Left Lumpectomy with Wireless Seed Localization for Ductal Carcinoma In Situ
Table of Contents
Breast-conserving surgery with radiation for early-stage breast cancers provides equivalent survival rates to mastectomy when all surgical margins are clear of residual cancer. For patients whose tumors are not palpable upon physical examination, preoperative localization of the malignant tissue to be removed is necessary. While wire localization is the traditional method of localization, a variety of wireless localization devices have become available as viable alternatives. Seed localizations provide several advantages over wire localization, including fewer scheduling issues, less patient anxiety, and reduced patient discomfort. Wire localization must occur on the day of the surgery, while seed localization may occur prior to surgery. Seed localization devices guide the breast surgeon to the target, typically a malignancy that must be removed in its entirety to give the patient the best likelihood of disease-free survival.
The patient is a 58-year-old postmenopausal woman who was seen for consultation regarding the management of newly-diagnosed ductal carcinoma in situ (DCIS) of the left breast detected on routine screening mammograms with no clinical or radiological evidence of lymph node involvement.
A routine screening mammogram identified a new 2.5-cm area of calcifications in the medial left breast. Radiologists did not identify any areas of concern in the right breast. Subsequent left breast core biopsy of the calcifications showed grade 2–3 estrogen-receptor-positive DCIS.
This patient underwent bilateral breast reduction surgery in 1992. A paternal cousin was diagnosed with breast cancer at age 55 and there is no other family history of breast or ovarian cancer. Because of the insignificant family history of breast and ovarian cancer, she was not recommended for genetic testing. She underwent a hysterectomy in 2013 due to fibroids and had no other surgical history.
This patient met with a breast oncology team 1 week after her biopsy-proven diagnosis of DCIS. On examination, the patient’s breasts appeared symmetric without palpable nodules or changes to the skin. She reported no nipple discharge. There was no axillary or supraclavicular adenopathy bilaterally.
She appeared to be healthy with no notable findings in her respiratory, cardiac, GI, musculoskeletal, or head and neck systems. No vitals were taken at her consultation with breast surgical oncology; however, at a recent prior office visit with her family medicine doctor, vital signs were as follows: BP 102/82, pulse 100, and BMI 37.44 kg/m.2 Her Eastern Cooperative Oncology Group (ECOG) score was 0, suggesting she was capable of full unrestricted activity. A recent blood evaluation showed that levels of organ function parameters were acceptable for surgery. She has a history of hypertension, and no other notable medical conditions or surgical history that would exclude her from a breast-conserving procedure.
Screening mammogram demonstrated calcifications that led radiologists to call the patient back for a diagnostic mammogram. She previously received screening mammograms annually, going back to 2013, that the radiologists used for comparison. A bilateral diagnostic mammogram revealed indeterminate calcifications in the left central inner breast. The overall assessment from the diagnostic mammogram was BI-RADS 4 and stereotactic biopsy was recommended. The subsequent stereotactic biopsy was performed 2 weeks after screening mammogram, returning a diagnosis of DCIS.
Once a diagnosis was made, an MRI was performed to gain a more accurate picture of the shape and span of breast cancer. The MRI showed areas of fibroglandular tissue and mild background parenchymal enhancement. There was a signal void from the core biopsy clip at the site of the biopsy-proven DCIS in the left upper inner breast (approximately the 9:00 position, 5 cm from the nipple with the patient in prone position). There was non-mass enhancement at the biopsy site measuring at least 1.5 cm. Additional small foci of enhancement extended inferiorly from the biopsy site suggesting that overall enhancement could span up to 2.5 cm.
The enhancement of the skin of the medial breast was compatible with post-biopsy changes. There were additional scattered small foci of enhancement bilaterally. No axillary lymphadenopathy was seen.
A team of breast oncologists reviewed the radiological images and stereotactic biopsy results in conjunction with the patient’s medical history and physical exam. She had a palpable, grade 2–3, ER-positive DCIS of the left breast.
