New tool allows surgeons to pinpoint breast tumors more easily

Breast surgeons at Hackensack Meridian Hackensack University Medical Center have a new tool that allows them to pinpoint breast tumors more easily, with many benefits to the patient.

The reflector device has proven useful as an alternative to wire localization for locating breast tumors before lumpectomy. Hackensack University Medical Center breast surgeons were early adopters of this technology, and they began to explore its use for pinpointing the location of cancerous lymph nodes before starting pre-surgical chemotherapy. The FDA approved the use of the reflector device in axillary lymph nodes in August 2018.

The system uses an innovative reflector device which is placed in the cancerous underarm (axillary) lymph nodes of the patient, two or more months before breast cancer surgery, to mark the location of these lymph nodes in women having pre-surgical chemotherapy,

In a recent study of the system, Hackensack physicians found it accurately identified which axillary lymph nodes, which often shrink greatly during preoperative chemotherapy, needed to be removed for analysis at the time of breast cancer surgery. The study was published in the June 23, 2021 issue of the journal Breast Cancer Research and Treatment.

Breast cancer cells that spread beyond the breast typically travel first to the axillary lymph nodes. Modern chemotherapy can be very effective in eradicating breast cancer cells in the axillary lymph nodes and, therefore, only the lymph nodes which had cancer before chemotherapy and the patient's first draining sentinel lymph nodes need to be checked at the time of breast surgery to determine if these lymph nodes still have breast cancer.

Traditionally, a radiologist implants a wire to mark the site of a cancerous lymph node during a procedure performed the same day as breast cancer surgery. The wire is uncomfortable and protrudes from the patient's armpit or back, and its implantation subjects the patient to an additional procedure right before the operation, causing even more anxiety.

Chemotherapy given before surgery has become very effective for eradicating breast cancer in the axillary lymph nodes, but with wire localization, it can be challenging during breast surgery to find the lymph nodes that were originally positive for cancer. This new approach makes localizing the lymph node much easier for the patient and the breast surgeon."

Leslie Montgomery, M.D., Director, Division of Breast Surgery, Hackensack University Medical Center

The radar localization system is a tiny metal reflector circuit implanted in cancerous underarm lymph node(s) weeks or even months before surgery and does not cause any discomfort while left in place. In the operating room, the surgeon holds a probe over the area and a beeping sound indicates where the reflector device is, guiding the surgeon to the node(s) to be removed. The surgeon also removes the reflector device.

In their study, 42 women with breast cancer had wire localization of their cancerous axillary lymph nodes and 57 others had localization with the new device. Successful identification of the cancerous lymph nodes at the time of surgery was equivalent between the two groups.

"Cancerous lymph nodes are big and easy to see before treatment, but they get much smaller after chemotherapy and can be hard to find during surgery. Our findings showed that using this new reflector , we were able to find the formerly cancerous lymph nodes just as well as when we used the wire," explained breast surgeon Tara Balija, M.D., who co-authored the study.

Nahomi Enrico, who was 32 when she discovered she had breast cancer, was concerned about how effective chemotherapy would be. As a mother of two young children, she was also concerned about the impact removing the lymph nodes would have on the range of motion in her arm.

The reflector was placed in Enrico's armpit before chemotherapy and remained as she underwent chemotherapy, with no restriction on her activities. At the time of her surgery Dr. Montgomery was able to pinpoint her previously positive axillary lymph node, remove it, and determined that she no longer had cancer in the lymph nodes. This meant that she did not need a full lymph node removal.

"I was put at ease knowing my doctors could see exactly where the cancer once was. Even with the ultrasound, if not for the new technology, they would not have been able to detect that."

The accuracy of lymph node localization grew to 100% among women who had the reflector device placed eight weeks or more before surgery, compared with 79.2% among those who had the reflector placed within 8 weeks of surgery. "We found it was easier to find the cancerous lymph nodes if the reflector was placed months in advance of surgery than if the nodes were localized closer to the time of surgery with the reflector or on the same day as surgery with the wire," noted Dr. Balija.

Moreover, because the reflector does not contain radiation (unlike radioactive seed placement, another form of pre-surgical lymph node localization), the technique is safe for long-term placement. Being able to accurately identify the lymph nodes during surgery also means that fewer lymph nodes need to be removed for analysis-;reducing the risk of lymphedema, an uncomfortable swelling of the arm that can happen when many axillary lymph nodes are removed.

Concluded Dr. Montgomery, "Using the reflector more than eight weeks before surgery is a very accurate way to identify cancerous axillary lymph nodes and the device stays in place throughout that time, even if the size and shape of a lymph node have changed. This approach has a significant benefit for both the patient and the surgeon."

Enrico would agree.

"This was an incredible experience for me. You don't think of where you're treated or doctors who treat you until it's your turn, but the care I've received at Hackensack University Medical Center has made a world of difference."