March 16, 2023 • 22 mins
In this episode, Dr Jamie Coleman is joined by Roi Weiser, MD, from the University of Texas MD Anderson Cancer Center, and Suzanne Klimberg, MD, PhD, MSHCT, FACS, from the Division of Surgical Oncology at the University of Texas Medical Branch. They discuss their study, which shows that fluoroscopic intraoperative neoplasm and node detection (FIND) can be used to localize the biopsy clip marking a non-palpable breast or axillary lesion, obviating the need for an additional procedure to insert a localization device. Furthermore, FIND shows promising results, with decreased margin positivity and re-excision rate compared with wire localization.
Disclosure Information: Dr Klimberg receives book royalties from Elsevier, Springer, and Saunders. Drs Coleman and Weiser have nothing to disclose.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:01):
Welcome to The Operative Word,
a podcast brought to you by the
Journal of the American College of
Surgeons.
I'm Dr. Jamie Coleman.
And throughout this series, Dr.
Dante Yeh and I will speak with
recently published authors about the
motivation behind their latest
research and the clinical
implications it has for the
practicing surgeon.
(00:22):
The opinions expressed in this
podcast are those of the
participants and not necessarily
that of the American College of
Surgeons.
Welcome to The Operative Word, a
podcast from the Journal of the
American College of Surgeons.
I'm Dr. Jamie Coleman, one of your
hosts for this series.
In this episode, I am
very excited.
(00:43):
I'm joined today by Dr. Roi Wiser
and Dr. Suzanne Kleinberg, and
we will be taking an in-depth look
into their current article,
"Intraoperative Fluoroscopy
and Breast Lesion Localization."
Dr. Weiser is an assistant
professor at the UT, M.D.
Anderson Cancer Center in Houston,
Texas.
And Dr. Klimberg is a professor
(01:05):
and Chief of the Division of
Surgical Oncology at the University
of Texas Medical Branch in
Galveston, Texas.
Dr. Weiser, Dr. Kleinberg, welcome
to The Operative Word.
Thank you.
Thank you very much for having us.
Well, before we begin and really get
into the good stuff, do either of
you have any conflicts of interest
that you would like to disclose?
(01:25):
No, I would not.
All right. Well, first off,
congratulations to both of you on
this publication.
I have to say, I was fortunate
enough to be in the audience at the
Southern Surgical Association, the
meeting this year when this paper
was presented.
Full disclosure, actually, as both
of you know, I'm a trauma surgeon
and I was enthralled
(01:45):
by this presentation.
So, when this came across my desk
and I had the opportunity to
really allow us to
highlight this paper, I just
I jumped at the chance.
So, thank you so much
for doing this.
And now I have to say
another disclosure.
I was a history major, so I'm
(02:06):
admittedly a bit biased
that I think the history
behind some of our surgical
dilemmas is important to talk
about because it really sets
the stage for
the niche of the research.
The reason why we
did, or you
did this project
(02:28):
and so I was wondering
if we could just start there a
little bit with how did this project
come about?
You know, you've got a woman in your
office, she's got a non-palpable
breast lesion.
It looks suspicious.
She gets a biopsy
and she needs this mass out.
So, you know, Dr. Klimberg, let's
start with you.
(02:49):
Talk to me a little bit about where
we are with this currently
and kind of how you came
to this paper.
Well, just since you're
a history major, historically,
mammograms started to, say, in the
70's, and when they
found a lesion on mammogram,
they would just triangulate
(03:10):
in the operating room.
So you can imagine taking huge
amounts of tissue to try to get
something out, because we didn't
have needle locs.
We didn't have that.
So needle looks came about.
And so they're rather
traumatic
because the patient has to usually
sit up and watch the needle
(03:32):
go in. And it's a little bit like
Battleship where you
go a
lesion A vs
numbers. And so the
needle is put in there
and it's put up in an upright
position. So when the patient lays
down that
they can't find
the area, the needle moves a little
(03:53):
bit or even comes out.
And so there was a whole
line of
different needles that you could
use.
And so the
missed rate was 5
to 10%.
And the, in other words, not
(04:13):
getting the lesion out.
And then the the
other was
40 to 75%
in the literature.
Of
a positive margin rate.
Wow.
Today, the positive margin rate is a
little bit less because
(04:34):
we've changed the margin positivity
criteria.
So you're talking 20%
range. Right?
