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Breast-conserving surgery (BCS) is considered the gold-standard treatment for early breast cancer.Various techniques were proposed for identifying non-palpable breast tumors, but the mostpopular one is the wire-guided localization (WGL technique). The most important drawback ofBCS is the possible presence of microscopic tumor at or close to the margin of excision.The work highlighted significance of screening programs in early detection and recent advancesin the management of early non palpable breast cancer. This was a prospective study on 30 patientswith a single non-palpable breast lesion. A preoperative USG or MMG-guided hook wirelocalization technique was performed then intraoperative frozen section was done.The results showed that 30 patients were treated with wire-guided localization and BCS, andintraoperativefrozen sections. According to positive margins, patient age, menopausal status, tumorsize and histologic type were associated with increased risk of positive margins. The re-excisionat the time of original operation was 6/30(20%), without second operation. Postoperative complicationswere 5(16.7%) due to neo-adjuvant chemotherapy, size of mass, specimen volume, marginstatus and LNs affection.

Background Vacuum-assisted breast biopsy (VABB) has been routinely recommended for stereotactic intervention in cases of isolate mammographically-detected calcifications. Herein we aimed to evaluate and compare the diagnostic consistency and accuracy of calcified and noncalcified specimens obtained from same sites of sampling on mammography-visible calcifications. In addition, we presented the biopsy procedure and retrospectively evaluated the usefulness of VABB as well as the complications of this technique over an eight-year experience in our centre. Methods This single-institution observational cohort study included 587 patients referred for stereotactic 11-gauge VABB of 594 mammographically-detected calcifications between January 2010 and December 2018. The rate of histopathological underestimation, the false negative, the diagnostic consistency and accuracy between calcified and noncalcified specimens of VABB were comprehensively evaluated based on the surveillance data and final histopathological result of the surgical specimens. Results In total, 594 biopsy procedures were performed in 587 patients (mean age 46 years, range, 21-80 years). The average number of biopsy specimens was 14.7 (range, 9-21) per lesion. VABB pathological results revealed 471 (79.3%) benign, 39 (6.6%) high-risk, and 84 (14.1%) malignant cases. The diagnostic inconsistency between calcified and noncalcified specimens was 14.6% (105/123) for high-risk and malignant lesions. Furthermore, calcified specimens exhibited higher diagnostic accuracy of malignant lesion as compared with the noncalcified specimens (97.7% versus 82.6%, respectively). Underestimation rate for high-risk lesions and in situ carcinoma was 5.1% and 54.1%, respectively, along with a false negative rate of 6.25%. In addition, mild complications were reported with high patient tolerance. Conclusions Stereotactic 11G-VABB might be preferred for the investigation of non-palpable mammographically-detected calcifications in terms of accuracy and safety profile. The high prevalence of diagnostic discordance between the specimens with and without calcifications revealed a higher value of calcified specimens in diagnosing high-risk and malignant calcifications.

Introduction. In 2018, the number of newly diagnosed breast carcinomas in the 28 countries of the European Union was 404 920, with an estimated annual incidence of 144.9/100 000. Figures have increased since the introduction of mammography screening and continue to rise with population aging. Mammograms may convey clinically occult breast cancer, which is associated in some cases with the presence of clustered microcalcifications. Case presentation. We present the case of a 64-year-old patient with multifocal invasive ductal left breast cancer and lobular carcinoma in situ, diagnosed after biopsy of a mammogram-marked area with clustered microcalcifications. The patient underwent subsequent radical surgical treatment. Conclusions. Clustered microcalcifications on mammograms may indicate clinically occult breast cancer. These lesions cause clinical and diagnostic difficulties due to the inability of ultrasound visualisation and the option to perform punch biopsy, as recommended by European Society for Medical Oncology. Excision biopsy by mammography-guided wire marking and pathological-anatomical examination of the entire resectate can detect tumour heterogeneity, which is important for the subsequent therapeutic strategy and prognosis of the disease. En 2018, le nombre de cancers du sein nouvellement diagnostiqués dans les 28 pays de l’Union européenne était de 404 920, avec une incidence annuelle estimée à 144,9/ 100 000. Les chiffres ont augmenté depuis l’introduction du dépistage par mammographie et continuent d’augmenter avec le vieillissement de la population. Les mammographies peuvent signaler un cancer du sein cliniquement occulte, associé dans certains cas à la présence de microcalcifications en grappes. Présentation du cas. Nous présentons le cas d’une patiente de 64 ans atteinte d’un cancer du sein gauche canalaire invasif multifocal et d’un carcinome lobulaire diagnostiqué in situ après biopsie d’une zone marquée par mammographie avec des microcalcifications en grappes. Le patient a subi un traitement chirurgical radical ultérieur. Conclusion. Les microcalcifications groupées sur les mammographies peuvent indiquer un cancer du sein cliniquement occulte. Ces lésions entraînent des difficultés cliniques et diagnostiques en raison de l’impossibilité de visualiser par les ultrasons et de l’option d’effectuer une biopsie par ponction selon la recommandation de la Société Européenne d’Oncologie Médicale. La biopsie d’excision par marquage au fil guidé par mammographie et l’examen anatomo-pathologique de la zone réséquée peuvent détecter une hétérogénéité tumorale qui est importante pour la stratégie thérapeutique et le pronostic de la maladie.

