Oncoplastic breastꢀconservingꢀsurgery:ꢀChallenges,ꢀcomplexitiesꢀandꢀpitfallsꢀinꢀpre-operativeꢀwireꢀlocalisation.F.ꢀMajid,ꢀL.ꢀTromans,ꢀH.ꢀKhan.

BACKGROUNDꢀꢀꢀꢀꢀꢀꢀꢀꢀꢀꢀꢀꢀꢀNewerꢀbreastꢀoncoplastic conservationꢀsurgeryꢀsuchꢀasꢀpedicleꢀperforatorꢀflapꢀtechniquesꢀ(LICAP,ꢀMICAP)ꢀallowꢀresectionꢀofꢀlargeꢀareasꢀofꢀDCISꢀorꢀmultifocal/multi-centricꢀdiseaseꢀwhilstꢀmaintainingꢀgoodꢀcosmeticꢀoutcomes.ꢀHowever,ꢀtheꢀperforatorꢀvesselꢀtoꢀbeꢀusedꢀusuallyꢀliesꢀwithinꢀtheꢀareaꢀrequiringꢀlocalisation.ꢀTheꢀfocusꢀisꢀshiftedꢀfromꢀinsertingꢀtheꢀwireꢀviaꢀtheꢀshortestꢀrouteꢀtoꢀNOTꢀinsertingꢀtheꢀwireꢀfromꢀtheꢀsiteꢀofꢀtheꢀvesselꢀtoꢀensureꢀthereꢀisꢀnoꢀdamage.

Thisꢀresultsꢀinꢀtheꢀneedꢀforꢀpre-operativeꢀplanningꢀwithꢀtheꢀsurgeonꢀandꢀaꢀmoreꢀtimeꢀconsumingꢀprocedureꢀwhichꢀisꢀusuallyꢀstereotactic.Onceꢀbracketed,ꢀsurgeonsꢀwillꢀrequireꢀmultipleꢀmeasurementsꢀtoꢀcreateꢀaꢀ3Dꢀrenderingꢀinꢀtheirꢀmindꢀofꢀtheꢀabnormalꢀtissue.ꢀAtꢀtimesꢀinꢀorderꢀtoꢀachieveꢀgoodꢀsurgicalꢀmargins,ꢀtheꢀbracketingꢀisꢀnotꢀforꢀtheꢀlesionꢀbutꢀtoꢀmarkꢀtheꢀlimitsꢀofꢀresection,ꢀwhichꢀmakesꢀtargetingꢀdifficultꢀandꢀmayꢀmeanꢀtheꢀwireꢀtravelsꢀaꢀmuchꢀgreaterꢀdepthꢀthanꢀwouldꢀbeꢀideal.Ourꢀpracticeꢀhasꢀevolvedꢀtoꢀincludeꢀaꢀpro-formaꢀandꢀweꢀdemonstrateꢀsomeꢀcasesꢀandꢀconsiderationsꢀforꢀimagingꢀstaffꢀwhoꢀareꢀlikelyꢀtoꢀneedꢀtoꢀstartꢀprovidingꢀtheseꢀservices.

CONCLUSIONS cLocalisationꢀforꢀtheseꢀOncoplastic proceduresꢀrequiresꢀmuchꢀmoreꢀtimeꢀtoꢀplan,ꢀperformꢀandꢀreportꢀtheseꢀcases.ꢀThereꢀisꢀanꢀincreaseꢀburdenꢀofꢀexpertiseꢀofꢀstereotacticꢀlocalisation,ꢀespeciallyꢀwhenꢀnotꢀtargetingꢀonꢀanꢀeasilyꢀidentifiableꢀtargetꢀwithinꢀtwoꢀplanes.ꢀGoodꢀcommunicationꢀpriorꢀtoꢀsurgicalꢀdateꢀandꢀwellꢀillustratedꢀdiagrams/mammographicꢀ imagesꢀareꢀneededꢀasꢀtheꢀpersonꢀplanning theꢀprocedureꢀwithꢀtheꢀsurgeonꢀmayꢀnotꢀbeꢀperformingꢀit.ꢀMultipleꢀclips,ꢀsomeꢀwhichꢀmayꢀnotꢀbeꢀintendedꢀtarget,ꢀmultipleꢀwires,ꢀusualꢀapproachesꢀmayꢀnotꢀbeꢀfeasibleꢀandꢀtheꢀsurgeonsꢀrequireꢀspecificꢀmeasurementsꢀforꢀeachꢀcase.RecognitionꢀofꢀappropriateꢀcasesꢀatꢀMDTꢀrequiresꢀimagingꢀstaffꢀtoꢀbeꢀsureꢀtheyꢀcanꢀlocaliseꢀtheꢀextentsꢀrequired,ꢀorꢀtoꢀbeꢀableꢀtoꢀtellꢀtheꢀsurgeonsꢀadditionalꢀextentꢀofꢀdiseaseꢀinꢀrelationꢀtoꢀMRIꢀifꢀperformedꢀasꢀtheyꢀmayꢀplanꢀonꢀextendingꢀsurgicalꢀsiteꢀtoꢀpectoralis/nippleꢀregardless.ꢀDepartmentsꢀwhereꢀtheseꢀproceduresꢀareꢀbeingꢀconsideredꢀshouldꢀalsoꢀconsiderꢀtheꢀaddedꢀtimeꢀtakenꢀtoꢀplanꢀandꢀexecuteꢀaccurateꢀlocalisation.ꢀNewer,ꢀnon-wireꢀtechniquesꢀwhichꢀutiliseꢀaꢀseed/detectorꢀsetꢀup,ꢀareꢀlikelyꢀtoꢀhelpꢀbutꢀstillꢀhaveꢀlimitationsꢀ inꢀuseꢀandꢀcostꢀimplications.ꢀꢀ

