Data on New Procedure to Remove Small Breast Cancers Shows Benefits to Patient Experience

Pictured: Lawrence Dauer

Medical Health Physicist and Radiation Safety Manager Lawrence Dauer

In late 2011, Memorial Sloan Kettering began offering women a new procedure to more precisely pinpoint and remove small breast cancers that can be detected on a mammogram but not felt in the breast. The method, called radioactive seed localization (RSL), begins with a breast radiologist injecting one or two tiny, sealed radioactive sources called seeds into the patient’s breast to mark the exact location of the cancer.

In the operating room, surgeons use a handheld radiation-detection device developed specifically for this procedure to zero in on the seed and precisely locate the cancer, which is removed along with the seed during the operation. No radioactivity is left in the body after the surgery.

Now, a multidisciplinary team of medical physicists, radiologists, pathologists, and surgeons, led by medical health physicist and radiation safety manager Lawrence T. Dauer, has detailed their initial year’s experience using RSL. Their report, published in the October issue of the journal Health Physics, shows that the procedure is safe and effective, and offers benefits to both patients and medical staff.

Memorial Sloan Kettering was the first hospital in the tri-state area to offer RSL, which is now standard practice for the majority of our patients with small breast cancers, and our experts have the most experience in the region with this technique.

Drawbacks of the Traditional Method

Traditionally, patients with small breast cancers have had the position of their tumor marked for surgery with breast needle localization (also called wire localization), in which a radiologist inserts a needle with a fine wire into the breast a few hours before a biopsy or lumpectomy. Because the wire remains partially outside the breast, it can be inadvertently moved before or during the surgery, which may limit the surgeon’s ability to locate the cancer and remove it completely.

In addition, the wire can be uncomfortable for patients, and because it must be placed in the breast the same day as surgery, wire localization is not only difficult to schedule in a busy hospital, it requires the patient to spend several extra hours at the hospital on the day of surgery.

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Advantages of the New Procedure

Over the course of one year, radioactive seed localization was performed on more than 1,000 women who had small breast tumors surgically removed at Memorial Sloan Kettering. The research team found that the new procedure has significant benefits over breast needle localization, including fewer scheduling conflicts and a better overall patient experience. While surgeons have had years of experience using breast needle localization, in only one year the new technique produced similar operating times and the same likelihood that the cancer is removed completely.

“Our findings validate our initial enthusiasm for the procedure and show that it is safe, with significant advantages for both our hospital staff and our patients,” says Dr. Dauer. “The total length of time a patient needs to be in the hospital is drastically reduced, and our efficiency in the operating room is improved.”

Monica Morrow, Chief of the Breast Surgical Service and a coauthor of the report, adds, “For women with small breast cancers that can’t be seen or felt, a surgeon needs a reliable map to completely remove all cancerous tissue. Radioactive seed localization is the most patient-friendly mapping system we have available.”

The use of RSL at Memorial Sloan Kettering was initiated by Elizabeth A. Morris, Chief of the Breast Imaging Service, and Jean St. Germain, an attending physicist and radiation safety officer, who were also involved in the research.

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Commenting is disabled for this blog post.

Is this procedure for DCIS cancer?

Les, thank you for your comment. We consulted with Dr. Morris, who confirmed that the procedure is used to locate DCIS as well as invasive breast cancers.

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Surgeons are taught from textbooks which conveniently color-code the types of tissues, but that's not what it looks like in real life -- until now. At TEDMED Quyen Nguyen demonstrates how a molecular marker can make tumors light up in neon green, showing surgeons exactly where to cut. W/O RADIATION

Does this also work on breast micro calcifications if found to be cancerous ?
And when do I worry about micro classifications ? After biopsy?
Are there any questions I should ask at my next Mamo ( tomorrow ) that will help me feel better ?

Denise, thank you for your comment. We consulted with Dr. Carol Lee and she provided this response:

Seed localization can indeed be used before surgery to pinpoint microcalcifications that have been biopsied and found to be malignant. As for when to worry about microcalcifications, it is an unusual woman who doesn’t have one or another calcification in her breast. On mammograms, radiologists analyze by how the calcifications look whether they need to be biopsied or not. Even when a biopsy is recommended for microcalcifications, the majority turn out to be benign.
When you have your mammogram, you can ask when and how you will get your results. It is important to remember that 90% of the time, a routine mammogram turns out fine.