It is estimated that 1 in 8 women in the United States will develop breast cancer over the course of their lifetime, with an average five-year survival rate for women with invasive breast cancer at approximately 90%.1, 2 Because of the likelihood of developing breast cancer, breast oncology societies recommend regular mammograms to track the progression of any abnormalities so that any malignancies can be caught at an early stage.3 With early detection, oncologists can begin local therapies as soon as possible.
Patients who undergo breast-conserving surgery have survival rates equal to those of patients who undergo total mastectomy, provided that the surgical team achieves clear margins.4, 5 Although surgical equivalency has been demonstrated, patient anxiety related to the possibility of positive margins, indicative of residual cancer in the breast cavity, sometimes pushes patients towards mastectomy over lumpectomy. Surgeons typically recommend lumpectomy if the tissue to be removed is less than 25% of the patient’s breast size.
For this patient, the size of her cancer relative to her breast size indicated that we could provide favorable oncologic and cosmetic outcomes with breast-conserving surgery. Because of the lack of palpability of cancer on physical exam, tumor localization was indicated for this patient to effectively excise cancer and achieve clear surgical margins.
Currently, surgeons may choose between wire localization or wireless localization approaches such as magnetic seeds (MAGSEED), radiofrequency identification (RFID) tags (Faxitron), SAVI-SCOUT, radioactive seeds, and others.
Given the lack of palpability of any axillary, supraclavicular, or inframammary lymph nodes, absence of abnormal lymph nodes on radiological imaging, and the early stage of her breast cancer, it was decided that a sentinel lymph node biopsy was not in the best interest of the patient.
The patient preferred breast conservation to mastectomy to maintain her natural breast shape. It was explained to her that additional treatment recommendations would be based on the final pathology of tissue excised at the time of her lumpectomy and would be presented upon her return to the Breast Center postoperatively.
We planned a left lumpectomy under general anesthesia and informed consent was obtained.
This patient was brought to the operating room for excision of biopsy-confirmed DCIS in the medial left breast. After a discussion of the options, she opted to proceed with lumpectomy. Prior to surgery, the patient underwent bracketed magnetic seed localization of known cancer by a team of interventional radiologists.
In the operating room, the patient was placed in the supine position. Preoperative antibiotics were administered, and the left breast and axilla were prepped and draped in the standard surgical fashion. The procedure started by infiltrating 1% lidocaine with epinephrine and 0.25% bupivacaine without epinephrine in the breast for local pain control. A curvilinear incision was made using a #15 blade scalpel. Flaps were raised in all directions using Bovie electrocautery. We grasped the tissue surrounding the RFID tag using two Allis clamps. The lumpectomy specimen was then excised using a #15 blade scalpel. The specimen was sent to breast imaging for confirmation of the presence of the lesion within the specimen. We then excised margins in several directions to ensure clean margins. Each of the new margins was oriented such that a stitch was placed on the new margin. After removing the specimen, the wound was well irrigated and hemostasis was achieved using Bovie electrocautery. Hemoclips were left to assist in orienting postoperative radiation. The incision was closed using interrupted 3-0 Vicryl and running 4-0 Monocryl sutures. There was no unexpected bleeding during the excision of the mass. Steri-Strips and a sterile dressing were applied.
The patient was awakened from anesthesia and brought to the recovery room without incident. She was monitored by a team of perioperative nurses following surgery and was discharged the same day. She was instructed to resist lifting anything heavier than 10 lbs until she was seen again at her first postoperative visit. The patient reported no postoperative complications. Upon her return to the Breast Center 3 weeks after surgery, her incision was healing well and she was cleared to resume daily activities. We recommended adjuvant whole-breast radiation therapy (WBRT) in the prone position, beginning 4–6 weeks after surgery. After radiation, she would consider tamoxifen therapy to reduce the risk of a local recurrence or new primary breast cancer.
