Radioactive Seed Localization for Nonpalpable Breast Cancer

Educational Objectives

The goal of this program is to improve the management of breast cancer. After hearing and assimilating this program, the clinician will be better able to identify the benefits, risks, and challenges of iodine (I) 125 seed placement for localization of breast cancer le­sions.

Summary

Wire-localized breast surgery: wire placement in breast lesions gold standard for excisional biopsy and lumpec­tomy of nonpalpable lesions; widely available and usable with typical types of imaging; does not require approvals; disadvantages  —requires codependent surgery and radiology scheduling; possible patient discomfort and inconve­nience; possible difficulty of surgical approach or with locating tip of wire; possible to fracture, cut across tip, or dislodge wire; wire may overshoot location

Iodine (I) 125 seeds: used to localize nonpalpable breast lesions; history  —  technetium (Tc) 99 accidentally injected into tumor; incident led to idea of using fixed radioisotopes as beacon to localize lesions and device that detects gamma radiation (eg, Neoprobe) to guide surgery; advantages  —  seed placement can be done £5 days before sur­gery; seed migration possible but infrequent; differing peaks of I 125 and Tc 99 allow localization of lesion and sentinel node during same surgery (some overlap when probe on I 125 setting); Gray study  —  showed no seed mi­gration; localizing and operative times equivalent to those for wire surgery; saw fewer positive margins and smaller excision volumes; Mayo study  —  all seeds retrieved; 1 of 383 seeds migrated; positive margins decreased to 8%; challenges  —  requires approval by Nuclear Radiation Safety Committee; radiation safety protocol required for all departments handling seeds; occasional seed migration

Placement of seeds: same technique used as with wire localization; seed preloaded in 25-gauge needle; needle tip placed next to lesion; seed position confirmed with mammography after injection; requirements  —  initial and re­fresher training for all involved staff; specific protocols needed in event of seed breakage; confirmation of seed re­moval; logistics  —  ambulatory centers and histology laboratories require licensing to handle seeds; local transportation department may regulate transport of seeds; billing code for surgeon same as that for placement of wire marker (currently, no clear-cut code for radiologists)

Operative techniques: prevention of overlapping signals  —inject seed into periareolar skin on side opposite to that of Tc-99 injection; seed localization  —  uses same detector as that used for sentinel node biopsy;  allows continual reorientation to lesion during surgery; after resection  —  assess specimen for presence of seed; radiation counts from patient recorded (should be low); most centers perform specimen radiograph (confirms removal); pathology surveys tissue for appropriate margins and recovery of seed; seed placed in lead container for decay; retrieved by nuclear medicine; radiation exposure  —  dose in single seed low (dose from computed tomography of abdomen and pelvis significantly higher); levels considered safe for hospital workers who may be pregnant

Seed-related emergencies: ruptured seed  —  requires shutdown and decontamination of operating room; consider thyroid saturation with stable iodine for all exposed persons; lost seeds  —  patients must agree to return for explan­tation; close proximity of operating room to laboratory preferred; avoid use of suction

Sequence of seed placement: seed loaded in needle; stereotactic technique used to place in breast; placement con­firmed with Geiger counter; mammography performed, and breast marked with number of seeds placed; detection device at I 125 setting used to guide surgery; Geiger counter continually monitored (continuous count when adja­cent to seed); specimen removed, and counts taken of patient and specimen

Readings

Suggested Reading

Azoury F et al: Thoracoscopic management of a pericardial migration of a breast biopsy localization wire. Ann Thorac Surg 87: 1937, 2009; Ciatto, S et al: Accuracy and underestimation of malignancy of breast core needle biopsy: the Florence experience of over 4000 consecutive biopsies. Breast Cancer Res Treat 10:291, 2006; Cox CE et al: Radioactive seed localization breast biopsy and lumpectomy: can specimen radiographs be eliminated? Ann Surg Oncol 10:1039, 2003; Crystal P et al: Accuracy of sonograph­ically guided 14-gauge core-needle biopsy: results of 715 consecutive breast biopsies with at least two-year follow-up of benign le­sions. J Clin Ultrasound 33:47: 2005; El-Sayed ME et al: Predictive value of needle core biopsy diagnoses of lesions of uncertain malignant potential in abnormalities detected by mammographic screening. Histopathology 53:650, 2008; Georgian-Smith D, Law­ton TJ: Controversies on the management of high-risk lesions at core biopsy from a radiology/pathology perspective. Radiolog Clin North Am 48:999, 2010; Gianni L et al: Neoadjuvant chemotherapy with trastuzumab followed by adjuvant trastuzumab versus neo­adjuvant chemotherapy alone, in patients with HER2-positive locally advanced breast cancer (the NOAH trial): a randomised con­trolled superiority trial with a parallel HER2-negative cohort. Lancet 395:377, 2010; Goss PE et al: Exemestane for breast-cancer prevention in postmenopausal women. N Eng J Med 364:2381, 2011; Gray RJ et al: Radioguidance for nonpalpable primary lesions and sentinel lymphnode(s). Am J Surg 182:404, 2001; Gray RJ et al: Randomized prospective evaluation of a novel technique for biopsy or lumpectomy of nonpalpable breast lesions: radioactive seed versus wire localization. Ann Surg Oncol 8:711, 2001; Giu­liano AE et al: Association of occult metastases in sentinel lymph nodes and bone marrow with survival among women with early-stage breast cancer. JAMA 306:385, 2011; Holmes FA et al: Correlation of molecular effects and pathologic complete response to preoperative lapatinib and trastuzumab, separately and combined prior to neoadjuvant breast cancer chemotherapy. J Clin Oncol 29(suppl):506, 2011; Hughes JH et al: A multi-site validation of radioactive seed localization as an alternative to wire localization. Breast J 14: 153, 2008; Jackman RJ et al: Stereotaxic large-core needle biopsy of 450 nonpalpable breast lesions with surgical cor­relation in lesions with cancer or atypical hyperplasia. Radiology 193:91, 1994; Jakub JW et al: Current status of radioactive seed for localization of non palpable breast lesions. Am J Surg 199:522, 2010; Lewis JT et al: An analysis of breast cancer risk in women with single, multiple, and atypical papilloma. Am J Surg Pathol 30:665, 2006; Pavelick W et al: Radiation safety with use of I-125 seeds for localization of nonpalpable breast lesions. Acad Radiol 13:909, 2006; Tang G et al: Recurrence risk of node-negative and ER-positive early-stage breast cancer patients by combining recurrence score, pathologic, and clinical information: A meta-analysis ap­proach. J Clin Oncol 28(suppl):509, 2010; Whelan TJ et al: NCIC-CTG MA.20: An intergroup trial of regional nodal irradiation in early breast cancer. J Clin Oncol 29(suppl): LBA1003, 2011.

 

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and plan­ning committee reported nothing to disclose. 

Acknowledgements

Dr. Grubbs was recorded at 75th Annual University of Minnesota Surgery Course  —  Advances in Breast, Endocrine, and Cancer Surgery, held June 16-18, 2011, in Minneapolis, MN, and sponsored by University of Minnesota Medical School. The Audio-Digest Foundation thanks the speaker and the sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

ON022302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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