K. Hack1, A. Maki2 and M. Yaffe1,2 1 Department of Medical Imaging 2 Department of Medical Biophysics Sunnybrook Health Sciences Centre University of Toronto Disclosures This presentation will discuss the investigational use of a medical device (digital breast tomosynthesis). No other relevant disclosures. Objectives Discuss the rationale and potential role for digital tomosynthesis (DT) in the assessment of gross surgical specimen margins following breast conserving surgery Discuss the technical challenges and artifacts encountered Discuss potential for future application Background Achieving negative surgical margins has important clinical implications in breast-conserving surgery. This is aided by the radiological assessment of the surgical specimen using ultrasound and/or conventional radiography. Background Limitations of conventional imaging modalities Ultrasound: • As with breast imaging, limited sensitivity for assessment of certain lesions, particularly microcalcifications Single specimen radiograph: • Overall sensitivity of 62% and specificity of 95%1 • 2D assessment of an irregularly shaped 3D specimen • Allows for assessment of inclusion of the lesion, but not all margins are optimally assessed • Overlapping fibroglandular tissue may obscure the lesion(s) American Journal of Roentgenology. 1994;162(1): 33-36. Background Digital Tomosynthesis • Uses conventional x-rays and a digital detector • Images acquired while rotating the x-ray tube in an arc around the breast or a volume of tissue • Images manipulated to produce thin slice tomographic cross- sectional images Moving X-ray tube Specimen with wire Digital detector Digital Tomosynthesis (DT) Over the past decade, Digital Breast Tomosynthesis has been added to the armamentarium of the Radiologist for breast imaging Potential to improve breast specimen margin assessment using 3D imaging vs. the conventional 2D radiograph To further evaluate this…. We carried out a pilot study to assess the feasibility of using DT to improve the accuracy of surgical specimen margin assessment in cases of radiographically visualized breast lesions. Pilot Specimen DT study Single tertiary care oncology centre Specialized breast radiologists, surgeons, and pathologists Inclusion criteria: patients undergoing preoperative wire localization followed by breast-conserving surgery for mammographically visible lesions including calcifications, masses, masses with calcifications, or clips Exclusion criteria: Mastectomy, mammographically occult lesions, and patients unable to give consent 29 surgical specimens imaged Specimen DT protocol DT performed immediately following the specimen radiograph using the same equipment Approximate scan time: 7 seconds 9 projection images acquired over a 25-degree angular range in a step-and-shoot manner Iterative reconstruction algorithm used to produce a reconstructed volume with slices every 0.5 mm in the z-direction Study methodology Image reviewer: Radiologist with subspecialty training in breast imaging Anonymized specimen radiographs and DT images reviewed by same reader at separate sittings Access to all pre-operative imaging for both sets of imaging reviews, but blinded to the other modality images and the pathology report Superior, inferior, lateral and medial margins measured for both imaging modalities Pathologic margins used as ground truth Technical Challenges Multiple technical challenges and artifacts were encountered upon review of the DT images Led to concerns about variability and reproducibility of the data Data felt to be unusable The remainder of this presentation discusses the challenges we encountered… Motion Artifact To maintain anatomical distances/depths, specimens were not compressed during image acquisition Specimen prone to minor motion as the machine moved through the range of angles • blurring of lesion margins and fine calcifications • blurring of the in-plane specimen margin Specimen secured with plastic wrap which was then taped to the imaging surface variable amount of motion artifact Hover mouse over image to Play Wire Echo Artifact Extensive echo artifact relating to the localization wire Arc/fan shaped distribution in a single plane, over multiple slices Related to image acquisition over multiple angles +/- motion artifact Limited assessment by obscuring adjacent small lesions / calcifications in that plane Hover mouse over image to Play Specimen Radiograph vs. DT Specimen Radiograph DT image No motion artifact Wire echo artifact and image blur 2a 2b Specimen Radiograph DT image (in plane of wire) No motion artifact No significant motion artifact Wire Echo Artifact Potential solutions to minimize this artifact: • Manipulating the reconstruction algorithm may help suppress/ minimize this artifact o However, this may also affect the appearance of the lesions within the specimen • Replacing localization wires with radioactive seeds Delineating margins DT measures x-ray transmission through Well-visualized cancer with minimal tissue over a range of angles series of motion or wire echo artifact. images reconstructed for different Can you define the margins of the heights above detector (z-axis) specimen on each plane? The true margin in a particular imaging plane should produce a sharper margin • However, in many cases it was difficult to delineate the true margin in that specific plane from the margin of an adjacent plane Each image includes tissue at the height of focal plane and overlapping tissue • This factor + multilobulated margins of specimens + motion artifact appearance of multiple possible margins Hover mouse over image to Play Posterior Margin Visualization Posterior-most aspect of specimen (directly on the specimen plate) incompletely included on the reconstructed images • improved by raising the specimen on a clear plastic block Hover mouse over images to play clips Directly on imaging plate Raised on block (Cine: Posterior Anterior) Note extensive motion artifact and wire echo artifact on both sets of images Additional Considerations Artifact inherent to the tomosynthesis equipment: • Degree of background noise inherent to the tomosynthesis unit may vary between vendors • All specimens were imaged using the same machine • Images acquired using step-and-shoot method • Trial using other units/vendors may be considered Conclusion While the concept of multiplanar specimen margin analysis with DT has potential, the multiple challenges and artifacts encountered in this preliminary study limit its practical application, at least in its current state. Future work on minimizing the technical issues may help improve the quality of the images, potentially making it more feasible and applicable to general practice. • Ideas to explore… o Adding reconstruction algorithms to suppress artifacts such as the wire echo artifact o Using radioactive seeds for localization instead of wires o Trial of continuous tube motion during x-ray exposure vs. the step- and- shoot method used in this study .
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