Numerous studies have demonstrated that breast-conserving surgery provides outcomes equivalent to those to mastectomy for the treatment of breast cancer if clean margins are achieved.4, 5 For palpable breast cancers, surgeons may opt to perform a lumpectomy using touch as a guide for complete tumor resection. For breast cancers that are nonpalpable upon clinical exams, surgeons routinely opt for preoperative tumor localization procedures. Wired and wireless localizations for nonpalpable breast cancers are now considered standard of care to ensure that the targeted malignancy can be identified and excised during breast-conserving surgery.
Embedding wires transcutaneously has long been the standard of care for tumor localization; however, emerging wireless localization technologies offer many potential advantages over the standard wire technique. Seed localization procedures can occur prior to the day of surgery, eliminating the problems that may arise when trying to schedule wire localization and lumpectomy for the same day. Additionally, wireless devices offer a level of comfort that wires do not; wires protrude from the breast and are often taped down until the lumpectomy has begun. Initial studies have shown that the use of magnetic seed localization is safe in terms of the low migration rate from its intended target, and its ability to be detected in breasts of varying densities and depths below the skin.
Radioactive seeds can be placed prior to surgery and have shown similar surgical outcomes to those of wire-guided localization6; however, they require careful handling. Because of the regulations regarding radioactive materials, the radioactive seed must be handled and disposed of under the supervision of an authorized user.7 Alternatively, a recent study found equivalent rates of re-excision following both RFID tag-localized lumpectomies and wire-localized lumpectomies.8 One disadvantage of RFID tags is that they require a 14-gauge introducing needle that may lead to small incisions at the insertion site. Further studies are needed to examine the costs associated with the use of wires, magnetic seeds, and other wireless localization methods to definitively compare their respective merits.
Between 20–40% of women undergoing lumpectomy require a second operation to obtain clear surgical margins. DCIS, such as in this patient, may have erratic geometry that can be difficult to excise. Patients with these types of lesions may therefore benefit from the use of multiple localizing markers to bracket the edges of the tumor. It has been shown that use of multiple localizing wires to bracket larger or more erratically shaped tumors had similar rates of re-excision as patients with only one localizing wire.9 McGugin et al. demonstrated a higher re-excision rate in RFID tag-localized lumpectomies than in wire-localized lumpectomies when more than one tag/wire was used to bracket the target. Additional studies are warranted to determine whether multiple magnetic seeds or other wireless localization markers are as effective as wires for bracketing larger and erratically-shaped breast lesions.
- Lumpectomy kit
- RFID tag LOCalizer (Faxitron)
- BioVision (Faxitron)
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Breast Cancer: Statistics. American Society of Clinical Oncology website. https://www.cancer.net/cancer-types/breast-cancer/statistics/2015. Accessed on August 22, 2019.
- U.S. Breast Cancer Statistics. Breastcancer.org website. https://www.breastcancer.org/symptoms/understand_bc/statistics. Accessed on August 22, 2019.
- What Is Breast Cancer Screening? Centers for Disease Control and Prevention website. https://www.cdc.gov/cancer/breast/basic_info/screening.htm. Accessed on August 22, 2019.
- Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347:1233-41. https://doi.org/10.1056/NEJMoa022152
- Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 17;347:1227-32. https://doi.org/10.1056/NEJMoa020989
- Chan BK, Wiseberg‐Firtell JA, Jois RH, Jensen K, Audisio RA. Localization techniques for guided surgical excision of non‐palpable breast lesions. Cochrane Database Syst Rev. 2015(12). https://doi.org/10.1002/14651858.CD009206.pub2
- Hayes MK. Update on preoperative breast localization. Radiol Clin North Am. 2017;55:591-603. https://doi.org/10.1016/j.rcl.2016.12.012
- McGugin C, Spivey T, Coopey S, et al. Radiofrequency identification tag localization is comparable to wire localization for non-palpable breast lesions. Breast Cancer Res Treat. 2019:1-5. https://doi.org/10.1007/s10549-019-05355-0
- Kirstein LJ, Rafferty E, Specht MC, et al. Outcomes of multiple wire localization for larger breast cancers: when can mastectomy be avoided? J Am Coll Surg. 2008;207:342-6. https://doi.org/10.1016/j.jamcollsurg.2008.04.019
Cite this article
Kelly BN, Brown CL, Specht MC. Left lumpectomy with wireless seed localization for ductal carcinoma in situ. J Med Insight. 2021;2021(277). doi:10.24296/jomi/277.
