Where’s Wally?

Have you seen that book with those busy pictures where you must find that guy with the red and white shirt? So, Wally in the breast can present in many places, and once you find him you need to tag him so you can remove him.

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Evolution of diagnosis

The Where’s Wally? books were childlike and finding Wally wasn’t difficult. This wasn’t unlike the diagnosis of breast cancer in the past. Historically, the diagnosis of breast cancer was made on a clinical assessment, followed by a pathological assessment of a mass post-surgical biopsy. The cancers were big and only found on breast examination. We didn’t have good radiology nor needle biopsies and the diagnosis was made by a surgeon cutting out a lump. This should never be the starting point today.

As radiology improved in the ability to assess the breast via a variety of techniques from mammography to ultrasound and MRI; so has the ability to obtain pathology tissue with more elegance than the scalpel. The gold standard being a radiologically-guided core biopsy.

Pathology has evolved from H and E staining (which is a basic chemical paint on the breast tissue that highlights cells) to a more detailed ability to understand the pathobiology (the nature of the tissue). This is done by using more refined stains that can tell us the nature of the cells (the clothes they’re wearing).With the pathologist evolving from a diagnostician (making the diagnosis) to prognostician (by understanding the type of cells we can determine the type of treatment needed). He/she can even tell you just from a small sample what the personality of a cancer is and what the best drugs and treatment strategies should be.

Radiology has evolved from mammography to digital mammography, tomosynthesis (3D mammography) and contrast mammography, from ultrasound to 3D ultrasound and electrography (looking at flexibility of the tissue). The addition of MRI has further enhanced our skills in the role of identifying malignant lesions.

Clinical pathology radiology correlation

As our ability to diagnosis breast cancer earlier and earlier i.e. smaller and smaller tumours not palpable but radiological visible, our technical skills as the William Tell of focused core biopsies have been honed. Whilst pinning the apple with an arrow dead centre has become a successful achievement of many specialist breast radiology units, this may not always be the case.

The glue that needs to hold this together must be the clinical pathology radiology review meeting. The ability to diagnose small lesions on radiology requires the clinical team to have a sense as to how the radiology and pathology fit. In other words, does the radiological findings reflect the pathology diagnosis? Therefore, clinical pathology radiology correlation (CPR) is needed.

CPR is the meeting between all three disciplines to ensure concordance. This protects the patient by ensuring there is congruence between what is seen on a mammogram and what is found on biopsy. I call this process CPR because just like the acronym suggests this is the life-saving starting point to ensure lives are saved and concerns aren’t missed.

Who is Wally? 

In other words, what do we need to biopsy? Not every mass or change on a mammogram is suspicious and needs a biopsy. Please note the theme here is identifying Wally without operating on him first.

Note, Wally can have many faces or disguises. When to biopsy a concerning area on a mammogram:

• An asymmetrical density

• An area of calcification that stands alone or looks like an area of shattered glass.

• A mass (big or small) that has a concerning look or is new and growing. Masses are biopsied under ultrasound guidance.

• A lymph node that is big or looks suspicious.

Wally is all cancers and sometimes large cancers can miraculously disappear after two cycles of chemotherapy. Yes, this happens more often than you think.

Check that it’s really Wally

Once you know who Wally is, you need to check that it’s really him. This is based on CPR. So, if your biopsy result says: benign breast tissue and your radiology report says: a suspicious area of calcifications is seen requiring a core biopsy, you don’t have Wally because the biopsy result must say breast tissue with micro-calcifications present in the biopsy sample.

If a mass or a lymph node is biopsied and it says benign breast tissue. The biopsy hasn’t confirmed accurately the correct area. The biopsy report must state mass or lymph node in the pathology.

What if the radiology report says a suspicious area highly-suggestive of a breast cancer (BIRADS 5) and the pathology says benign breast tissue? Then Wally has definitely not been found.

The reason why one confirms who Wally is with a radiologically-guided core biopsy and not a fine needle aspirate (FNA) is a FNA gives a few cells. This can’t tell you accurately what something is. Neither can it tell you the details (clothes of the cancer).

What, when, why and how of tagging Wally

Once you know who Wally is, you need to find him to remove him or tag him so you can watch him. There are rules: The radiology and pathology must always be reviewed. This is the when for tagging Wally. 

The tagging can be done at the time of the needle biopsy or after radiology and pathology review and sometimes after further radiology studies, such as an MRI scan. The best devices are placed at the time of the radiological core biopsy, either under ultrasound or stereotactic guidance (mammographic).

The whys are many-fold. If the area that is biopsied is small, it could be fully removed during the biopsy and therefore needs to be marked. This marker will then be visible if future imaging or procedures are required. A marker can also be placed in a cancer or abnormal lymph node as these areas will respond to oncology treatment and may be too small to locate on imaging later.

