Rapid Implementation of Intraoperative Ultrasonography to Reduce Wire Localization in The Permanente Medical Group.

CONTEXT: Preoperative wire localization (WL), the most common localization technique for nonpalpable breast lesions, has drawbacks including scheduling constraints, cost, and patient discomfort. OBJECTIVE: To reduce WL use in our health care system, we investigated using hydrogel clips to facilitate intraoperative ultrasonography-guided lumpectomies. DESIGN: We retrospectively reviewed electronic medical records of patients with nonpalpable, ultrasound-visible breast lesions who underwent lumpectomy by 7 surgeons at 4 pilot sites in Kaiser Permanente Northern California between January 2015 and October 2015. Hydrogel clips, used for several years before the study period, were placed routinely during core-needle biopsy in all patients with nonpalpable, ultrasound-visible breast lesions. MAIN OUTCOME MEASURES: Localization method, lesion size, margin positivity, and receipt of neoadjuvant therapy. RESULTS: One hundred forty-three patients underwent hydrogel clip placement and lumpectomy by pilot-site surgeons. Localization consisted of intraoperative ultrasonography alone, preoperative skin marking, or WL. Of the 143 patients, 71.3% did not need WL (60.8% ultrasonography alone and 10.5% skin marking). The non-WL and WL groups had similarly sized lesions, and the positive margin rate was 7.2% overall, with no significant difference between the non-WL and WL groups (5.9% vs 11.5%, p = 0.33). Of the 12 patients who underwent neoadjuvant chemotherapy, 8 (67%) did not require WL. CONCLUSION: A multifacility protocol using intraoperative ultrasonography to visualize hydrogel clips was implemented, which decreased WL procedures and produced no significant difference in margin positivity between the WL and non-WL groups. This technique can be a cost-effective alternative to WL in patients who are candidates for hydrogel clip placement.

Benign Papillary Breast Mass Lesions: Favorable Outcomes with Surgical Excision or Imaging Surveillance.

BACKGROUND: There is no consensus regarding the management of benign papillary breast lesions diagnosed on image-guided core needle biopsy (IGCNB). METHODS: This is a retrospective review of 407 patients within Kaiser Permanente Northern California diagnosed between 2012 and 2013. The study focused on patients presenting with a mass lesion and who were diagnosed with a benign papillary breast lesion (BPBL) on IGCNB. Patients who did not have surgical excision of the IGCNB papilloma were followed for at least 2 years. RESULTS: A total of 327 patients (80%) underwent surgical excision, 61 patients (15%) had follow-up imaging, and 19 patients (5%) had no surgery or imaging. Overall among women with surgical excision, 9.5% had a high-risk lesion, 3.4% had in situ cancer, and 2.4% had invasive cancer. An upgrade to an in situ cancer or invasive cancer was more common among women with a lesion greater than 1 cm, a palpable breast mass, age > 50 years, or if the lesion was > 5 cm from the nipple. No cancers were diagnosed in 61 women followed by imaging surveillance. CONCLUSIONS: This is the largest, single-cohort study of benign papillary mass lesions diagnosed on IGCNB. On surgical excision, the overall rate of upgrade to in situ cancer and invasive cancer was low, and almost all cancers diagnosed had favorable features. Because no cancers were found in women who were followed by imaging, we conclude that outcomes for BPBL diagnosed on IGCNB are favorable whether surgical excision or surveillance is the treatment choice.

Computer-aided detection in diagnostic mammography: detection of clinically unsuspected cancers.

OBJECTIVE: We had two objectives: to determine the percentage of women presenting with clinical findings whose diagnostic mammogram led to detection of a breast cancer at a site distant from the original clinical complaint and to assess the performance of computer-aided detection (CAD) on diagnostic mammography. MATERIALS AND METHODS: Three institutions contributed consecutive cases in which a mammogram was obtained to evaluate a clinical finding, after which a histologic diagnosis of breast cancer was made. Clinical data and the mammograms were reviewed to determine the nature of the clinical findings and to document the location and characteristics of 212 biopsy-proven cancers in 197 patients who met the study criteria. Standard four-view breast mammograms were then analyzed by a CAD system. RESULTS: The most common clinical finding was a palpable mass (90%, 177/197), with nipple discharge (5%, 9/197), focal tenderness or pain (2%, 5/197), and miscellaneous complaints (3%, 6/197) also noted. Two separate cancers were found in 7.6% (15/197) of the cases. In another 7.6% (15/197) of the cases, the single diagnosed cancer was not at the location of the specific clinical finding. The CAD system correctly marked 87% (26/30) of those cancers that were clinically unsuspected (i.e., not at the location of the clinical finding). CONCLUSION: Breast cancers occurred at locations other than the site of the presenting clinical finding in 15% (30/197) of patients undergoing diagnostic mammography in whom a cancer was detected. CAD identified 87% of these incidentally detected cancers and may therefore be useful as a detection aid to the radiologist when interpreting diagnostic mammograms.