Table of Contents
- 1. Introduction
- 2. Demonstration of Localizing Device
- 3. Patient Prep
- 4. Surgical Approach
- 5. Incision
- 6. Flap Raising
- 7. Seed Localization
- 8. Excision of Lesion
- 9. Specimen Orientation
- 10. Intraoperative Imaging for Confirmation of Margins
- 11. Resection of Cavity Shave Margins
- 12. Hemostasis, Shave Margin Orientation, and Results from Radiology
- 13. Clip Placement to Mark Cavity for Radiation Oncology
- 14. Closure
- 15. Post-op Remarks
- Inject Local Anesthetic
So today we're going to perform what's called a wireless localized lumpectomy. So, traditionally, patients who underwent a breast surgery, whether it be a breast surgery for cancer or for atypical cells, a wire, a physical wire, would be placed via breast imaging through the lesion of concern. Patients often thought the wire was uncomfortable. Logistically, having a wire placed at the time of lumpectomy is challenging from a scheduling perspective. Wires that are placed need to be removed on that day, and therefore any operation that required localization needed to be begun after wire placement, i.e. after the radiologist embarked upon and completed their process. And so therefore I could not begin a lumpectomy until that wire was completed.
There are many different ways to perform wireless lumpectomies. The first was utilizing seed technology, which was embedded with a nuclear signal and utilizing essentially a Geiger counter to identify the spot. This seed would be excised - first localized and first identified the area to be localized and excised, and then the probe in the operating room would define it.
There are now multiple different modalities that include a radar signal, that include metallic field, that includes radio frequency signal, to perform wireless lumpectomies. And it's been wonderful. Patients have reported less pain postoperatively in the recovery room. And again, logistics with regards to scheduling has made it such that these - localizers can be placed days before the operation, and therefore the lumpectomy could be performed very early in the morning, without the added logistics associated with localization placement.
There are some tricks in terms of performing wireless localization and today we are reviewing a lumpectomy for a patient who was diagnosed with ductal carcinoma in situ via a screening mammogram. Her area of concern measured about 2.5 cm mammographically. This had presented with calcifications, and therefore we opted to proceed with a localization utilizing one of these wireless techniques, but used 2 localizers bracketing the area of concern. And I hope that you learned a lot from this video.
The first step was to bring the patient to breast imaging. This patient did have her localizers placed on the day of the operation. She had a mammogram while she was in the sitting position. The radiologist numbed up the skin, took mammographic views, and placed the seeds.
And so here you can see 2 images that were taken post-tag, or seed, placement. This is a view which was taken in the cranial caudal view, and this is a medial lateral approach. The large rectangles are the seeds. This barbell-shaped clip represents the clip that was left of the time of her core biopsy. And her calcifications spanned this direction.
Once these seeds were placed, she was brought in the operating room, and in the operating room we do this operation under what's called monitored sedation, so not general anesthesia. She was in a supine position. I confirmed that the seeds’ signals were identifiable with the device that was provided by this product.
Once that was done, I then prepped and draped in the standard surgical fashion. I consulted with the radiology team as to the location of the seeds in the area which I desired to excise. I made an incision using a prior incision she had from reduction mammoplasty with a 15 blade knife. I then raised flaps using Bovie cautery just underneath the skin because this lesion was so superficial. So by mobilizing the breast tissue from the skin flap, I was able to deliver it through the incision. Once those flaps were identified, I used abdominal retractors, and the key to this operation is using those retractors to stabilize the tissue so that I can use the probe and confirm that the seed is in front of me.