Halstedian radical mastectomy is practiced over 40 years as surgical treatment of breast cancer. For the last twenty years, breast conserving surgery (BCS) has been more practiced in the treatment of breast cancer as it provides oncological safety as well as cosmesis. Non palpable breast lesions are being increasingly diagnosed in the recent years as a result of introduction of breast cancer screening, high quality digital mammography and increase in public awareness. Accurate localisation of small, nonpalpable breast lesions is mandatory for accurate surgical management. The purpose of this article is to review the techniques systematically those have been used to locate non-palpable breast lesions which could easily be introduced in Bangladesh. Breast conserving surgery means complete removal of the tumour with a concentric margin of surrounding healthy tissue with maintenance of acceptable cosmesis. It should be followed by radiation therapy (RT) to achieve an acceptably low rate of local recurrence. Breast conserving surgery with radiotherapy has same survival benefit as mastectomy. BCS plus RT provided better outcome than mastectomy for early breast cancer and should be offered as a preferred treatment option. Experience, logistical support, and multidisciplinary approach is key to success. Radiological support with ultrasound or stereotactic localization with wires and /or ultrasound skin marking are key to have accurate wide local excision of non palpable lesions which is gold standard. Other newer techniques such as radio guided occult lesion localisation (ROLL), magnetic seeds, radiofrequency seeds localisation are a feasible and safe method of breast lesion localization as well and gaining popularity slowly. Faridpur Med. Coll. J. Jul 2019;14(2): 93-99

Multiple wire-free technologies for localization of non-palpable breast cancers have emerged as satisfactory alternatives to wire. However, no study has compared two non-radioactive wire-free approaches to one another. The purpose of this study was to compare outcomes among LOCalizer™ radiofrequency identification (RFID), SAVI Scout® (SAVI), and wire localization (WL). This was a retrospective, cross-sectional cohort study of patients undergoing lumpectomy for non-palpable breast cancer at a single institution between August 2017 and February 2019. Patients were divided into three cohorts based on localization technique: RFID, SAVI or WL. Operative times and average tumor volumes were compared using one-way analysis of variance. Positive margin and re-excision rates were compared with Fisher’s exact test. Among 104 patients who underwent lumpectomy for non-palpable breast cancer, 33 patients (31.7%) had RFID, 21 (20.2%) had SAVI, and 50 (48.0%) had WL. Operative times were 79 min for RFID, 81 min for SAVI, and 78 min for WL (p = 0.91). Volume of tissue resected was 36.3 cm3, 31.7 cm3, and 35.3 cm3 for RFID, SAVI, and WL, respectively (p = 0.84). Positive margin rates (RFID 3.0% vs SAVI 9.5% vs WL 8.0%, p = 0.67) and re-excision rates (RFID 6.1% vs SAVI 9.5% vs WL 10.0%, p = 0.82) were similar across groups. Wire-free localization technologies have been compared to WL demonstrating similar efficacy. Our study suggests that RFID and SAVI Scout also perform similarly to one another. Physicians and institutions may consider more nuanced features of each localization system rather than performance alone when choosing a wire-free alternative.

Background: With the introduction of breast cancer screening the number of non-palpable breast cancers and so the number of breast conserving surgery (BCS) has increased. Wire-guided localization (WGL) is used as invasive standard method for localization. IOUS is an alternative non-invasive, time-sparing and safe localization method with many cost benefits. Patient and methods: A retrospective observational study was performed in a single breast unit where IOUS was used as localization method by two surgeons in the period June 2013 to October2016. The surgeons did not have any special experience with Ultrasound (US) apart from one week of bed-side training. Results: During a 41 months period the two surgeons treated 452 with BCS. Of them 126 were non-palpable and visible by US 28%. The 126 cancers were identified with IOUS at surgery and removed successfully by the surgeons. In the period a total of 156 had a BCS with WGL. These cases had a nonpalpable cancer which were non-visible on US with either calcifications, DCIS or non-specific lesions. In the study we also found that the re-lumpectomy rate for BCS with IOUS was lower than without IOUS. In the entire breast unit, the number of BCS were 848 and number of BCS+WGL were 320 in the same period. Of them 263 (22.5%) had a re-lumpectomy. The number BCS with IOUS were 452 and the number of BCS+WGL with IOUS were 156. Of them 72 (11.8%) had a re-lumpectomy. Conclusion: In our breast unit, IOUS was used after a short bed-side training, with 100% success rate, to remove non-palpable cancers if visible on US. IOUS is easy to learn and easy to use and offers many financial and time-sparing benefits. IOUS has a reasonable learning curve and can reduce the work load on the Radiology Department. Citation Format: Shideh Pour Zahed, Thor Knudsen Andersen. Intraoperative ultrasound localization (IOUS) for non-palpable breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-20.

Background The most important prognostic factor in squamous cell carcinoma of the head and neck (HNSCC) is the presence or absence of clinically involved neck nodes. The presence of metastases in a lymph node is said to reduce the 5-years survival rate by about 50%. The appropriate diagnosis of the presence of metastatic node is very important for the management of HNSCC Aim To compare difTerent diagnostic modalities for assessment of the clinically non palpable lymph nodes in HNSCC including by meta-analysis: CT, MRI, US, USFNAC and PET/CT for the proper cervical lymph node staging. Methods Met-analysis study on patients with HNSCC of clinically non palpable lymph nodes (cN0). Results Analysis was divided in 6 groups .Each group contain analysis of one modality according to available studies per patient, per level and per lesion .US is fair test per patient and per lesion.CT is good test per patient and excellent test per lesion.MRI is poor test per patient and fair test per lesion.CT-MRl combined is fair per patient and excellent per level.PET/CT is good per patient, fair per lesion and excellent per level. USFNAC is excellent per lesion. Conclusion CT, CT-MRI combined, PET/CT and USFNAC proved to be excellent in detecting cN0.MRI was poor test in detecting cN0.US was a fair test in detecting cN0 if used alone.

Surgical therapy of non-palpable malignant breast lesions requires precise preoperative localisation. Recently, radioactive iodine seed localisation has excelled among the number of localisation methods. We present our first experience with this method at our department. We describe the structure of the radioactive iodine seed, the principles of preoperative localisation and peroperative detection of the seed, the specimen transport process, histopathological examination, storage and disposal of the seed, as well as aspects of radiation protection.