With a needle loc.
And that's in our institution
as well.
So originally
this came about because
of the
vasovagal events, watching this
needle go in 10 to
(04:55):
20%.
That's a huge percentage.
I was struck by that in your
manuscript.
And it's painful, right?
It's yeah.
And you have to watch it.
So it's not it's not uncommon.
And so.
We've gone about
trying to find different ways to
(05:17):
to do this.
And there's a lot of research in
this area with radio frequency
and all kinds of stuff, but
all of them require a second
procedure.
So you have to go back, get
back in the mammogram vise and get
another procedure.
So we were in the operating
room doing a needle loc, and this is
(05:37):
probably 10 years ago now,
5, 5 to 10, I can't even remember.
And my fellow
pulled out the needle before we got
the clip.
So usually when that happens,
which isn't an uncommon thing to do,
but usually
(05:59):
you have to wake the patient up,
send them back down and get it
relocalized, which is a terrible
thing for the patient.
And you as a surgeon, you're
mortified. Anyway so
she pulled it out. I said, well, we
said, let's try
and just do a fluoro
because every surgeon knows how
(06:20):
to use fluoro. So we said,
Let's see if we can see the clip.
And so we could.
And we took it out.
So then we started looking
at all the clips because
this isn't rocket science.
Somebody must have thought of this
before, right?
Or they probably were looking
for a clip that couldn't be
identified on fluoro.
(06:40):
So we looked at all the clips we
had, some of them couldn't be seen.
Some of them could.
Thank goodness we had one that can
be seen that day.
And so we said to the
radiologist, just use these clips
and then we can see all of them.
And then the patient doesn't have to
have a procedure ahead of time,
which, by the way, takes
an hour or two and you can never
(07:01):
have a first start.
It messes up scheduling patients.
You know, it's just
the coordination is a problem.
So this really circumvented this.
Now, before that, I developed
a procedure which I actually have a
patent on, using the hematoma
developed by a biopsy
or even injecting an hematoma.
(07:21):
But the problem is most surgeons
don't know how to use ultrasound
or are not expert at
it to be able to find every
hematoma.
But every surgeon worth
their salt knows how to use fluoro.
And so you have to have to use
something that everybody is
comfortable with.
And the other thing is you can
charge for it.
(07:41):
Yeah.
So this is how FIND
was born, right?
So let's do
this then. I mean, what
let's talk about it.
What does it stand for?
How does a surgeon do it?
Tips and tricks.
Is there a patient population
in which FIND wouldn't work?
So let's take one one question
(08:02):
at a time. I guess first of all as
far as patient populations,
I'd say it should work on most any
patient that needs a lesion
localized. And this would be
patients with
breast cancer that are going for
breast conserving surgery.
It would also go for patients with
high-risk lesions that need an
incisional biopsy.
And in the area of neoadjuvant
(08:22):
treatment, it can also go for
patients or it can be used for
patients that had a lesion that
was palpable to start off with.
But thanks to neoadjuvant treatment
became non-palpable and they're
eligible for breast-conserving
surgery, the. This is also
relevant for axillary
nodes.
And in the era of neoadjuvant
treatment and targeted axillary
(08:43):
dissection, we need to localize
those positive nodes.
So this works as well, and
maybe we'll get to the results soon.
But I think one of the things I
like the most about about
our paper is the fact that
in the
FIND group in our cohort,
100% of clips were found,
while only 80% were found
(09:05):
using wire localization.
So so this has to do with, I guess,
the patient population that can can
benefit from from the FIND
procedure.
And by the way, also we can use it
for multiple lesions.
So if a patient has a few clips in
her breast, we can also
use the fluoro and FIND
for that.
And in those cases, many times with
(09:25):
the wire localizations,
they need to have multiple wires put
in their breast, which you can
imagine is not pleasant
multiple times.
And by the way, in our court, there
are 30% of patients that had to have
or almost 30% of patients that had
have 2 or more wires put in.
So I'd say actually there's
a very large patient population that
(09:47):
can benefit from this technique.
And what does FIND stand for?
It's fluoroscopic
intraoperative neoplasia
and nodal detection.
So, it can.
I love it.
Just using fluoroscopy to find
tumors.
Yes, but I
you know, what really struck me with
this was--and
(10:08):
we're going to go into findings
next--is it was so
interesting to me that in this era
now of this continuous advancement
of surgery through technology,
this was almost, not
the opposite, but it was an
advancement through technology
that we already possess.