Each one of these devices, the probe is such that it detects the signal as what we describe as a balloon. And so therefore the signal - in some of the devices, not 100%, is on the side and also in front of you. And misadventures occur, i.e. times when I have not been able to identify the localizer at the first operation, as when I perceived that it was in front of me but it was actually on the side of the probe. And so my trick of the trade is to use those retractors in a very flat fashion, minimize how much - mobilization the breast tissue has, and really confirm that it's directly in front of me.
This probe is such that you can use it to scan the area and localize the spot. Ideally I want begin to take tissue when I detect the seed to be less than 10 mm from my probe. Under a centimeter. And that is read out on the screen. Once I clearly identify both tags, then the tags are discernible because they have a label associated with them. A number. And so, in her, she had one tag that began with the number 4, and the second one began with the number 9. I placed 2 Allis clamps directly on top of it, knowing that those - that localizer seed would be in front of me. And then I utilized the 15 blade knife to excise the tissue that was bracketed by the Allis clamps and that were identifying the localizers.
The specimen was then removed, it was oriented, first using a silk stitch to orient the superior and lateral sides of the cube that I created. I also added a radiopaque localizer because I have a specimen imaging device in the operating room that allows me to see how well I did. And so the radiopaque things that I used are hemoclips. I put one hemoclip in the superior direction and two hemoclips in the lateral direction.
I then place the specimen in our intraoperative specimen imaging machine, which confirmed that the calcifications were excised, that the 2 tags were excised, and that the barbell clip in the center was excised as well. I then noted that the calcifications were close in one direction.
As a routine, though, I do take shave margins for every lumpectomy case. And so therefore I used a grasper to grasp the tissue, usually a DeBakey, and used a 15 blade knife to excise - margins in each of 5 directions: one in the superior direction, one in the medial direction, one in the lateral direction, in the inferior direction, and the deep direction. I then oriented each one of these specimens with a silk stitch, designating it "stitch marks new margin." I.e. was not the margin that was looking at the cavity, but on the outside. The pathologist will then be able to ink these specimens on that new margin and section it perpendicularly to be able to quickly assess where there's residual disease within those shave margins and if it was too close to the margin.
Finally, hemoclips were left to mark the cavity itself. Those are helpful for our radiation oncologists to boost the cavity if they would like to as part of the radiation treatment, and also helpful for our breast imagers when they're doing mammography in the future to identify the site where the prior lumpectomy had taken place.
The wound was then well irrigated. Hemostasis was achieved using Bovie cautery. I did use some deep Vicryl sutures to close the seroma cavity to help minimize a large seroma from happening or occurring. And then finally closed the skin using an interrupted 3-0 Vicryl suture and a running 4-0 Monocryl suture, in which I did not place knots. Steri-Strips were left on top. I did note that these seeds or localizers sometimes require introduction by the radiologist through a stab incision or through an introducer. And there are times that I'll utilize a Steri-Strip to close the introduction site that was made by the radiologist.
So this patient's just arrived to the operating room. She was in breast imaging this morning having 2 seeds, or tag markers, placed in the site bracketing the area that I want to excise in the lumpectomy specimen. She's come to the operating room, we placed her in the supine position on the operating table, exposed her left breast, and placed her under monitored anesthesia, giving her a dose of antibiotics preoperatively.
The first stage is just to confirm with our localizer device that the seeds are at the site. So I put the - press the "on" button. It does a small self-test. And now I'm going to place it over the skin to confirm that I hear one of the seeds. And these seeds, they have a label to them. Each one of them has a number. And so, this operation was such that the - area of concern that needed to be excised spanned an area of about 2.5 cm, and so we placed 2 seeds. So I'm looking for - both the numbers associated with it.
So no longer we're hearing the signal, and as we get close, we hear it.
So now that I've confirmed that the seeds are in an appropriate location, for me to plan my - incision - this will be draped in a sterile fashion.