Several localization techniques are in use for localization of non palpable breast cancer but data on comparative effectiveness of these techniques are sparse. Our aim was to provide the first comparative effectiveness data on the topic.PubMed, Ovid, Scopus and Cochrane library were searched for randomized controlled trials. Pairwise meta-analysis was performed when more than 2 studies reported on the same head-to-head comparison. Network meta-analysis was performed in Stata.Eighteen studies with 3112 patients were identified. A star shaped network was formed for every outcome as all studies had as common comparator the wire localization technique (WGL). Ultrasound guided surgery (UGS) had decreased positive margin both in the pairwise [OR = 0.19(0.11, 0.35); P 0.01] and network meta-analysis OR = 0.19 (0.11,0.60). There was also a statistically significant reduction in re-operation rate [OR = 0.19 (0.11, 0.36); P 0.01] and operative time [MD = -4.24(-7.85,-0.63); P = 0.02] as compared to WGL in pairwise meta-analysis. Re-operation rate and operative time did not hold there statistical significance in network meta-analysis. On network meta-analysis UGS had a statistically significant reduction in positive margin as compared to radio-guided occult lesion localization (ROLL) OR = 0.19 (0.11,0.6) and radioactive seed localization (RSL) OR = 0.26(0.13, 0.52). UGS had a 54.6% of being the best technique for positive margin. All techniques were equivalent for successful excision, localization complications, operative time and overall complications.UGS has potential benefits in reduction of positive surgical margin, the rest of the techniques seem to have equivalent efficacy. Further randomized trials are required to verify these results.

Breast cancer is one of the leading killers among women the world over. Widespread mammographic screening programs have led to almost 20% of breast cancers being detected when they are radiologically visible but clinically impalpable. For the localization of these cancers before surgical excision, the Kopan hook wire is the standard technique, but the extent of margins excised still needs to be determined. In this study, we have evaluated the accuracy of specimen mammogram (SM) with digital breast tomosynthesis (DBT) for margin assessment by comparing it to the excised margins as measured in final histopathology. This is a prospective observational study of patients with radiologically suspicious impalpable breast lesions. The patients underwent ultrasound-guided hook wire placement followed by excision of the lesion, subjected to digital tomosynthesis mammogram, and margins were revised on table when indicated. These findings were correlated with final histopathological margin. Our study included 30 patients and out of the 6 lesions, which showed positive margins on specimen mammography, 4 were histologically confirmed to have tumour at the surgical margin and 2 were confirmed to be tumour free. All DBT-positive margins were re-excised at the time of primary surgery. Individual comparison of the margins revealed a good agreement and high level of correlation between DBT and histopathology margins. None of the cases required a second surgery for margin revision. It can be concluded that specimen mammogram with DBT can be used as a reliable tool for intraoperative surgical margin assessment in non-palpable breast lesions to reduce rate of margin revision as well as reduce the volume of breast excised without compromising the oncological safety of the procedure.

BACKGROUND: Magseed technology is a recently introduced localisation technique for impalpable breast lesions with possible advantages over traditional techniques. These include improved theatre logistics, flexibility in incision placement and improved patient experience. This multicentre study evaluates the experience of introducing Magseed technology into routine surgical practice. METHODS: A prospective multicentre study of Magseed localised procedures was performed. Insertion data were recorded by the radiologist including lesion characteristics and Magseed insertion accuracy. The surgical team recorded time from insertion to operation, operating time and surgical satisfaction. Pathology results were reviewed for specimen weight and margins. RESULTS: Between February 2019 and June 2020, 100 patients were enrolled. Magseed localised procedures included 18 excisional biopsies, 23 wide local excisions (WLE), 50 WLE with axillary surgery and four cases of Magseed localised breast WLE with Magseed localised axillary surgery. There were three therapeutic mammoplasties and two cases of Magseed localised targeted axillary node dissection alone. A total of 90% of Magseeds were radiologically placed within 5 mm of the target lesion/node. Time between incision and specimen removal was 17 min (range 6-40 min). All breast and axillary Magseeds were successfully identified and retrieved during surgery. The target lesion was identified in the specimen in all cases. A total of 10% of cases required further surgery for pathologically positive margins. Overall, surgeons reported that Magseed localisation was "easy" or "very easy" in 77% of cases. CONCLUSION: Magseed is a reliable, safe and accurate surgical technique that provides logistical advantages and flexibility of surgical approach. The method was well-accepted by all users.

Background There are several techniques for localization of non-palpable breast tumors, but comparisons of these techniques in terms of margin positivity and volume of tissue resected are lacking. Methods Between 2011-2013 and 2016-2018, 2 randomized controlled trials involving 10 centers across the United States accrued 631 patients with stage 0-3 breast cancer, all of whom underwent breast conserving surgery. Of these, 522 had residual non-palpable tumors for which localization was required. The localization technique was left to the discretion of the individual surgeon. We compared margin positivity and volume of tissue resected between various localization techniques. Results The majority of the patients (n = 465; 89.1%) had wire localization (WL), 50 (9.6%) had radioactive seed (RS) localization, and 7 (1.3%) had Savi Scout (SS) localization. On bivariate analysis, there was no difference in terms of margin positivity (37.8% vs. 28.0% vs. 28.6%, P = .339) nor re-excision rates (13.3% vs. 12.0% vs. 14.3%, P = .961) for the WL, RS, and SS groups, respectively. Further, the volume of tissue removed was not significantly different between the 3 groups (71.9 cm3 vs. 55.8 cm3 vs. 86.6 cm3 for the WL, RS, and SS groups, respectively, P = .340). On multivariate analysis, margin status was affected by tumor size (OR = 1.336; 95% CI: 1.148-1.554, PConclusions While there are a number of methods for tumor localization, choice of technique does not seem to influence volume of tissue resected nor margin status.