Like Dr. Klimberg, you stated,
(10:28):
you know, you're finding a clp with
fluoro. Surgeons know how to do
this.
So this is a technology that
already existed,
that's also been used to simplify
and therefore advance the care of
our patients with breast cancer.
I just you know, it was just
it really struck me.
If you think of the rural surgeon
(10:50):
or the surgeon
does some, but not a lot
of breast cancer, this
is ideal for them because they can't
afford to
buy some fancy techniques that
they're only going to use a little
bit.
Right. I mean, this is
you know, this is equipment
that hospitals already own,
other departments use as well.
(11:11):
It's not something just for us,
obviously, in general surgery or
breast surgery, it's not surgery
or specialty-specific.
It's got vascular surgery,
orthopaedics, urology,
so many other specialties that are
using it.
So now let's talk about how does it
work? What are the findings?
What did you guys find?
What did we find or how does it work
practically in the OR?
(11:32):
Let's do both.
Okay, so we start with the OR.
I think it actually starts with
how what Dr. Klimberg said
with invasive radiology.
They just simply need to know to put
the right clips in.
And that proved very, very
simple at UT, where I did
my fellowship, because simply all
the clips were visible on fluoro.
And then in the OR, you
(11:53):
positioned the patient more or less
like you would for any other
procedure. You just need to make
sure, like for any other fluoroscopy
procedure, that there's nothing
obstructing the
vision of the fluoroscope.
And then you start surgery
after you prep and drape, you bring
the fluoro in, and
we shoot a new image, and then you
(12:13):
see where the the clip is
on the breast and you use
whatever instrument you like to
localize on the skin where that clip
is.
Then you can plan your incision,
plan your dissection.
You can also draw your dissection on
the skin if you want, and then you
start working around that
marking that you had.
And what I think another advantage
that FIND has is that
(12:36):
during or as you're working,
you can re-shoot the fluoro
and see where your dissection
planes are compared to the fluoro
because you can put your Bovie in
the breast or wherever you're,
you're working and shoot the fluoro
and see where that is compared to
the to the clip.
So you always have this feedback
or live feedback on where
you are compared to that clip, which
(12:57):
I found very, very useful during
surgery.
And of course, you know, the surgeons
are very visual.
Yes, right.
We are.
And so you can actually choose the
margins you wish to have
and you put your Bovie in and you
can oh, it's too close
or I've taken too much.
You can move closer.
You can you as Roi said,
you have feedback.
And the thing about it is you
(13:19):
do the placing of a needle
loc or clip in a
position that's upright.
Right?
Right. You have a cranial, caudal,
and a medial. When you lay down,
the breast usually falls on the
axilla.
The clip totally moves where
you think it should be and
a needle loc you place in
(13:39):
visually under
radiograph.
And then we try and palpate
it at surgery. That's how a needle
loc is, it totally
doesn't make sense and totally I
don't even know how accurate, how it
is as accurate
as it is.
But this it changes
position. I can put my
(14:00):
incision wherever I want and I can
choose my margins.
And when you open the skin
on a
lumpectomy, it
again, the breast falls apart.
So it even moves.
And that's why, as Roi pointed out,
it's important that you can relook
and say, okay, I need to change
up a little bit.
So how effective is this if we're
(14:21):
going to compare this to needle
or wire localization, how well
does it work?
So I guess what we did in this
paper was to retrospectively go
back and look at all the wire
localizations that that were
performed in the time period that we
looked at and all the FIND
procedures that were performed,
both for breast lesions and for
(14:42):
axillary lymph nodes.
And what we wanted to see was, first
of all, I guess oncological
safety in the sense that
what was our
margin positivity rate or what was
the margin positivity rate of
the wire locs compared to the FIND?
That was our, I guess,
primary outcome that we were looking
at. And as secondary outcomes, we
(15:03):
also looked at re excision rates and
also the specimen weight to see if
it was affected by the technique,
the surgery time and also
complications.
And what we were able to find was
that there was a significantly
better, or lower percentage
of margin positivity using
FIND.
It did lose
(15:25):
significance on multivariate
analysis, but it was still number
wise, it was quite significant.
The improvement with
FIND and also the re-excision rates
were a bit lower with FIND.
