Left Lumpectomy with Wireless Seed Localization for Ductal Carcinoma In Situ

CHAPTER 1

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.

CHAPTER 2

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.

CHAPTER 3

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CHAPTER 4

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.

CHAPTER 5

The next step is to make an incision. I usually make this with a 15 blade knife.

CHAPTER 6

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.

CHAPTER 7

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.

CHAPTER 8

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.

Okay, 15.

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.

CHAPTER 9

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.

CHAPTER 10

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.

CHAPTER 11

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.

Okay.

CHAPTER 12

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.

CHAPTER 13

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.

CHAPTER 14

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.

Thank you.

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.

CHAPTER 15

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.