Introduction

Since the implementation of screening mammography and improvements in imaging, breast conservation surgery has increased due to the detection of breast cancer at an early stage [1,2]. In patients with non-palpable breast cancer, several studies showed that breast conserving surgery (BCS) is the best choice [3]. Nowadays, wire-guided localization (WL) is the most commonly used method for the localization of non-palpable breast lesions. WL has been a reliable and cost-effective procedure for over 40 years [4]. The limitations of WL have led to the development of alternative approaches, such as SAVI SCOUT® (SS), a nonradioactive radar localization system. These techniques are more comfortable, eliminate protruding wires, risk of dislodging, and allow the incision site to be independent from the skin entry site [5]. In addition, SS not interfering with the surgical instruments used, so there is no need to replace it. Another advantage is that the SS reflector does not produce significant magnetic susceptibility artifact. Despite the fact that BCS is currently the best option of surgical approach, this procedure in some cases, such as macromastia, is associated with certain oncological and cosmetic challenges. In these cases, the oncoplastic surgery approach should be the first choice. We present a case of breast cancer and macromastia in which SS was used for the localization and delimitation of the tumour area. A bilateral oncoplastic reduction mammoplasty (ORM) was performed. In addition, we described our experience with the first 40 cases who underwent breast conservation surgery using SS.

Case Presentation

75-year-old female patient who consulted for self-palpation of a nodule in the upper external quadrant of the left breast. Clinical examination revealed macromastia and palpation of a nodule in the upper external quadrant of the left breast of about 2 cm (Figure 1).

Figure 1: A: Patient front view showing macromastia. B: Right side view. C: Left side view showing tumour area with blue circle.

Initially, an ultrasound was performed which described a hypo echogenic nodule of irregular borders with a hyper echogenic halo of 14 mm. Subsequently, the study was completed with a mammography in which the lesion described in the ultrasound was observed in the left upper external quadrant, and approximately 2 cm caudal, medial and superficial, a second nodule of similar characteristics, measuring 1 cm, was observed. Between both lesions and in depth an area of about 4cm of suspicious micro calcification clusters with a malignant morphology was also described (Figure 2). A core needle biopsy of both nodules was performed and two SS reflectors were placed identifying both and delimiting the area of micro calcifications (Figure 3). The reflectors were deployed into the target using ultrasound guidance. These reflectors provide the exact location of the target allowing for better planning and excision of less uninvolved tissue. The FDA has approved implantation of the reflector for an indefinite time [6], so it can be placed on the same day as the biopsy. The system consists of an implantable 12 mm reflector preloaded in a 16G-delivery needle, a hand piece and a console (Figure 4). The hand piece and console system emit pulses of infrared light and radar wave signals, and receives signals back from the reflector to provide real-time localization and target proximity information to the surgeon [7]. The histologic study of both nodules was compatible with infiltrating ductal carcinoma. In addition, the tumour was estrogen receptor-positive and HER2-negative, and had high Ki-67 score, so it was classified as luminal B breast cancer.

Figure 2: A: Cranio-caudal mammography. B: Latero-oblique mammography. The yellow arrows show the nodules and the yellow circles delineate the micro calcification area.

Figure 3: A: Cranio-caudal mammography. B: Latero-oblique mammography. The yellow arrows show the two SAVI SCOUT® reflectors.

Figure 4: SAVI SCOUT® surgical guidance system. A: Console system B: Hand piece C: Hand piece macro front view. Infrared lights can be seen C: Delivery needle (16G) E: Reflector (12mm). Images provided by courtesy of MERITMEDICAL.

The patient was presented to the multidisciplinary breast cancer committee and surgical approach was determined. After explaining the different surgical options, due to the tumour area and the presence of macromastia, it was decided that an oncoplastic surgery should be performed. A bilateral ORM was proposed as the first choice. On the day of surgery, with the patient standing, the pattern was drawn. First, the sternal fork was marked and then 5 cm lateral to the clavicle were measured. Subsequently, the medial mammary line was traced and the projection of the inferior mammary sulcus was made on it to define the upper limit of the new location of the nipple areola complex (NAC). Then, the vertical and horizontal branches were made. Once the pattern of the affected breast was finished, we proceeded to draw the pattern on the contralateral breast to achieve adequate symmetry (Figure 5). The surgical procedure was performed under general anaesthesia. Before surgery began, the area to be removed and the presence of the SS reflectors were checked with the use of hand piece system (Figure 6). The incisions were performed following the previously drawn pattern. After tumour excision, the specimen was sent to radiology where the presence of both SS reflectors in the specimen was verified (Figure 7). Subsequently, the incision was closed. No drains were placed. The surgery was performed as an outpatient procedure (Major Outpatient Surgery).