Super. And now we'll prep the patient to prepare her for the operation.
So this is a patient who was diagnosed with ductal carcinoma in situ in the left breast. We discussed the risks and benefits of breast-conserving therapy, or lumpectomy, versus mastectomy, and given the size of the lesion, opted to proceed with a lumpectomy.
We're now going to perform a time-out procedure to increase patient safety. She's in the supine position, her site's marked. She's having a left lumpectomy with localization.
Perfect, she’s supine, she has her safety strap on. No allergies. Antribiotics? She did, she got 2 grams of Ancef. Perfect, she’s a low risk for blood loss, no DVT prophylaxis… She’s a high fire risk. We waited for the prep to dry, we have some saline on the field. And what do you have for local? I have 5% Marcaine with epi, and it’s 1:1 with 1% of Lidocaine A. Anything else? No.
Prior to making the decision as to where I will make the incision, I'm going to do two things. The first is, I will look at the images that was sent to me from our radiology team that are displayed on our monitors. And that will allow us to think about the generalized location. So the abnormality is slightly superior, posterior to the nipple, and fairly close to the skin on one of the views.
The second thing is, I will again utilize the localizing device to identify the 2 localizers that's allowing us to bracket the lesion. So I just press the "on" button. So we've got one spot there. And the second one is sometimes hard to identify if it's just posterior to the prior tag, because - the signal that's being emitted from the first one - There it is. So I found it right there - is hidden.
The last piece - marker, please - is she has a prior incision from a reduction mammoplasty. And so therefore, utilizing her prior incision is a great idea from a cosmetic perspective.
I'm going to now localize the incision. I localize it with both a short-acting agent and a long-acting numbing medication. Pinch and a burn. Just in that subcutaneous plexus. And then I'll continue localizing it along the subcutaneous plexus and the areas in which I think I'll - create a flap.
The next step is to make an incision. I usually make this with a 15 blade knife.
Double skin hooks. And then I utilize the Bovie cautery - to proceed - with the dissection. I use my double skin hooks in order to create the plane, and I know that this lesion is very superficial based on the mammogram findings, and so therefore I'm creating a plane that's a subcutaneous plane.
I find that it's really best to kind of do this - dissection - early on, it allows the tissue underneath to be mobilized in a more efficient way. It makes the excision easier. I'm also thoughtful about trying not to retract on skin envelopes in a forceful way, because that can cause skin ischemia, and therefore necrosis.
Okay. So I've now created a flap all the way around, and therefore this tissue will be able to be easily pulled forward through the incision. I'm going to use the baby abdominals.
And one of the keys in terms of utilizing this wireless approach to excision of a lumpectomy is almost to think about the way you would do wires.
So my first step is to flatten the tissue out as much as possible. These probes detect a signal as a bloom effect around - the entire white surface, not just in front, and so therefore you could be on the side of the lesion and still pick up a signal. And I've found that challenges arise in that you think it's in front of you where it's actually just on the side. And so if you utilize your retractors to flatten out the surface, trying to make it less floppy, you can make - be more confident that the lesion's in front of you as opposed to the side of you.
What we read on the monitor is the distance from the probe to the tag. And here we can see - that it, again, is very superficially placed, there in fact telling me it's just 1 mm to me. And this is one of the tags, the tag that is labeled 40249.
So there's our first tag. We've got to find our second one. This is going to be a little bit more of a challenge because it is posterior to the other one. And that tag is - number starts with a 97. There we go. It's helpful to utilize these metal instruments to isolate the other tag, to hide it from this detector. And so now we can see how nice it is where I see my 97533.
So now I've successfully identified both tags and I'm going to utilize the Allis clamp to grasp the tissue in a bracketed form. So this one's right in front of me. I'm going to grasp this with an Allis. And it's best not to be fearful of not grabbing too hard.