So it's
better for the patient is not
another procedure
and it works better,
it's more effective, you're getting
(15:45):
cleaner margins and
your re excision rate.
So again, the
number of times a woman has to go
through or a patient has to go
through another procedure, another
surgery is better.
You know, one other thing that we
know that all ORs care
about is how long is it taken us to
do it? You know, do you have
(16:05):
any data?
In fact, I know you do, because I
read it in the paper. But can you go
over a little bit about your
thoughts on how long it takes for a
surgeon to do this compared to what
they've been doing for years and
years, which obviously the majority
of which is wire localization.
So what I can say is that first of
all, we did look at the time of
surgery between these two
(16:27):
techniques. But I have to say that
there are a few limitations that
I'll tell you about,
about the numbers we found.
And we found that actually
FIND was about the FIND procedures
were about 170 minutes and
the wire localization to about 155
or 7.
Now it's a bit longer.
That's the first thing.
But I think what's more striking is
(16:48):
the fact that both of these are very
long compared to what we would
expect for a simple lumpectomy.
But the thing is that this was a
retrospective study,
and so the time of surgery
included anesthesia, the time of
surgery included axillary surgery.
And we had a few axillary
dissections in this cohort.
The time of surgery included if
plastic surgery came in and did a
(17:09):
reconstruction.
And I also and also the
oncoplastic reconstruction that
some of our surgeons, especially Dr.
Klimberg, performs during
surgery. So it's
difficult for me to to
to be sure that these numbers are
completely accurate.
Any other limitations on the paper
that you would like to mention?
Well, I think the limitations we
(17:31):
have on this paper, we first of all,
of course, the fact that it's a
retrospective study
and on top of that, the fact that
the technique for localization and
also the margins, how many shaved
margins each one of the surgeons
took was by surgeon
preference.
And that obviously introduced some
biases.
But I have to say that I think that
what's what was, at least for
(17:52):
me as a fellow important to
find out or to show in this paper
is that this is a safe
procedure, if it's necessarily
better or not better, as far as
these numbers compared
to wire localization, I think it's
a bit less important.
And I think what is important is
that this is by definition
(18:14):
a technique that is
equitable, and
it is readily available
and that it improves
considerably the experience for
the patient.
Absolutely.
Absolutely.
Another thing I would comment
on is that
it's easier to teach a resident, in
other words,
(18:36):
a needle loc is,
I think, extremely hard for
a resident to think in 3D
around the needle,
or at least that's what I have found
in teaching people needle
locs.
But this is, you know, is
straightforward in terms
you can see where it is,
(18:56):
right. And I think that's another
advantage.
And I can say that I as a fellow
before in residency, I've never I
only did
wire localizations, I only saw wirelocalizations.
So this is a technique that I
learned from the start,
from Dr. Klimberg and it
was, you know, maybe in the
first couple of times it was a bit
strange, but then it became very
intuitive. And I think it's my
(19:16):
preferred way of excising lesions
at this point.
I love that.
And Dr. Klimberg, any
last thoughts?
What are your what are the next
steps for this? Do you think this is
going to surpass
or become so useful
and so preferred
by a patient even?
Do you think this is the future?
(19:37):
Well, it's hard to
know how to
tell this to a patient, right?
When you, when you're not familiar
with all the ways you can do stuff,
how do you tell a patient there's an
easier way to do this?
Or where you don't have
to use a second procedure?
(20:00):
And, you know, there's
some other techniques where they can
have something put in ahead of time.
And that's certainly good for
scheduling,
but it doesn't prevent the patient
from having to have a second
procedure.
And so most patients don't
know how you find a lesion anyway.
(20:20):
So really,
we have to find a better way
to market what we're doing.
And the other problem
is, as
always, there's not a company
behind it, so that
sells something, right?
Yes, But no, I think the marketing
is key for this.
I mean, I think if you break it down
(20:42):
with, "Well, do you want to have
this done in two procedures
in the sense of a biopsy and a
surgery?
Or do you want to have a biopsy and
then another procedure and then a
and then a surgery?" You
know, I think you're right.
I mean, I think most patients,
although they may not understand how
they're found, they definitely
understand watching needles
(21:02):
go into them, you know, and
especially with that, especially
that 10 to 20% incidence of
vasovagal episode, nausea, vomiting,
those are real numbers.
Well, thank you again both
so much for
your forward thinking and all that
you do for the care of
patients with cancer.