Marker placement is now very much standard practice. Think of the placement as a type of map co-ordination to correlate lesions across different imaging (mammogram; ultrasound and MRI), to follow up benign lesions over time. This will assist surgeons in finding lesions that need to be removed, to demarcate the extent of an area that needs to be removed, and to guide the pathologist in identifying the abnormal area that has been removed.

What to use?

There are many different devices that the radiologist can use to tag Wally. Some radiologists used to place a small tattoo on the skin of the patient so that the surgeon can find it. This is a very primitive approach and shouldn’t be used. The reason for this is the breast is marked while squashed in a mammogram machine and is different to the breast position in a lady that is either sitting orlying flat on her back.  

If a small dilated duct (papilloma) is seen and needs to be removed, the area can be marked with a dye on the day of the procedure. The deeper areas in a breast need a more sophisticated marking system. 

Markers 

Usually when a radiologist sees Wally, they tag it automatically at the time of biopsy with a small marker, commonly known as a V marker or twirl marker. There are several various makers (including ribbon, coil and wing markers). All can be visualised, with ease, on mammograms. Some markers have a small gel bubble on the back, allowing them to be visible on ultrasound as well.

A tissue marker is a very small object (about 2 to 3mm) that is inserted into the breast either at the time of biopsy, or to mark a previously diagnosed abnormality.  

Because a variety of markers are available, the radiologist may use the marker most suitable for your requirements. This can also include using different markers to delineate different areas at the same time. 

The markers can’t be felt; don’t set off metal detectors; and seldom migrate or move (to other parts of the body). Although, occasionally some may not be placed accurately or move slightly in the breast tissue.

Magnetic seed

Because the marker is small and if the marker is needed to be removed, a further device is needed to find the marker at the time of surgery. Because of this, various clever, more permanent markers have been developed that can be placed when needed and detected with various probes. Thus, allowing for less patient trauma; more radiology flexibility and surgical ease. 

One of these is a magnetic seed. This can be placed at the time of diagnosis or as a stand-alone technique to detect an area that the radiologist is concerned about or has marked previously. This seed is detected in theatre with the use of a machine, called a Sentimag machine. The surgeon uses the machine to detect the seed 

and allows a depth-finder to determine where the seed is in the excised specimen. The value of this device is that the seed can be placed at any time. The seed is inactive and is only activated when the Sentimag probe is placed over it. Other devices involve electromagnetic wave technology and use a wire-free radar. 

How do we remove markers?

Remember not all markers need to be removed. If the biopsy is benign, the marker can just remain.

Tips and tricks for catching Wally

What is the setting for removing Wally? There are two basic scenarios: a diagnostic procedure, this is for diagnosis which is less common today. Then secondarily, a therapeutic procedure. This is more common: you know who Wally is and now need to tag or remove him.

Once Wally (specimen) with the marker is removed, the specimen must be taken to the radiology unit to be photographed confirming that the marker is in the specimen. We have a fancy machine in our theatre that does this real-time. Thus, ensuring the patient doesn’t have extended time on the operating table.

A relatively staid, if not old-fashioned way of removing a marker is to place a wire into the marker on the day of surgery. The pros are: it’s an inexpensive means of marking an area. The cons are: the wire needs to be placed on the day of the surgery and can be dislodged as the wire sticks out the skin. All these incisions need to be done through cosmetic excisions.

A diagnostic-guided biopsy is done when an area on a mammogram is suspicious and a needle biopsy result is inconclusive, unsuccessful or equivocal. The area of the breast is marked on a mammogram and the wire is inserted, under local anaesthetic, into the area that is suspicious. This will later guide the surgeon on the area to remove. 

A therapeutic-guided excision is done when an impalpable (can’t be felt) breast cancer is detected on mammography and a core biopsy has confirmed breast cancer. A hook-wire (or other device) is inserted into the cancer under mammography control. Now the surgeon can readily excise the cancer including the hooked needle. This avoids removing the entire breast (to be avoided at all costs) to find the lesion.

A variation on the wire excisions is the radioisotope localisation (ROLL) technique. An isotope is injected into the suspicious area and a hand-held probe (a gamma probe) is used to locate the area. Again the radioisotope needs to be placed within 24 hours of surgery.

With Magseed localisation, the seed can be placed at any time (we use it in public and private) to mark cancers up front. Thus, saving the patient the back and forth of placing a marker and then a marker or wire to remove the marker. Saving time and expense for the patient and radiologist.

Furthermore, having the probe in theatre means that the area can be removed with an appropriate margin. Time is not wasted in theatre with taking a specimen to the radiology unit to confirm that the marker is present. This ensures negative margins and is currently my favourite way to remove Wally.

Embrace new technologies

Don’t find Wally by tearing the page from the book (surgery without radiology). Use finesse and work as a team. Embrace new technologies and remember patient care involves decreasing the stressors around radiology, biopsy and surgery.