Experience with Seed Localization for Nonpalpable Breast Lesions in a Public Health Care System

Abstract

BSL is an attractive alternative to WL in a high-volume, county-based population. It allows increased efficiency in the operating room and has a low rate of complications. Cautionary measures must be taken to ensure proper seed chain of custody to prevent seed loss.

ROLL versus RSL: toss of a coin?

“…The two largest cohort series [7][8][9] each composed of approximately 1,000 patients supports the excellent outcomes achievable with RGL. The economical assessment has also demonstrated no disadvantage for RGL [7,[9][10][11]. In view of the mounting evidence supporting RGL, the question no longer remains that of the previous decade in terms of deciding between RGL and WGL, but rather the clinically relevant issue has now progressed to deciding between ROLL and RSL in the treatment of non-palpable breast cancers.…”

“…Concern has been raised at the issue of migration and subsequent loss of inserted seeds, but clinically relevant seed migration is rare and has been reported in \1 % of RSL procedures [19]. In the eight published studies [7,[14][15][16][17][18]20] on RSL, 2 studies [11,17] have failed to demonstrate 100 % successful intraoperative localization for RSL, with failure rates of 2 % [11] and 7.9 %. [17] The largest published series of RSL with 978 patients recorded a 100 % successful localization rate [7].…”

“…However, this remains an important issue requiring the establishment of a defined protocol to allow the safe handling of the seeds from intake in the nuclear medicine department, through sterilization, implantation, excision and removal. Errors at any point along this chain can convert a controlled procedure to a potentially dangerous one and result in temporary closure of RSL programmes until resolved [11]. Twenty-nine studies have been published on ROLL [8,12,13, and nine of these studies [8, 12, 23-26, 39, 45, 46] failed to achieve a 100 % intraoperative localization rate, with failure rates being recorded between 0.4 % [8] and 4.5 %, [12] with the figure of 0.4 % being from the largest published series of ROLL with 959 patients [8].…”

“…This is largely due to the large series of patients undergoing RSL at the institution, which can consequently order seeds in large bulk reducing costs, but the additional time required for the nuclear medicine department to process, sterilize and package the seeds is not taken into account in this calculation. This would mean that in units performing smaller case numbers, the savings on material costs would not be as significant and costs between RSL and WGL would be similar [11]. Postma et al [10] in their comprehensive cost-benefit analysis of their randomized controlled trial (RCT) of ROLL versus WGL [45] found that there was no economic difference between ROLL and WGL when considered overall in terms of costs associated with morbidity and re-operation rates.…”

“…It can be demonstrated from what has been presented from the published evidence that it is not possible to identify any differences in clinical outcomes including complications between ROLL and RSL to suggest the superiority of one over the other. Both techniques have proven to be competitively priced in comparison with WGL [7,10,11] and to have no significant learning curves for surgeons [7,8,17,46]. The single area where a difference can be identified currently is in terms of the flexibility and timing of RSL over ROLL.…”