Message Biomedical Imaging Advances in Localizing Nodes and - - PowerPoint PPT Presentation

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Message Biomedical Imaging Advances in Localizing Nodes and - - PowerPoint PPT Presentation

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3/7/2015 UCSF Department of Radiology and Message Biomedical Imaging Advances in Localizing Nodes and Image-guided wire localization is Tumors and Who Should Do It? Breast designed to assist the surgeon in Why and How of

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SLIDE 1

3/7/2015 1 Advances in Localizing Nodes and Tumors and Who Should Do It? Breast ‘Why’ and ‘How’ of Image-guided Localization of Breast Lesions

Bonnie N. Joe, MD, PhD

Chief, Women’s Imaging University of California, San Francisco

UCSF Department of Radiology and Biomedical Imaging

Message

  • Image-guided wire localization is

designed to assist the surgeon in successful resection of the target lesion and promote conservation of normal breast tissue.

In the next 15 minutes….

  • Historical background
  • Mammographic localization

– Freehand, Grid techniques

  • US and MRI localization
  • Recent Developments

– Radioactive Seed, US-visible clips

Before Wire Localization

  • 1960s & 1970s Surgical excision based
  • n palpation
  • Management of nonpalpable suspicious

mammographic lesions was problematic

  • Surgeon would often resect a large

portion of breast quadrant based on mammographic report

  • Multiple benign lesions excised for

every cancer diagnosed

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SLIDE 2

3/7/2015 2

Freehand Localization

  • Developed in late 1970s, early 1980s to

maximize likelihood of including the questionable mammographic lesion in the resected tissue

  • Freehand insertion of a needle into the

region of the suspicious lesion preoperatively

Freehand Localization

  • Iterative approximations to get close to target
  • Risk of pneumothorax (needle pointing towards chest wall)

Stephenson, American Journal of Roentgenology. 1980;135: 184-186. http://www.ajronline.org/doi/abs/10.2214/ajr.135.1.184

Early Grid Localization

  • Developed in 1980s
  • Needle insertion parallel to chest wall

– Reduce risk of pneumothorax

  • Difficult to judge depth of needle

placement in orthogonal view

– Two needles placed a different depths

Early Grid Localization

  • One to two needles placed into grid openings closest

to target (arrow) based on mammographic image

From Goldberg, et al. Radiology 1983:146(3):833-839

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SLIDE 3

3/7/2015 3

Modern Mammographic Grid Localization

  • Grid technique allows accurate targeting
  • f lesion
  • Orthogonal imaging allows adjustment
  • f needle to proper depth of target
  • Wire deployed after optimizing needle

position

Clip marking site of cancer

Mammographic Wire Localization

Pt imaged in

  • pen grid

“E-12” localization

Mammographic Wire Localization

Needle inserted perpendicular to skin at site of clip

Mammographic Wire Localization

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SLIDE 4

3/7/2015 4

Orthogonal view to determine needle placement relative to clip

Mammographic Wire Localization

Wire deployed with clip located at distal stiffener (circle) BB markers placed on nipple and at skin entry site for reference

Mammographic Wire Localization

Confirms removal

  • f intact hook wire

and clip

Specimen Radiograph US Localization

  • For mammographically occult lesions

– No marker clip; significantly migrated clip

  • Real-time visualization of needle

placement through target

  • Post-procedure *noncompressed*

mammogram

– Minimize wire migration

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SLIDE 5

3/7/2015 5

Breast MR Localization

  • For lesions not amenable to

mammographic or sonographic localization

  • Prone position
  • Obligate lateral or medial approach
  • Uses grid compression device and open

coil

  • MR-safe needles and wires

Breast MR Localization 3D visualization Breast MR Wire Localization

seen on a different slice

Sagittal T1 Post-gad Sagittal T1 Verification

foci of susceptibility corresponding to 3 needle locations

Post-Procedure Mammogram

Planning Verification Post Mammogram

Radioactive Seed Localization

  • Placement of I125 Seed prior to surgery
  • Intra-operative localization with Gamma

probe

  • Reports of equivalency to wire localized

excision

  • May be performed days in advance

Chiu JC, et al.Am Surg. 2014 Jul;80(7):675-9. Sung, et al. Eur J Radiol. 2013 Sep;82(9):1453-7. Giesbrandt, McDonough. Pract Radiat Oncol. 2013 Apr-Jun;3(2 Suppl 1):S20.

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SLIDE 6

3/7/2015 6

Radioactive Seed Localization

Seed Biopsy clip marker Seed deployment via 18g needle

Sung, et al. Eur J Radiol. 2013 Sep;82(9):1453-7.

Specimen Radiograph

Radioactive Seed Localization

  • Process of handling radioactivity

nontrivial (strict CA regulations)

  • Seed must be tracked from birth to

grave

– Multiple departments (rad onc, mammography, OR, pathology) – Patient ID bracelet and tracking outside of facility – Protocol for lost or transected seeds

US Visible Clips

  • Can be visualized intraoperatively by

US to assist localization

  • No radiation
  • Requires additional surgeon/OR time to

localize clip under US

  • Reports of “lost” clips in specimen
  • US visibility can vary

Corsi et al, Am J Surg. 2014 Oct 12. pii: S0002-9610(14)00506-6. Eby, et al. Acad Radiol. 2010 Mar;17(3):340-7.

US Visible Clips

Corsi et al, Am J Surg. 2014 Oct 12. pii: S0002-9610(14)00506-6. http://www.sciencedirect.com/science/article/pii/S0002961014005066#

Metallic component visible radiographically Echogenic collagen visible by ultrasound

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SLIDE 7

3/7/2015 7

Message

  • Image-guided wire localization is

designed to assist the surgeon in successful resection of the target lesion and promote conservation of normal breast tissue.

Thank you for your attention

Bonnie.joe@ucsf.edu