Introduction: Screening programs and improved imaging result in higher frequency of non-palpable breast lesions, requiring preoperative localisation. Several localisation methods have been developed, with Magseed® among the more recent techniques. This observational study registered safety, effectiveness and surgeon satisfaction of Magseed® localisation. Data were compared with hooked-wire procedure. Methods: Data regarding safety, effectiveness and surgeon satisfaction of 100 patients who underwent Magseed® localisation were prospectively collected between September 2018 and April 2019, and compared with retrospectively collected data of 91 patients who underwent hooked-wire localisation between March 2018 and September 2018. Results: In total, 103 seeds and 102 wires were included. All magnetic seeds were placed under ultrasound guidance, with a median of two days preoperative. Complication rate did not significantly differ between Magseed® and hooked-wire (2.97% vs. 2.13%; p = 1.000). 94.06% of the seeds were detected with Sentimag®, with a retrieval rate of 100%. Positive margin rate was lower for Magseed®, although not significant (4.76% vs. 10.39%; p = 0.233). Due to positive margins, 1 additional mastectomy was performed, in contrast with 3 mastectomies and 1 additional re-excision in the hooked-wire group. Surgeons scored 81% of the Magseed® procedures as ’easier than hookedwire’. Conclusion: Rate of positive margins and re-excision/mastectomy showed a tendency to be lower with Magseed® localisation compared to hooked-wire localisation. Complication rate was equal. Moreover, high surgeon satisfaction and logistical advantages designate Magseed® as preferable over hooked-wire.

Background: Wire-guided localization is the gold-standard for the detection of non-palpable breast lesions, although with acknowledged limitations. The aim of this study was to evaluate the combined use of LOCalizerr™ (Hologic, Santa Carla, CA, USA), and intraoperative ultrasound (IOUS) for localization and surgery of non-palpable breast cancer. Patients and Methods: Patients with non-palpable breast lesions underwent localization procedure with LOCalizer™ and IOUS. After the placement of the marker, eight measures were made to guide the excision. LOCalizerr™ Pencil and IOUS were performed to obtain the distance between the dissection plane and the margins of lesions. Results: The procedure was feasible in the five enrolled patients and associated with clear oncological margins in all cases. Moreover, a high satisfaction according to Likert scale for surgeons, radiologists and patients, performing limited and tailored resections, was reported. Conclusion: Combining LOCalizerr™ and IOUS is an effective method for locating non-palpable breast cancer, guarantying excellent oncological and cosmetic results.

In penile carcinoma, inguinal lymph node metastasis is a poor prognostic factor for survival outcomes. Management of patients in the clinical setting of non-palpable and non-bulky inguinal nodes (cN0) is challenging and can be controversial. While survival rates are notably improved with early inguinal lymph node dissection (ILND), this procedure is invasive and can be associated with significant postoperative morbidity. Thus, prophylactic ILND on all patients with penile cancer would imply overtreatment in most cases.

Breast conserving surgery has become the standard of care and is more commonly performed than mastectomy for early stage breast cancer, with recent studies showing equivalent survival and lower morbidity. Accurate preoperative lesion localization is mandatory to obtain adequate oncological and cosmetic results. Image guidance assures the precision requested for this purpose. This review provides a summary of all techniques currently available, ranging from the classic wire positioning to the newer magnetic seed localization. We describe the procedures and equipment necessary for each method, outlining the advantages and disadvantages, with a focus on the cost-effective preoperative skin tattoo technique performed at our centre. Breast surgeons and radiologists have to consider ongoing technological developments in order to assess the best localization method for each individual patient and clinical setting.

INTRODUCTION A magnetic seed marker system (Magseed, Endomagnetics, Cambridge, United Kingdom) is used as a localisation method for non-palpable breast lesions in the United States, Europe, and Hong Kong. It overcomes many limitations of conventional techniques and allows scheduling flexibility. We sought to evaluate its efficacy and safety in the Chinese population. METHODS We retrospectively reviewed all Chinese women who underwent magnetic seed marker-guided breast lesion excision from June 2019 to February 2020 at a single institution. Placement success (final target-to-seed distance

Ultrasound (US) is the first-line imaging modality when evaluating scrotal pathology. This review will examine some common pathologies that can present diagnostic and clinical ambiguity, including testicular microlithiasis, incidental non-palpable lesions, varicoceles, and testicular infarctions. This review aims to summarize the current literature and evidence-based guidelines for these entities and to describe the important sonographic features for diagnosis as well as discuss associated clinical implications. Current guidelines suggest that management for testicular microlithiasis is dependent on associated patient risk factors and the presence or absence of other findings on ultrasound. Incidental non-palpable lesions are a diagnostic and management challenge and evolving recommendations depend on the size of the lesion and other associated features. Alternatively, varicocele is a relatively straightforward entity to diagnose, but management strategies depend on the patient’s clinical symptoms and fertility status. Testicular infarctions can also have challenging diagnostic and management approaches, especially when they are segmental. In all of these testicular pathologies, patient risk factors, clinical history, and physical exam are important factors to help guide diagnosis and management. In difficult cases, additional modalities including MRI can add to diagnostic certainty. Ultrasound plays a vital role in distinguishing multiple testicular abnormalities, including testicular microlithiasis, incidental non-palpable lesions, varicoceles, and testicular infarctions. This review summarizes the current literature as well as the available evidence-based guidelines to help define the strength and limitations of US. This review helps delineate the indications for follow-up ultrasound, the salient patient risk factors and clinical findings, and the role of other imaging modalities to increase diagnostic accuracy. This review will assist the radiologist in better identifying and managing these testicular abnormalities, and, in some cases, reduce the number of unnecessary radical orchiectomies.