And thank you for taking the time to
discuss your recent article with us
(21:24):
here on The Operative Word.
If you have any feedback for us here
at The Operative Word, please drop
us a line at postmaster@facs.org.
Thank you to our listeners today
and we look forward to seeing you
again next time.
Thank you for listening to the
Journal of the American College of
Surgeons Operative Word Podcast.
(21:45):
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spread the word on social media by
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Operative Word wherever podcasts are
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College of Surgeons website at
facs.org/podcast.
Welcome to The Operative Word,
a podcast brought to you by the
Journal of the American College of
Surgeons.
I'm Dr. Jamie Coleman.
And throughout this series, Dr.
Dante Yeh and I will speak with
recently published authors about the
motivation behind their latest
research and the clinical
implications it has for the
practicing surgeon.
(00:22):
The opinions expressed in this
podcast are those of the
participants and not necessarily
that of the American College of
Surgeons.
Welcome to The Operative Word, a
podcast from the Journal of the
American College of Surgeons.
I'm Dr. Jamie Coleman, one of your
hosts for this series.
In this episode, I am
very excited.
(00:43):
I'm joined today by Dr. Roi Wiser
and Dr. Suzanne Kleinberg, and
we will be taking an in-depth look
into their current article,
"Intraoperative Fluoroscopy
and Breast Lesion Localization."
Dr. Weiser is an assistant
professor at the UT, M.D.
Anderson Cancer Center in Houston,
Texas.
And Dr. Klimberg is a professor
(01:05):
and Chief of the Division of
Surgical Oncology at the University
of Texas Medical Branch in
Galveston, Texas.
Dr. Weiser, Dr. Kleinberg, welcome
to The Operative Word.
Thank you.
Thank you very much for having us.
Well, before we begin and really get
into the good stuff, do either of
you have any conflicts of interest
that you would like to disclose?
(01:25):
No, I would not.
All right. Well, first off,
congratulations to both of you on
this publication.
I have to say, I was fortunate
enough to be in the audience at the
Southern Surgical Association, the
meeting this year when this paper
was presented.
Full disclosure, actually, as both
of you know, I'm a trauma surgeon
and I was enthralled
(01:45):
by this presentation.
So, when this came across my desk
and I had the opportunity to
really allow us to
highlight this paper, I just
I jumped at the chance.
So, thank you so much
for doing this.
And now I have to say
another disclosure.
I was a history major, so I'm
(02:06):
admittedly a bit biased
that I think the history
behind some of our surgical
dilemmas is important to talk
about because it really sets
the stage for
the niche of the research.
The reason why we
did, or you
did this project
(02:28):
and so I was wondering
if we could just start there a
little bit with how did this project
come about?
You know, you've got a woman in your
office, she's got a non-palpable
breast lesion.
It looks suspicious.
She gets a biopsy
and she needs this mass out.
So, you know, Dr. Klimberg, let's
start with you.
(02:49):
Talk to me a little bit about where
we are with this currently
and kind of how you came
to this paper.
Well, just since you're
a history major, historically,
mammograms started to, say, in the
70's, and when they
found a lesion on mammogram,
they would just triangulate
(03:10):
in the operating room.
So you can imagine taking huge
amounts of tissue to try to get
something out, because we didn't
have needle locs.
We didn't have that.
So needle looks came about.
And so they're rather
traumatic
because the patient has to usually
sit up and watch the needle
(03:32):
go in. And it's a little bit like
Battleship where you
go a
lesion A vs
numbers. And so the
needle is put in there
and it's put up in an upright
position. So when the patient lays
down that
they can't find
the area, the needle moves a little
(03:53):
bit or even comes out.
And so there was a whole
line of
different needles that you could
use.
And so the
missed rate was 5
to 10%.
And the, in other words, not
(04:13):
getting the lesion out.
And then the the
other was
40 to 75%
in the literature.
Of
a positive margin rate.
Wow.
Today, the positive margin rate is a
little bit less because
(04:34):
we've changed the margin positivity
criteria.
So you're talking 20%
range. Right?
With a needle loc.
And that's in our institution
as well.
So originally
this came about because
of the
vasovagal events, watching this
needle go in 10 to
(04:55):
20%.
That's a huge percentage.
I was struck by that in your
manuscript.
And it's painful, right?
It's yeah.
And you have to watch it.
So it's not it's not uncommon.
And so.
