Tiny gold seed that can help surgeons target breast tumours
SURGERY TO REMOVE BREAST TUMOUR
LINDA ROWE, 70, a grandmother from Newcastle-upon-Tyne, was one of the first women in the UK to undergo a new procedure to locate cancer in the breast, as she tells ADRIAN MONTI.
STHE PATIENT
INCE I turned 50, I’ve had a mammogram every three years — but a fortnight after the one in July last year, I got a letter asking me to return for another. I hadn’t felt any lumps but it set alarm bells ringing.
The second mammogram showed a ‘shadow’ in my left breast, so I had a biopsy under local anaesthetic the same day.
Two weeks later Henry Cain, a breast cancer surgeon at the Royal Victoria Infirmary, in Newcastle, said I had a small cancerous tumour below my left nipple which needed to come out before it spread.
Mr Cain then explained that the hospital was trialling a new way to make the surgery easier — they were using a tiny radioactive seed about the size of a grain of rice as a ‘marker’ to help direct the surgeon more accurately to where the tumour is.
The main benefit was that it would mean less healthy breast tissue being removed, because the marker pinpoints the tumour so well.
Two weeks before the operation, a radiologist inserted the seed into my breast using a thin needle, under local anaesthetic. I was quite relaxed about the procedure.
The next day my husband Dennis and I went to France on holiday. I put the cancer to the back of my mind and enjoyed our break. The day after we got back in midSeptember, I went for my surgery.
I had a general anaesthetic before Mr Cain carried out the 90-minute surgery. He removed the 14mm tumour and the radioactive seed by making a 20mm long downward cut under my nipple. I felt a bit sore afterwards but was able to go home the same day.
AFTER healing, it left a s mall s car which doesn’t show, even if I’m wearing a bikini. For the next five years I’ll take a daily dose of letrozole. It’s an anti-oestrogen drug — oestrogen had caused my cancer to grow, so reducing it will hopefully stop it returning.
In November I had three weeks of radiotherapy as a precaution, and I’ll now have regular mammograms to check the cancer hasn’t returned.
THE SURGEON
HENRY CAIN is a consultant oncoplastic breast surgeon at Newcastle’s Royal Victoria Infirmary. EaCH year more than two million UK women undergo breast cancer screening. Of those, 4 per cent are recalled for a second mammogram and about one in five of these will have cancer.
Mammograms are particularly good at detecting ‘impalpable’ tumours — the ones that cannot be felt as a lump, as in Linda’s case. But it’s the way we mark the tumour which is new.
Linda is among the first 150 patients in the UK to undergo this procedure, called radioactive seed localisation.
If a lump can’t be felt, the surgeon traditionally relies on a guide wire to locate it. On the day of surgery the radiologist finds the lump using a mammogram or an ultrasound scan. Then, under local anaesthetic, a flexible metal wire, 0.5mm wide, is threaded into the breast using a fine needle, while the radiologist looks at the mammogram or ultrasound scan on the screen to ensure it reaches the lump.
This guide wire has a barb on the end which goes into, or as close as possible to, the cancer. The other end sticks out from the patient’s breast. Putting in the wire can take up to an hour.
Once the wire is in place, the surgeon relies on it to guide them to the tumour. This involves looking at a 2D mammogram on a screen, then back at the breast itself, and moving your gaze constantly between the two to try to find exactly where the wire’s tip is. This can be quite an art. You then make an incision in the breast and tunnel towards the wire’s tip to remove the tumour.
Then, in 2001, a U.S. surgeon devised a new way of marking a breast tumour, using radioactive seeds as a marker.
as with the guide wire technique, the seed is inserted by a radiologist using an ultrasound scan or mammogram.
The seed has a titanium outer shell, so it’s strong and light. Inside is a tiny gold wire — this shows up easily on a scan — and iodine 125, a very low- dose radioactive source.
We use a special probe that detects this radioactive source to pinpoint the seed’s location. This means a smaller amount of healthy tissue is taken away — and there’s an improved clearance of the tumour, too.
We were the first unit in the UK to start using the radioactive seeds, in October 2014.
The seed can be inserted at least a week before surgery and even longer if need be. This reduces anxiety for patients.
The seed is put into the exact spot where the cancer has been found, using a thin needle, as the radiologist watches what’s happening on screen. This takes about 15 minutes using an ultrasound scan, and up to an hour using a mammogram.
Once in theatre, I use a gamma probe, which detects radiation. It’s about the size of a marker pen and I hold it close to the patient’s breast. as I move it closer to the seed, the digital dial shows a higher reading as it’s measuring the amount of radiation being emitted from it.
By constantly checking the seed location with the probe, I take out the lump. I use the probe throughout the operation and check the seed is still inside THE the tumour once it is removed.
seed makes removing the t u mour more straightforward, and research shows this technique gives greater accuracy in locating the tumour.
The new technique reduces the risk of incomplete removal of the tumour at the first operation.
We also plan to use more than one seed in a breast to remove multiple cancers, or to ‘bracket’ larger areas of tissue that need to be removed.
ANY DRAWBACKS?
‘RaDIOaCTIVE seeds are a “win-win” for both the patient and the hospital — with the guide wire you are never completely sure where the tip is,’ says Jenny Piper, a consultant oncoplastic breast surgeon at York Hospital.
‘The only downside is the cost: guide wires are about £30, compared with £80 for the seed.
‘There are also very strict rules on using radioactive material in a hospital, so gaining approval is causing some delay. But we hope to introduce the same technique at York Hospital soon.’