Background Non-palpable breast lesions are more frequent now than in the past due to the attention toward the mammary pathology and the screening diffusion; the marking of such lesions is very important for a successful surgery. The SentiMag System uses a magnetic marker that is inoculated transdermal in the breast through an 18-gauge needle. Methods Between April 1st and June 30th, 2018, 16 patients with non-palpable breast lesions were selected and subjected to surgery using the SentiMag System in our Unit. They were women with a mean age of 52 years (range 30-84 years). Seven of 16 (43.7%) had a borderline preoperative histological or cytological diagnosis (C3/B3), and nine (56.3%) a diagnosis of carcinoma (C5/B5). Six (37.5%) were marked on ultrasound guidance and 10 (62.5%) on a mammography stereotaxic guide. Results The time for the marker positioning ranged from 2 to 10 minutes. The radiological control of the surgical specimen always showed the presence of both the lesion and the marker, both centered within the specimen and intact. The pathology revealed seven benign lesions, one in-situ, and eight infiltrating carcinomas. Conclusions The SentiMag represents a fast and safe preoperative marking system of non-palpable breast lesions, cutting the radio exposure for personnel and patients. The marker is not displaced over time and it is rapid to place and easy to locate intraoperatively, allowing a clear dissection plane around the lesion. Thus, this reduces the amount of gland removed, improving the aesthetic result mostly in small breasts.

Background The aim was to determine the cost-effectiveness of radioguided occult lesion localization using 125I-labelled seeds (125I seeds) versus hookwire localization in terms of incremental cost per reoperation avoided for women with non-palpable breast cancer undergoing breast-conserving surgery. Methods This study was based on a multicentre RCT with eight study sites comprising seven public hospitals and one private hospital. An Australian public health system perspective was taken. The primary effectiveness outcome for this study was reoperations avoided. Cost-effectiveness was expressed as an incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses were used to explore uncertainty. The willingness to pay (additional cost of localization using 125I seeds justified by reoperation cost avoided) was set at the weighted, top-down cost of reoperation. Costs were in 2019 Australian dollars ($1 was equivalent to €0.62). Results The reoperation rate was 13.9 (95 per cent confidence interval 10.7 to 18.0) per cent for the 125I seed group and 18.9 (14.8 to 23.8) per cent for the hookwire localization group. The ICER for 125I seed versus hookwire localization was $4474 per reoperation averted. The results were most sensitive to uncertainty around the probability of reoperation. Accounting for transition probability and cost uncertainty for 125I seed localization, there was a 77 per cent probability that using 125I seeds would be cost-effective, with a willingness to pay of $7693 per reoperation averted. Conclusion Radioguided occult lesion localization using 125I seeds is likely to be cost-effective, because the marginal (additional) cost compared with hookwire localization is less than the cost of reoperations avoided.

Summary Introduction and objective In the case of non-palpable testes, we often find a small nodule which is called “testicular nubbin (TN)” in scrotum or inguinal canal. There is no agreement about the treatment for TN. This time we investigated whether or not ultrasound examination (US) can be a useful modality for detecting TN. Materials and methods We recruited 66 boys who were diagnosed with non-palpable testes and who had undergone US studies. We examined age, affected side, size of the unaffected side, presence of testicular hypertrophy, and findings from US studies. Radiologists or sonographers familiar with examination of testicular nubbin carried out the ultrasound studies. When TN is detected in a patient, preservation or excision of the TN was chosen by their families. Results Sixty-six boys and 76 testes were examined. Thirty-four testes (44.7%) were diagnosed as having TN, 39 (51.3%) were undescended testes, and 3 (3.9%) were retractile testes. The median age of all participants was 13 months (range: 2–118 months). The mean ages of patients with TN, undescended testes, and retractile testes were 7.6 months, 14.5 months and 55 months, respectively. The size ratio between the affected and unaffected sides in cases of TN was 0.144 (range; 0.03–0.48) and in cases of undescended testes was 0.99 (0.46–1.2). Thirty cases of TN (88.2%) had testicular hypertrophy on the unaffected side. Only one case of TN underwent excision; viable cells were not seen. A high US region was observed in 31 (91.1%) cases with TN. Conclusion US was a useful modality for detecting TN. From this study, TN can be detected if the size ratio between the affected and unaffected sides is Download : Download high-res image (134KB) Download : Download full-size image Summary Figure . Ultrasound findings of TN. TN (arrow), Spermatic cord (arrowhead).

Background Wire-guided localization (WGL) has been the mainstay for localizing non-palpable breast lesions before excision. Due to its limitations, various wireless alternatives have been developed. In this prospective study, we evaluate the role of radiation-free wireless localization using the SAVI SCOUT® localization at a European centre. Patients and methods This technique was evaluated in a prospective cohort of 20 patients. The evaluation focused on clinical and pathological parameters in addition to patient and physician acceptance. Results SAVI SCOUT reflectors (n=23) were deployed to localize 22 occult breast lesions and one axillary lymph node in 20 patients. The mean deployment duration was 5.6 min, with a mean distance from the lesion of 0.6 mm. The migration rate was 0% and the mean identification and retrieval time was 25.1 min. In patients undergoing therapeutic excision for malignancy (n=17), only one (5.9%) required reoperation for positive surgical margins. Radiologists and surgeons rated the technique as better than WGL and patient satisfaction was high. Conclusion Our study demonstrates that wireless localization using SAVI SCOUT® is an effective and time-efficient alternative to WGL with excellent physician and patient acceptance.