We've gone about
trying to find different ways to
(05:17):
to do this.
And there's a lot of research in
this area with radio frequency
and all kinds of stuff, but
all of them require a second
procedure.
So you have to go back, get
back in the mammogram vise and get
another procedure.
So we were in the operating
room doing a needle loc, and this is
(05:37):
probably 10 years ago now,
5, 5 to 10, I can't even remember.
And my fellow
pulled out the needle before we got
the clip.
So usually when that happens,
which isn't an uncommon thing to do,
but usually
(05:59):
you have to wake the patient up,
send them back down and get it
relocalized, which is a terrible
thing for the patient.
And you as a surgeon, you're
mortified. Anyway so
she pulled it out. I said, well, we
said, let's try
and just do a fluoro
because every surgeon knows how
(06:20):
to use fluoro. So we said,
Let's see if we can see the clip.
And so we could.
And we took it out.
So then we started looking
at all the clips because
this isn't rocket science.
Somebody must have thought of this
before, right?
Or they probably were looking
for a clip that couldn't be
identified on fluoro.
(06:40):
So we looked at all the clips we
had, some of them couldn't be seen.
Some of them could.
Thank goodness we had one that can
be seen that day.
And so we said to the
radiologist, just use these clips
and then we can see all of them.
And then the patient doesn't have to
have a procedure ahead of time,
which, by the way, takes
an hour or two and you can never
(07:01):
have a first start.
It messes up scheduling patients.
You know, it's just
the coordination is a problem.
So this really circumvented this.
Now, before that, I developed
a procedure which I actually have a
patent on, using the hematoma
developed by a biopsy
or even injecting an hematoma.
(07:21):
But the problem is most surgeons
don't know how to use ultrasound
or are not expert at
it to be able to find every
hematoma.
But every surgeon worth
their salt knows how to use fluoro.
And so you have to have to use
something that everybody is
comfortable with.
And the other thing is you can
charge for it.
(07:41):
Yeah.
So this is how FIND
was born, right?
So let's do
this then. I mean, what
let's talk about it.
What does it stand for?
How does a surgeon do it?
Tips and tricks.
Is there a patient population
in which FIND wouldn't work?
So let's take one one question
(08:02):
at a time. I guess first of all as
far as patient populations,
I'd say it should work on most any
patient that needs a lesion
localized. And this would be
patients with
breast cancer that are going for
breast conserving surgery.
It would also go for patients with
high-risk lesions that need an
incisional biopsy.
And in the area of neoadjuvant
(08:22):
treatment, it can also go for
patients or it can be used for
patients that had a lesion that
was palpable to start off with.
But thanks to neoadjuvant treatment
became non-palpable and they're
eligible for breast-conserving
surgery, the. This is also
relevant for axillary
nodes.
And in the era of neoadjuvant
treatment and targeted axillary
(08:43):
dissection, we need to localize
those positive nodes.
So this works as well, and
maybe we'll get to the results soon.
But I think one of the things I
like the most about about
our paper is the fact that
in the
FIND group in our cohort,
100% of clips were found,
while only 80% were found
(09:05):
using wire localization.
So so this has to do with, I guess,
the patient population that can can
benefit from from the FIND
procedure.
And by the way, also we can use it
for multiple lesions.
So if a patient has a few clips in
her breast, we can also
use the fluoro and FIND
for that.
And in those cases, many times with
(09:25):
the wire localizations,
they need to have multiple wires put
in their breast, which you can
imagine is not pleasant
multiple times.
And by the way, in our court, there
are 30% of patients that had to have
or almost 30% of patients that had
have 2 or more wires put in.
So I'd say actually there's
a very large patient population that
(09:47):
can benefit from this technique.
And what does FIND stand for?
It's fluoroscopic
intraoperative neoplasia
and nodal detection.
So, it can.
I love it.
Just using fluoroscopy to find
tumors.
Yes, but I
you know, what really struck me with
this was--and
(10:08):
we're going to go into findings
next--is it was so
interesting to me that in this era
now of this continuous advancement
of surgery through technology,
this was almost, not
the opposite, but it was an
advancement through technology
that we already possess.
Like Dr. Klimberg, you stated,
(10:28):
you know, you're finding a clp with
fluoro. Surgeons know how to do
this.
So this is a technology that
already existed,
that's also been used to simplify
and therefore advance the care of
our patients with breast cancer.