Now we're going to go back to our other tag, which was - right there. I'll take my second Allis. And now we've identified the bracketed extent - Can I have a suction? - of the calcifications associated with her ductal carcinoma in situ.
I prefer to use knives to excise lumpectomy specimens. I think that the pathologists like to see a non-Bovied lumpectomy.
And so therefore I'll use my 15 blade to come around the specimen.
I can use that blade again. Suction, please.
The negative aspect, obviously, is there's an increased risk of bleeding. But if it makes it easier for them to read the margins, there appears to be a benefit.
I'll take a Bovie.
Perfect. So I'm going to continue to come around, taking about 1 cm of tissue - around it. As I start to mobilize it into the tissue, I want to confirm that I have my tag. And so as I've rocked it this way, I can now look. And there's my 97. And now I can look deep and say, is it behind? Did I leave it behind? It does not - appear that I left it behind. Excellent.
I'm going to focus on the second tag for a period of time. This one is much more superficial. I don't have to be as deep.
This is a larger lumpectomy because of the bracketing and also due to patient preference. She requested that I go large so we could reduce the risk of having a second.
So there's one tag. It's 5 mm away from the probe. And then if I look for the second one - 1 mm away from the probe. 15. I'll amputate the specimen. And then the next step is to orient the specimen. We utilize an intraoperative imaging device to confirm that we retrieved all the calcifications and both tags and clip.
And therefore it's helpful to orient the specimen in 2 ways. The first is, I'll do stitches. That's something that's permanent that the pathologist will be able to see and orient. This is called - This is going to be oriented short stitch superior and long stitch lateral. Short. Lateral aspect of the tissue.
And I'm going to add hemoclips, which are radio-apparent, and therefore if calcifications come close to one of these margins, we can excise more tissue in a directed way. So I'm going to put one hemoclip superior and 2 hemoclips in the lateral aspect.
So now we need to image our specimen. This is done by placing the specimen in a bag and then utilizing our intraoperative imaging - device. We center the specimen in the machine and then take a picture.
And it looks great. We identified both seeds. That was what was detected by our localizer. We identified the clip that was left at the time of her core biopsy. We also see calcifications within the specimen. I do note that the calcifications extend a little bit to that lateral inferior margin, since our one hemoclip is superior and our 2 hemoclips are lateral. So when I take my shaved margins, I'm going to be more focused to ensure that I excise that tissue.
As a standard for all our patients, we take shaved margins. Shaved margins means that we're trying to minimize an - a falsely positive margin, a margin such that, because of the fat that lives in breast tissue, could get wiped away as a specimen is transported.
Can I have a rat tooth?
And so as a routine for every patient, we've found that excising these margins separately and orienting them - 15 - we're able to minimize the likelihood of her needing to come back for a second operation. These margins can be very thin. You grasp it with a rat tooth. I come along the process. I'm trying to create - a rectangle of tissue that's representative of that whole superior margin. Her tissue's really fatty, unfortunately, it doesn't hold together very well. And then we place it on our Mayo stand so that they can be oriented later on.
The next margin we take is a deep fashion. So I continue on from where I left off superiorly and excise the posterior aspect of the cavity.
The next margin that I'll excise is a medial margin. That one we're a little less worried about. Again, grasping the tissue, taking out a rectangle. Most shaved margins are about 5 mm in thickness and don't seem to have a big impact on cosmetic results.
Now again, I'm really thinking about the lateral and inferior, because those were the parts that looked like the calcifications were close. So I might be a little bit more generous on this side because of that.
At the same time, our nursing staff is sending that image that I took down remotely to our radiology team so that they can review it. They'll add their input with regards - Can I have a fresh blade? - to - whether I - excised everything I needed to. This is inferior. And then our final specimen is in the lateral direction. So laterally, I'm going to take a shave margin. I'm thinking that it was really superficial in this lateral direction.
The next step is to create hemostasis, I do that with Bovie. And then finally we're going to clip the cavity so that the radiation oncology team who will treat this patient after will be able to target the boost if they would like to boost the cavity.