Lymphomas have frequent relapses; early diagnosis is important to treat and improve outcomes. Clinical exam and imaging are useful but confirmation with biopsy is always required. Minimally exploratory surgery is a tool to take good samples with precision and safety. Evaluate the use of ROLL technique to track non-palpable lesions on the neck which were suspicious of recurrence in lymphoma patients. A retrospective review of the patients with high probability of lymphoma relapse who were biopsied using ROLL technique. Suspicious lesions on the neck where identified on the follow up of five lymphoma patients. Roll technique was used successfully to guide the biopsy. There were no complications. Relapse was confirmed in two patients; the other three was reactive follicular hyperplasia. Management was redirected on relapsing patients. ROLL technique proved to be a simple, safe and effective method to detect and biopsy non- palpable lesions on the neck of patients with suspicious relapsing lymphoma.

Background/aim The problem of adequately marking any given lesion within a breast surgical site is commonly solved by introducing a titanium clip. However, clip dislocation and/or stereotactic hook-wire dislocation are common problems. An ideal solution would be a clip that can be easily found without the use of stereotactic intervention. This work reviews the available data on radiofrequency identification devices (RFID) in breast surgery, reports initial experience data in Europe and discusses surgical pitfalls, advantages and disadvantages. Patients and methods This study represents a single center, consecutively recruited, initiation trial with subsequent surgeon questionnaire for the first institution in Europe to report Faxitron LOCalizer™ chip data. Four patients with non-palpable tumors were marked with the system and were correlated via mammography, pre- and intra-operative ultrasound and pathology. Data were then compared to available literature and a literature review was added. Results The four patients marked with this RFID system, displayed a 100% success location rate at a 0% complication rate. Surgeons evaluated the new system as being safe to use and only slightly more difficult to place compared to a standard clip. A significant improvement in ultrasound localization and intraoperative localization was also reported for the LOCalizer™ system when compared to a standard titanium clip. Conclusion This trial added a small number of consecutively recruited patients to an existing number of available data, resulting in a total of 121 evaluated and reviewed Faxitron LOCalizer™ marked non-palpable in-breast lesions worldwide.

Excisional biopsy of non-palpable rib tumors still represents a challenge for thoracic surgeons: in fact primary or metastatic tumors originating from a rib can be difficult to localize topographically at the time of excisional biopsy, thus potentially resulting in inappropriately placed skin incisions, incomplete tumor excision or even in wrong rib or segment resection (1).

Purpose: Our study was designed to assess the role of intra-operative ultrasound (IOUS) as a method of localization of palpable or non-palpable breast tumors during breast conserving surgery (BCS) and ensuring adequate margins by comparing pathological results of these lesions to be sure if the IOUS localization is effective as a localization tool or not. We included both palpable and non-palpable to add a great effect to the BCS to ensure adequate margins that are not accurately palpated by the surgeon. Introduction: Breast conserving surgery (BCS) is an alternative to mastectomy in treatment of cancer breast. The matter of tumor localization is a problematic issue with the wire localization being the commonest with multiple drawbacks. Another method for localization which is the IOUS is investigated. Patients and methods: This prospective, controlled study enrolled 60 female patients. 30 of them comprised case group (group I) had breast conserving surgeries guided by IOUS and the other 30 patients as a control (group II) who had breast conserving surgeries without any guidance. Specimens Pathological examination was done to ensure the adequacy of free margins. Results: 6 patients from the case group and 14 of the control group had involved inadequate margins. Conclusion: IOUS is an essential adjunct to surgery that should be experienced to maintain safety and cosmoses as the two major impacts of BCS. Keywords: Breast-conserving surgery (BCS), Intra-operative ultrasound (IOUS), Localization, Safety margins

Background Radioactive seed localisation (RSL) is a preoperative localisation method using a small titanium seed containing iodine-125. The method is increasingly applied for localising non-palpable lesions in the treatment of breast cancer. We believe that RSL has the potential to be used in various surgical specialties. The aim of this feasibility study was to test RSL as a preoperative localisation of non-palpable lymph nodes. Methods Between November 24, 2015 and October 26, 2016, 15 patients with suspicious lymph nodes on imaging were included in the study. The lymph nodes were located in the axillary region (n = 9), the head and neck region (n = 5) and the inguinal region (n = 1). The seeds were placed in the centre of the lymph node, in the capsule or just outside the capsule guided by ultrasound. During surgery, incision and localisation of the lymph nodes were performed based on the auditory signal of the gamma probe. After excision, lymph nodes including iodine seeds were sent for pathologic examination and the seeds were returned to the Department of Nuclear Medicine. Results The non-palpable lymph nodes were all successfully marked using ultrasound. The lymph nodes were successfully localised and excised during surgery, and the procedure was performed without complications in the majority of the cases. Conclusion Localisation of suspicious non-palpable lymph nodes using RSL is feasible. RSL may ease the surgical procedure, minimise trauma to the surrounding tissue and ultimately benefit the patient. Future prospective studies are necessary to determine the further use of RSL within different surgical specialties.

Objective: To determine the negative predictive value of ultrasound for breast masses with probably benign morphology, and to assess whether follow-up may be an acceptable alternative to biopsy. Methods: After Institutional Review Board approval, all solid breast masses categorized as probably benign (American College of Radiology Breast Imaging Reporting and Data System [BI-RADS] 3) on ultrasound from January 2014 to December 2015, and having either tissue diagnosis or imaging stability for 24 months, or downgrading to BIRADS 2 during imaging surveillance were included. Result: A total of 157 lesions in 40 patients constituted the study population. The mean patient age was 31.3 years (range, 20-56 years). Seventeen of these 157 lesions underwent tissue diagnosis with no invasive breast cancer. Out of the remaining 140 lesions, 115 were stable on imaging for 24 months or more. The rest 25 were deemed benign because of decrease in size on follow up (n=1), non-recommendation of further imaging by the second radiologist on follow up ultrasound (n= 13) or presence of benign tissue diagnosis in the largest lesion (n=11). Conclusion: Ultrasound has 100% negative predictive value for breast lesions with probably benign morphology, whether palpable or not. Follow up is an appropriate option to immediate biopsy of such lesions keeping in mind that noncompliance with surveillance may be a potential problem.