I just you know, it was just
it really struck me.
If you think of the rural surgeon
(10:50):
or the surgeon
does some, but not a lot
of breast cancer, this
is ideal for them because they can't
afford to
buy some fancy techniques that
they're only going to use a little
bit.
Right. I mean, this is
you know, this is equipment
that hospitals already own,
other departments use as well.
(11:11):
It's not something just for us,
obviously, in general surgery or
breast surgery, it's not surgery
or specialty-specific.
It's got vascular surgery,
orthopaedics, urology,
so many other specialties that are
using it.
So now let's talk about how does it
work? What are the findings?
What did you guys find?
What did we find or how does it work
practically in the OR?
(11:32):
Let's do both.
Okay, so we start with the OR.
I think it actually starts with
how what Dr. Klimberg said
with invasive radiology.
They just simply need to know to put
the right clips in.
And that proved very, very
simple at UT, where I did
my fellowship, because simply all
the clips were visible on fluoro.
And then in the OR, you
(11:53):
positioned the patient more or less
like you would for any other
procedure. You just need to make
sure, like for any other fluoroscopy
procedure, that there's nothing
obstructing the
vision of the fluoroscope.
And then you start surgery
after you prep and drape, you bring
the fluoro in, and
we shoot a new image, and then you
(12:13):
see where the the clip is
on the breast and you use
whatever instrument you like to
localize on the skin where that clip
is.
Then you can plan your incision,
plan your dissection.
You can also draw your dissection on
the skin if you want, and then you
start working around that
marking that you had.
And what I think another advantage
that FIND has is that
(12:36):
during or as you're working,
you can re-shoot the fluoro
and see where your dissection
planes are compared to the fluoro
because you can put your Bovie in
the breast or wherever you're,
you're working and shoot the fluoro
and see where that is compared to
the to the clip.
So you always have this feedback
or live feedback on where
you are compared to that clip, which
(12:57):
I found very, very useful during
surgery.
And of course, you know, the surgeons
are very visual.
Yes, right.
We are.
And so you can actually choose the
margins you wish to have
and you put your Bovie in and you
can oh, it's too close
or I've taken too much.
You can move closer.
You can you as Roi said,
you have feedback.
And the thing about it is you
(13:19):
do the placing of a needle
loc or clip in a
position that's upright.
Right?
Right. You have a cranial, caudal,
and a medial. When you lay down,
the breast usually falls on the
axilla.
The clip totally moves where
you think it should be and
a needle loc you place in
(13:39):
visually under
radiograph.
And then we try and palpate
it at surgery. That's how a needle
loc is, it totally
doesn't make sense and totally I
don't even know how accurate, how it
is as accurate
as it is.
But this it changes
position. I can put my
(14:00):
incision wherever I want and I can
choose my margins.
And when you open the skin
on a
lumpectomy, it
again, the breast falls apart.
So it even moves.
And that's why, as Roi pointed out,
it's important that you can relook
and say, okay, I need to change
up a little bit.
So how effective is this if we're
(14:21):
going to compare this to needle
or wire localization, how well
does it work?
So I guess what we did in this
paper was to retrospectively go
back and look at all the wire
localizations that that were
performed in the time period that we
looked at and all the FIND
procedures that were performed,
both for breast lesions and for
(14:42):
axillary lymph nodes.
And what we wanted to see was, first
of all, I guess oncological
safety in the sense that
what was our
margin positivity rate or what was
the margin positivity rate of
the wire locs compared to the FIND?
That was our, I guess,
primary outcome that we were looking
at. And as secondary outcomes, we
(15:03):
also looked at re excision rates and
also the specimen weight to see if
it was affected by the technique,
the surgery time and also
complications.
And what we were able to find was
that there was a significantly
better, or lower percentage
of margin positivity using
FIND.
It did lose
(15:25):
significance on multivariate
analysis, but it was still number
wise, it was quite significant.
The improvement with
FIND and also the re-excision rates
were a bit lower with FIND.
So it's
better for the patient is not
another procedure
and it works better,
it's more effective, you're getting
(15:45):
cleaner margins and
your re excision rate.
So again, the
number of times a woman has to go
through or a patient has to go
through another procedure, another
surgery is better.
You know, one other thing that we
know that all ORs care
about is how long is it taken us to
do it? You know, do you have
(16:05):
any data?