Hi. After a lumpectomy using the radioactive seed localization, is radiation for DCIS still needed (generally) ? Thanks

Judy, thank you for your comment. We consulted with Dr. Carol Lee, and she responded:

The amount of radioactivity associated with the radioactive seed is extremely low and is used only to pinpoint the spot to be removed at surgery. In general, when a lumpectomy is done for DCIS, it is followed by radiation but each case is unique so a woman’s doctor can make the determination of whether radiation is needed after surgery in each individual case. Radiation therapy after surgery for DCIS does not depend on whether or not radioactive seed localization was done.

Thanks very much !

Is the seed localization any more effective than the wire procedure?

Ellice, thank you for your question. We consulted with MSK radiologist Kimberly Feigin, and she responds: “As radioactive seed localization is a relatively new technique, there are not a lot of research data. A fairly comprehensive review article published in 2014 in the Journal of Surgical Oncology including data on 2732 patients concluded that the rate of complete tumor resection was similar or slightly better with radioactive seed localization than with wires. Here is a reference to the study: Pouw, B., de Wit- van der Veen, L. J., Stokkel, M. P.M., Loo, C. E., Vrancken Peeters, M.-J. T.F.D. and Valdés Olmos, R. A. (2015), Heading toward radioactive seed localization in non-palpable breast cancer surgery? A meta-analysis. J. Surg. Oncol., 111: 185–191. doi: 10.1002/jso.23785”

Can you state why supine position is recommended for small breast radiation after lumpectomy ? It is widely seen that the prone position is recommended for large breasts, but in my case, it is right sided, and small breasts. I received two conflicting ideas from radiologists, and need to decide. Thanks!

Mary, we are not able to provide medical advice on our blog, but we did send your comment to Beryl McCormick, Chief of the External Beam Radiotherapy Service, and she responded, “Radiation treatment for women with early staged breast cancer who have breast conservation surgery can be given radiation face down (prone) or face up (supine). The radiation oncologist can sometimes know from the physical examination of the patient which patients will be best treated supine. Those women tend to have small, non-movable breasts. But whether the prone position is best for treatment can only be determined at the time of the planning CAT scan for simulation when the doctor can see 1) if the breast to be treated moves by gravity away from the underlying heart and lungs and 2) if the heart moves by gravity towards the front of the chest and directly into the path of the radiation beam. Patients whose hearts move forward are usually best treated supine when the heart usually moves backwards and away from the breast tissue.” Thank you for your comment.

Hi. I am struggling with trying to acquire a copy of the PubMed article Radioactive Seed Localization with I125 for nonpalpable lesions prior to breast lumpectomy and/or excisional biopsy: methodology, safety, and experience of initial year; 2013 Health Physics Society, pgs 356-364, Please direct me on how i can purchase this publication. Thank you.

Is seed localization sufficiently precise for a re-excision of DCIS, where the remaining area is even smaller than before?

Dear Erin, we forwarded your question to Dr. Morrow and she responded:

“Localization with a seed or a wire is only necessary when there is an abnormality on an imaging study (mammogram, ultrasound, or MRI) which cannot be felt. For re-excision, localization is not needed simply for the finding of a positive margin. If suspicious calcifications remain on the mammogram, then a seed localization would be necessary. How precise the seed localization technique is depends upon how close the seed is placed to the target abnormality. This will vary with the experience of the radiologist, the ease of visualizing the abnormality on the x-ray, and the ability of the patient to hold still during the procedure.”

Thank you for reaching out to us.

I had 2 mammograms and a stereotactic biopsy showing multiple Microcalcifications that are cancer..I am seeing a surgeon tomorrow morning, what questions should i ask?

what company makes the Radioactive seed? i would like to research it further.

Dear Ana, there are a number of different companies that make these seeds.

Thank you for your comment.