Objectives Accurate tumour localisation is essential for breast-conserving surgery of non-palpable tumours. Current localisation technologies are associated with disadvantages such as logistical challenges and migration issues (wire guided localisation) or legislative complexities and high administrative burden (radioactive localisation). We present MAgnetic MArker LOCalisation (MaMaLoc), a novel technology that aims to overcome these disadvantages using a magnetic marker and a magnetic detection probe. This feasibility study reports on the first experience with this new technology for breast cancer localisation. Materials and methods Fifteen patients with unifocal, non-palpable breast cancer were recruited. They received concurrent placement of the magnetic marker in addition to a radioactive iodine seed, which is standard of care in our clinic. In a subset of five patients, migration of the magnetic marker was studied. During surgery, a magnetic probe and gammaprobe were alternately used to localise the markers and guide surgery. The primary outcome parameter was successful transcutaneous identification of the magnetic marker. Additionally, data on radiologist and surgeon satisfaction were collected. Results Magnetic marker placement was successful in all cases. Radiologists could easily adapt to the technology in the clinical workflow. Migration of the magnetic marker was negligible. The primary endpoint of the study was met with an identification rate of 100%. Both radiologists and surgeons reflected that the technology was intuitive to use and that it was comparable to radioactive iodine seed localisation. Conclusion Magnetic marker localisation for non-palpable breast cancer is feasible and safe, and may be a viable non-radioactive alternative to current localisation technologies.

Objectives Although wedge resection can be curative for small lung tumours, tumour marking is sometimes required for resection of non-palpable or visually undetectable lung nodules as a method for identification of tumours. Tumour marking sometimes fails and occasionally causes serious complications. We have performed many thoracoscopic segmentectomies using 3D computed tomography simulation for undetectable small lung tumours without any tumour markings. The aim of this study was to investigate whether thoracoscopic segmentectomy planned with 3D computed tomography simulation could precisely remove non-palpable and visually undetectable tumours. Methods Between January 2012 and March 2016, 58 patients underwent thoracoscopic segmentectomy using 3D computed tomography simulation for non-palpable, visually undetectable tumours. Surgical outcomes were evaluated. Results A total of 35, 14 and 9 patients underwent segmentectomy, subsegmentectomy and segmentectomy combined with adjacent subsegmentectomy, respectively. All tumours were correctly resected without tumour marking. The median tumour size and distance from the visceral pleura was 14 ± 5.2 mm (range 5-27 mm) and 11.6 mm (range 1-38.8 mm), respectively. Median values related to the procedures were operative time, 176 min (range 83-370 min); blood loss, 43 ml (range 0-419 ml); duration of chest tube placement, 1 day (range 1-8 days); and postoperative hospital stay, 5 days (range 3-12 days). Two cases were converted to open thoracotomy due to bleeding. Three cases required pleurodesis for pleural fistula. No recurrences occurred during the mean follow-up period of 44.4 months (range 5-53 months). Conclusions Thoracoscopic segmentectomy using 3D computed tomography simulation was feasible and could be performed to resect undetectable tumours with no tumour markings.

The aim of the present study was to compare the application value of the 3D stereo wire localization technique guided by a full digital breast X-ray machine, and general location technique in the resection of breast non-palpable lesions. A retrospective analysis of the clinical data of 80 patients with abnormal findings for non-palpable breast molybdenum target X-ray was conducted between June, 2011 and July, 2014. The patients were divided into two groups: 40 cases with a general location of lesions identified by perturbation axial + standard lateral radiograph to guide the clinical operation biopsy (group A); and 40 cases with a general location of lesions identified by the 3D stereo wire localization method to guide the clinical operation biopsy (group B). The one-time success rate of the resection of breast lesions of the two groups of patients was compared. Both groups of patients completed the operation. Of the 40 cases in group A, 33 cases had one-time complete resection of lesions, 5 cases had incomplete resection with the second resection, and the lesions of 2 cases were not excised and the one-time success rate of the breast lesion resection was 82.5%. Of the 40 cases in group B, lesions of 38 cases were one-time complete resection and 2 had vagal reaction; thus, the one-time success rate of breast lesion resection being 95%. Compared to group A, the one-time success rate of breast lesion resection of group B was statistically and significantly higher (χ2=3.638, P

Background Exact localization of non-palpable breast lesions is necessary to ensure that the correct lesion is removed. Conventional methods come with several disadvantages. Patients and methods We compared 28 patients who underwent breast-conserving surgery for a non-palpable lesion. By surgeon choice, 14 patients were assigned to undergo magnetic seed localization and 14 underwent standard wire localization. The primary outcome was the operative time, and secondary outcome was the patient pain level. Results The mean age was 52±10 (SD) years in the seed arm, and 55±13 years in the wire arm. The median time from skin incision to tumor extraction was not significantly different between the two groups. Patients in the wire localized group significantly more often reported pain during coughing/breathing, movement, and sleep. Conclusion Using seed localization at Charite Breast Center did not lead to a significant decrease in operative time but might allow time savings once established, while increasing patient comfort and reducing organizational burden.

Endometriosis is a benign disease characterized by endometrial glands and stroma outside the endometrial cavity. We reported two cases of endometriosis of the abdominal wall, with subcutaneous and intramuscular localization, that became symptomatic a few years after a cesarean intervention. These cases have a clinical pattern quite similar to cutaneous endometriosis, but they are more difficult to diagnose through physical examination because they are barely palpable. In this sense, coupled with suggestive symptoms, ultrasound examination can confirm the clinical suspicion of endometriosis without the use of computed tomography and/or magnetic resonance imaging.