In fact, I know you do, because I
read it in the paper. But can you go
over a little bit about your
thoughts on how long it takes for a
surgeon to do this compared to what
they've been doing for years and
years, which obviously the majority
of which is wire localization.
So what I can say is that first of
all, we did look at the time of
surgery between these two
(16:27):
techniques. But I have to say that
there are a few limitations that
I'll tell you about,
about the numbers we found.
And we found that actually
FIND was about the FIND procedures
were about 170 minutes and
the wire localization to about 155
or 7.
Now it's a bit longer.
That's the first thing.
But I think what's more striking is
(16:48):
the fact that both of these are very
long compared to what we would
expect for a simple lumpectomy.
But the thing is that this was a
retrospective study,
and so the time of surgery
included anesthesia, the time of
surgery included axillary surgery.
And we had a few axillary
dissections in this cohort.
The time of surgery included if
plastic surgery came in and did a
(17:09):
reconstruction.
And I also and also the
oncoplastic reconstruction that
some of our surgeons, especially Dr.
Klimberg, performs during
surgery. So it's
difficult for me to to
to be sure that these numbers are
completely accurate.
Any other limitations on the paper
that you would like to mention?
Well, I think the limitations we
(17:31):
have on this paper, we first of all,
of course, the fact that it's a
retrospective study
and on top of that, the fact that
the technique for localization and
also the margins, how many shaved
margins each one of the surgeons
took was by surgeon
preference.
And that obviously introduced some
biases.
But I have to say that I think that
what's what was, at least for
(17:52):
me as a fellow important to
find out or to show in this paper
is that this is a safe
procedure, if it's necessarily
better or not better, as far as
these numbers compared
to wire localization, I think it's
a bit less important.
And I think what is important is
that this is by definition
(18:14):
a technique that is
equitable, and
it is readily available
and that it improves
considerably the experience for
the patient.
Absolutely.
Absolutely.
Another thing I would comment
on is that
it's easier to teach a resident, in
other words,
(18:36):
a needle loc is,
I think, extremely hard for
a resident to think in 3D
around the needle,
or at least that's what I have found
in teaching people needle
locs.
But this is, you know, is
straightforward in terms
you can see where it is,
(18:56):
right. And I think that's another
advantage.
And I can say that I as a fellow
before in residency, I've never I
only did
wire localizations, I only saw wirelocalizations.
So this is a technique that I
learned from the start,
from Dr. Klimberg and it
was, you know, maybe in the
first couple of times it was a bit
strange, but then it became very
intuitive. And I think it's my
(19:16):
preferred way of excising lesions
at this point.
I love that.
And Dr. Klimberg, any
last thoughts?
What are your what are the next
steps for this? Do you think this is
going to surpass
or become so useful
and so preferred
by a patient even?
Do you think this is the future?
(19:37):
Well, it's hard to
know how to
tell this to a patient, right?
When you, when you're not familiar
with all the ways you can do stuff,
how do you tell a patient there's an
easier way to do this?
Or where you don't have
to use a second procedure?
(20:00):
And, you know, there's
some other techniques where they can
have something put in ahead of time.
And that's certainly good for
scheduling,
but it doesn't prevent the patient
from having to have a second
procedure.
And so most patients don't
know how you find a lesion anyway.
(20:20):
So really,
we have to find a better way
to market what we're doing.
And the other problem
is, as
always, there's not a company
behind it, so that
sells something, right?
Yes, But no, I think the marketing
is key for this.
I mean, I think if you break it down
(20:42):
with, "Well, do you want to have
this done in two procedures
in the sense of a biopsy and a
surgery?
Or do you want to have a biopsy and
then another procedure and then a
and then a surgery?" You
know, I think you're right.
I mean, I think most patients,
although they may not understand how
they're found, they definitely
understand watching needles
(21:02):
go into them, you know, and
especially with that, especially
that 10 to 20% incidence of
vasovagal episode, nausea, vomiting,
those are real numbers.
Well, thank you again both
so much for
your forward thinking and all that
you do for the care of
patients with cancer.
And thank you for taking the time to
discuss your recent article with us
(21:24):
here on The Operative Word.
If you have any feedback for us here
at The Operative Word, please drop
us a line at postmaster@facs.org.
Thank you to our listeners today
and we look forward to seeing you
again next time.
Thank you for listening to the
Journal of the American College of
Surgeons Operative Word Podcast.
(21:45):
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