Why don't you go and orient those specimens.
At the same time, my assistant will be orienting the specimen. We do this by just placing a silk stitch on the surface that we designate as the new margin. Again, we did an analysis that demonstrated that this really improved the likelihood of having to go back for a second operation.
Great. So this is the radiology team calling us with the results.
Hey Dr. Specht, it's Gary. The specimen looks great, there's just a couple tiny [unintelligible] along the - sorry, the anterior/superficial margin. I just assumed that that was very superficial, so otherwise it looks great.
Super. Thank you, Gary.
Ok, thanks Dr. Specht. Bye.
So we were in slight disagreement with regards to the location of where the extra calcifications were. That's why it's always helpful to have the radiologist assist. And he is correct, because that anterior - calcifications extended to the skin, we don't usually take an additional anterior margin, because we haven't seen that excising skin for an area of ductal carcinoma in situ would change the local recurrence rate.
May I have a DeBakey, please?
A lot of what we can Bovie is just direct Bovie to the - tissue.
As I said previously, the next step is to mark the cavity for the radiation oncologist. I do this by simply grasping the tissue with the - DeBakey and placing a hemoclip in the superior direction - the medial direction - lateral - and inferior direction.
Now I'm going to rearrange some of this tissue with some deep Vicryl sutures to help improve the cosmetic look. Fortunately I've already - done my homework, as I said previously, by mobilizing the skin. I'll take a rat tooth and a 15 - I mean, and a Vicryl.
It's always best to mobilize tissue from lateral to medial as opposed to top to bottom from a cosmetic perspective. Again, unfortunately her tissue is quite - has a big component of fat, and so therefore trying to create this - closure, sometimes the stitches will rip through it.
And then the skin layer is closed in 2 layers. One is an interrupted - 3-0 Vicryl layer, and the second is a running - layer using a Monocryl suture.
I'll take a Monocryl suture. Second layer is a running subcuticular layer utilizing a Monocryl suture.
I prefer not to utilize knots when I close my lumpectomy specimens - incisions. And that's because they can create a palpable lump that, um - is not an optimum cosmetic result.
I try to think of this as a watertight closure, just because in all patients who undergo a lumpectomy, a seroma will form. And, you know, we obviously don't want that to leak.
When I get to the end of the incision, I go from the apex out about 1 cm, making sure that that's an area that was previously numbed. I then leave my tails long until after I place my Steri-Strips on.
May I have a wet and a dry?
Now one of the challenges in terms of these wireless localizing - devices, or tags, is how they're placed. And every company's different. There are some in which the introducers are smaller than others, and so when we encounter something in which the tag placement - you can see these 2 sites here by the radiology team are larger in nature, I will add a Steri-Strip to that site.
May I have the Steri-Strips? And can you cut 2 Steri-Strips shorter?
My intention is to cut these Monocryl sutures flush to the skin. So I do place my Steri-Strips first. Cut it flush to the skin. Not really had trouble in terms of these opening up.
So there's one closing the site. A second.
And now we'll put a dressing on. Patients really find the Tegaderm dressing is caustic. It often can cause blistering worse than the actual incision. So we minimize how much Tegaderm is on the skin, but at the same time we want to be able to cover it so that they can take a shower tomorrow after the operation.
And that was a successful lumpectomy. We'll wait for her final pathology to come back to confirm that the margins are clear. And then she'll likely move forward with radiation.
The patient was awoken from MAC anesthesia, brought to the recovery room without incidence, and she did extraordinary well. It was, in our mind, a successful operation, but the ultimate success will be dependent on her final pathology report, in which we'll be sure that the margins are clear. In our experience, there's about a 15% likelihood that the patient will need to return to the operating room for a second operation due to positive or close margins. Some of the techniques that I described today have helped mitigate that - and we have data to support this - one being obtaining 2 localizers bracketing the area of calcifications, and the second, utilizing the shave margin technique.