Background Wire-guided localisation (WGL) remains the most widely used technique to guide surgical excision of non-palpable breast lesions worldwide. However, recent technological advances have led to the advent of less invasive radiation-free localisation methods to overcome the limitations of WGL. Patients and methods This study prospectively evaluated the role of two radiation-free non-wire localisation methods. Magnetic seeds (n=16) and radiofrequency tags (n=6) were deployed under imaging guidance to guide the surgical excision in 19 consecutive patients. Results The identification/retrieval and migration rates were 100% and 4.5%, respectively. Twenty-one out of 22 (95.5%) cases had clear surgical margins and no complications were observed. All radiologists and the surgeon rated these methods as being much better than wire localisation. Patient satisfaction data were recorded using a linear visual analogue scale (n=10/19). The mean score was 9.7/10 (range=8-10). Conclusion Our study provides further evidence that radiation-free wireless breast localisation is an effective alternative to WGL.

IntroductionMagseed is an alternative method of localising non-palpable breast lesions that has addressed many of the limitations of wire guided localisation (WGL). It consists of a paramagnetic seed that can be visualised on mammography and ultrasound. Intraoperative localisation of the seed is achieved with the use of the Sentimag probe. The aim of this study was to prospectively compare localisation in patients undergoing wide local excision (WLE) for non-palpable lesions between Magseed and WGL.MethodsWe prospectively collected data on all patients undergoing image-guided WLE between October 2017 and September 2018 in two academic breast units with a planned accrual of 100 consecutive patients undergoing Magseed localisation. Data was also collected on a cohort of 100 consecutive patients undergoing WGL in the same time period.ResultsDemographic and disease characteristics were well balanced between the two groups. 4/104 patients were converted preoperatively from Magseed to WGL (2 misplaced Magseeds; 2 undetected Magseeds). Intraoperative identification and excision of the localised lesion was successful in all patients as confirmed with specimen radiography. Overall no significant differences were observed in the proportion of patients requiring re-excision between the two groups (Magseed 16% vs. WGL 14% p = 0.692). Specimens size by weight and volume was similar for both groups (Magseed 39.6 g vs. WGL 44.5 g p = 0.206 and 90.1 cm3 for Magseed vs. 95.6 cm3 for WGL p = 0.579).ConclusionsIn our series Magseed localisation proved to be as reliable and effective as WGL in terms of lesion identification, excision with tumour free margins and specimen weight.

Purpose Magnetic Occult Lesion Localization Instrument (MOLLI) is a wireless, non-radioactive alternative for non-palpable breast lesion localization. The primary objective of this first-in-human study was to evaluate the clinical feasibility of using MOLLI for intraoperative localization of non-palpable breast lesions. Methods Twenty women with non-palpable breast lesions at a single institution received a lumpectomy using the MOLLI guidance system. Patients were co-localized with magnetic and radioactive markers up to 7 days before excision by a dedicated breast radiologist under sonographic guidance. Both markers were localized intraoperatively using dedicated hand-held probes. The primary outcome was successful excision of the magnetic marker, confirmed radiographically and pathologically. Demographic data, margin positivity, and re-excision rates were collected. Surgical oncologists, radiologists, and pathology staff were surveyed for user satisfaction. Results Post-radiological analysis: Post-implant mammograms verified that 17/20 markers were placed directly in the lesion center. Radiologists reported that all marker implantations procedures were “easy” or “very easy” following a single training session. Post-surgical analysis: All MOLLI markers were successfully removed with the specimen during surgical excision. In all cases, surgeons ranked the MOLLI guidance system as “very easy” for lesion localization. Pathologic analysis: All patients had negative margins. All anatomic pathology staff ranked the MOLLI system as “very easy” to localize markers. Conclusions The MOLLI guidance system is a reliable and accurate method for intraoperative localization of non-palpable breast lesions. Further evaluation of the MOLLI system in studies against current standards of care is required to demonstrate system cost-effectiveness and improved patient-reported outcomes.

Background Precise preoperative localization of small pulmonary nodules is a key prerequisite to their successful excision. With the advent of hybrid operating rooms (HORs), a patient-tailored approach encompassing simultaneous localization and removal of small pulmonary nodules has become feasible. In this study, we describe our individualized image-guided video assisted thoracoscopic surgery (iVATS) strategies implemented within a HOR environment. Specifically, localization was performed through different marking approaches (single- versus double-marker) and access routes [percutaneous technique with Dyna-computed tomography (DynaCT) imaging versus electromagnetic navigation bronchoscopy (ENB)]. Methods Between April 2017 and November 2018, a total of 159 consecutive patients (harboring 174 pulmonary nodules) were treated with iVATS. The marking approach and access route were individually tailored according to lesion localization and its distance from the pleural surface. The efficacy and safety of our iVATS technique were determined through a retrospective review of clinical charts. Results All of the localization procedures were performed in a HOR by a single team of thoracic surgeons. The mean tumor size on preoperative CT was 8.28 mm (95% confidence interval [CI]: 7.6−8.96 mm), whereas their mean distance from the pleural surface was 9.44 mm (95% CI: 8.11−10.77 mm). Of the 174 tumors, 150 were localized through a percutaneous DynaCT-guided approach (single-marker: 139, dual-marker: 11), whereas localization in the remaining 24 was accomplished via the ENB-guided approach (single-marker: 4; dual-marker: 20). The mean localization time was 17.78 mins (95% CI:16.17-19.39 mins). The overall localization success rate was 95.9%. We failed to localize a total of seven nodules either because of technical complications (pneumothorax, n = 3; microcoil dislodgement; n = 1) or machine failure (n = 3). No operative deaths were observed, and the mean length of postoperative stay was 3.65 days (95% CI: 3.19−4.11 days). Conclusions The use of tailored marking approaches and access routes allowed us to individualize the iVATS procedure for small pulmonary nodules, ultimately promoting a more patient-centered workflow.