Pre-OperativeꢀPlanning

Reviewꢀanteriorꢀtoꢀposterior,ꢀsuperiorꢀtoꢀinferiorꢀandꢀmedialꢀtoꢀlateralꢀdimensionsꢀwhereꢀappropriateConfirmꢀsurgicalꢀprocedureApproachesꢀtoꢀavoidSignificanceꢀofꢀclip/sꢀStateꢀwhichꢀextentsꢀareꢀtoꢀbeꢀlocalisedꢀandꢀnumberꢀofꢀwiresTargetsꢀforꢀimaging;ꢀclip,ꢀcalcification,ꢀdensityꢀStereotacticꢀorꢀultrasoundꢀguidanceꢀSkinꢀmarksSpecificꢀinformation/measurementsꢀrequiredꢀfromꢀpostꢀwireꢀmammogram

LICAPꢀCaseꢀ1:Extensiveꢀcalcification. Stereotacticꢀwiresꢀxꢀ2.ꢀTwoꢀmigratedꢀclipsCranio-caudalꢀ(superiorꢀtoꢀinferior)ꢀapproachꢀtoꢀtargetꢀonꢀmostꢀmedialꢀandꢀlateralꢀcalcification.ꢀSuperiorꢀandꢀinferiorꢀextentꢀdescribedꢀinꢀreportꢀinꢀrelationꢀtoꢀwireꢀtips

LICAPꢀCaseꢀ2:Ultrasoundꢀwiresꢀxꢀ2Lesionsꢀatꢀ4ꢀ&ꢀ5ꢀo’clock,ꢀbothꢀclipped.ꢀꢀInfero-superiorꢀapproachꢀtoꢀavoidꢀlateralꢀaspect

MICAPꢀCaseꢀ1:Stereotacticꢀwiresꢀxꢀ3. Cranio-caudalꢀ(superiorꢀtoꢀinferior)ꢀapproachꢀforꢀmedialꢀandꢀlateralꢀextentMedio-lateralꢀapproachꢀforꢀsuperiorꢀextent

MICAPꢀCaseꢀ2:Mammographically occultꢀlesion.ꢀ47mmꢀonꢀultrasound,ꢀ46mmꢀonꢀMRIUltrasoundꢀwiresꢀxꢀ2.ꢀMedialꢀandꢀlateralꢀapproach

LICAPꢀCaseꢀ3: 9ꢀo’clockꢀ40mmꢀlesionꢀafterꢀNAC.ꢀRoutineꢀultrasoundꢀwireꢀtoꢀtransfixꢀlesionꢀnotꢀappropriateꢀasꢀmedialꢀandꢀlateralꢀextentsꢀrequired.ꢀStereotacticꢀwiresꢀxꢀ2.ꢀCranio-caudalꢀ(superiorꢀtoꢀinferior)ꢀapproach.ꢀPotentialꢀforꢀinaccurateꢀtargeting,ꢀi.e.ꢀwireꢀtooꢀshortꢀorꢀtooꢀdeep

SurgicalꢀSpecimenꢀOrientation:

1ꢀClipꢀ– Superior2ꢀClipsꢀ– Lateral3ꢀClipsꢀ- Medial

References:ꢀOncoplasticapproachesꢀtoꢀbreastꢀconservation.ꢀHolmesꢀetꢀal,ꢀInt JꢀBreast Cancer. 2011;2011:303879.Oncoplastic breast surgery:ꢀcomprehensive review.ꢀBertozzi N1ꢀetꢀal.ꢀEur Rev Med Pharmacol Sci. 2017ꢀJun;21(11):2572-2585.Localization techniquesforꢀguided surgical excision ofꢀnon-palpable breast lesions.ꢀChanꢀBK1 etꢀal.ꢀCochrane DatabaseꢀSyst Rev. 2015ꢀDecꢀ31;(12):CD009206.ꢀdoi:ꢀ10.1002/14651858.CD009206.pub2.