Exploiting the advantages of a wireless seed localization system that differentiates between the seeds: Breast cancer resection following neoadjuvant chemotherapy

Abstract

Background: Most wireless localization methods utilize only one means of detection for the surgeon, sufficient to localize a single small breast lesion for excision. Complex cases requiring bracketing of a larger lesion or localization of two or more close lesions can superimpose the signal from separate "seeds" with such methods. The lack of discernment between the localization "seeds" can disorient the surgeon, risking a missed lesion on excision and longer operative times. with the use of neoadjuvant chemotherapy prior to breast surgery, the necessity of localizing both a breast lesion and an axillary lymph node previously biopsied is becoming frequent.

Case: A 44 year-old woman underwent neoadjuvant chmotherapy for a breast cancer the did not express estrogen receptor, progesterone receptor, or HER2 receptor. In establishing the extent of disease, a suspicious ipsilateral lymph node was biopsied and found to contain metastatic disease. She had an excellent response to the chemotherapy, with decreased size of the primary tumor and the previously biopsied lymph node. The patient desired breast conservation. The primary tumor and associated calcifications were bracketed using two different Smartclips™, with a third localizing the lymph node biopsied.

Conclusion: This report illustrates how the use of three SmartClips™, within the EnVisioTM system, allowed for separate tracking of each "seed" throughout a complex surgery in a patient following neoadjuvant chemotherapy. This resulted in successful resection of both the tumor and the tagged lymph node.

Keywords: breast localization; tagged axillary dissection; tagged lymph node; wireless localization.

FIGURE 1

Relative size and shape of a SmartClip™

FIGURE 2

Images of single‐view bracketed SmartClip™ localization of the malignant mass and calcifications using a superior approach in the craniocaudal view. (A). Tomosynthesis facilitates targeting and insertion of the applicator to the posterior margin of the calcifications, (B), and deployment of the Pink SmartClip™ (pink arrow), (C), immediately followed by placement of the Green SmartClip™ applicator (green arrow) along the anterior margin, D

FIGURE 3

Ultrasound images during SmartClip™ localization of the tagged left axillary lymph node containing a Tumark Vision™ marker (solid arrow). (A). The applicator is placed into the lymph node with the bevel adjacent to the marker, (B), and the Purple SmartClip™ is deployed (dashed arrow), C

FIGURE 4

Bracketed residual left breast cancer with Pink (square) SmartClip™ posterior to the lesion, Green (circle) SmartClip™ anterior to the lesion, and Purple (triangle) SmartClip™ targeting the node. The patient's larger breast size overlapped the axilla at rest

FIGURE 5

The orientation of the patient is depicted by the small gray circle “head” relative to the gray boxed “torso” central within the concentric rings. Using the foot pedal, the Purple (triangle) SmartClip™ was chosen for localized resection. The left margin indicates the relative depth (anterior to posterior) of the electrocautery tip to the targeted SmartClip™. The target circles indicate planar distance from the target in centimeters. The numeral in the lower right indicates the direct distance in millimeters to the chosen SmartClip™ target—here 3 mm. The pictured electrocautery tip is pointing to the Purple SmartClip™ within the tagged node

FIGURE 6

Resection of a SmartClip™‐bracketed lesion allows the surgeon to toggle between the two SmartClip™ images on the HUD; the SmartClips™ are actually physically placed along the posterior and anterior aspects of the lesion in this case. Relative distance to the other SmartClip™ can be visualized as denoted by the small geometric figure that is not concentrically located. A denotes the posterior Pink SmartClip™ and B denotes the anterior Green SmartClip™

FIGURE 7

Post‐procedure ML projection of the left breast demonstrates SmartClip™ localization of the tagged node (purple arrow) and SmartClip™ bracketed localization of the posterior (pink arrow) and anterior (green arrow) extent of the malignant mass (Tumark Q™ marker) and calcifications. Two additional benign biopsy markers are present in the lower breast, which were not targeted for excision

FIGURE 8

Specimen radiograph of the tagged axillary dissection node, revealing the tagged metastatic lymph node with biopsy marker and the purple SmartClip™ (arrow) used for localization

FIGURE 9

Radiograph of bracketed lumpectomy specimen demonstrates the malignant calcifications with biopsy marker and the Pink and Green SmartClips™ (arrows) used for the posterior and anterior localization respectively