Application value of digital tungsten-molybdenum dual target three-dimensional positioning indwelling guide wire excision biopsy in diagnosis of breast microcalcification

Abstract

OBJECTIVE:

To explore the application value of digital tungsten-molybdenum double target three-dimensional positioning indwelling guide wire and guided surgical resection biopsy in the diagnosis of breast microcalcification.

METHODS:

A retrospective analysis of 168 patients with negative clinical palpation and molybdenum target X-ray examination found breast abnormalities were equally divided into two groups according to different surgical positioning methods. The control and observation group underwent gross positioning biopsy and digital tungsten-molybdenum dual-target three-dimensional positioning indwelling guide wire to guide surgical resection biopsy, respectively. The results of molybdenum target X-ray examination and the success rate of one-time complete resection of the lesions were compared between the two groups, and the corresponding relationship between the pathological diagnosis results of the lesions after surgical resection and the performance of mammography in the observation group was compared.

RESULTS:

There was no significant difference in age and molybdenum target X-ray examination results between the two groups (P > 0.05). General information is comparable; the success rate of one-time complete resection of lesions in the observation group was significantly higher than that in the control group (95.2% vs 78.6%, P = 0.024). There were 34 cases of malignant lesions in the observation group, accounting for 40.5% (34/84), including 11 cases of invasive ductal carcinoma (64.7%), 50 cases of benign lesions, accounting for 59.5% (50/84), including 16 cases of breast lobular hyperplasia (32%), 18 cases of breast cystic hyperplasia (36%).

CONCLUSION:

In diagnosis of breast microcalcifications, surgical resection biopsy guided using digital tungsten-molybdenum double target three-dimensional positioning indwelling guide wire achieves high success rate and has advantages of high safety and accurate diagnosis. Thus, it has potential to play a greater role in early diagnosis of breast cancer and is worthy of clinical application.

Keywords

Tungsten and molybdenum microcalcification of breast Three-dimensional stereoscopic guide wire target X-ray

1 Introduction

The incidence of breast cancer in China is increasing year by year and is now close to the level of developed countries, ranking first in the mortality rate of female malignant tumors [1]. In patients with early breast cancer, there are many cases that cannot be diagnosed by initial diagnosis and single imaging examination, and surgical biopsy may lead to patient resistance and delay the condition [2]. At present, breast cancer screening is widely used in the early detection and early diagnosis of breast cancer [3], and mammography is still the preferred method for breast screening because of its simplicity and reliability [4]. Mammographic microcalcifications are considered early signs of breast cancer and a potential diagnostic indicator for non-palpable breast cancers [5, 6]. Over the past few decades, much attention has been paid to exploiting this property, which forms the basis for advances in diagnostic procedures and imaging techniques.

In recent years, with the wide application of digital X-ray molybdenum target, the detection rate of early breast cancer has been further improved. In addition, to increase the diagnostic accuracy of biopsy for minimal change disease, a three-dimensional stereotactic hook wire placement biopsy technique for breast has been newly developed, which has the advantages of minimally invasive, directional, accurate localization, and small operating range compared with conventional lesion resection. It can not only provide sufficient technical guarantee for clinical surgery, but also improve the accuracy of pathological diagnosis, identify the nature of the lesion, determine the classification of malignant lesions, and provide the basis for further selection of surgical methods. Molybdenum target X-ray hook wire localization followed by resection of the lesion has been clinically considered the gold standard for the diagnosis of subtle calcifications of the breast [7]. Studies have shown that the accuracy of X-ray three-dimensional guidewire localization surgical biopsy is high, the coincidence rate of technical diagnosis is 90.9%, and the accuracy rate of diagnosis of early breast cancer is 100% [8].

This study retrospectively analyzed the clinical data of 168 patients with clinically negative palpation and breast abnormalities found by molybdenum target X-ray examination who were admitted to our hospital from February 2020 to May 2022, and compared and analyzed the success rate of one-time resection of surgical biopsy lesions under gross localization and digital tungsten molybdenum dual-target three-dimensional stereotactic guidewire localization techniques and the degree of coincidence between mammographic findings and pathological diagnosis results after surgical resection. To investigate the value of digital tungsten molybdenum dual-target three-dimensional stereotactic indwelling guide wire and guided surgical resection and biopsy in the diagnosis of breastmicrocalcifications.

2 Materials and methods

2.1 Study subjects

Collected February 2020 to May 2022 in our hospital for health examination or other reasons of active treatment of patients, are female. Patients were divided into control and observation groups according to different preoperative localization methods. The control group underwent gross localization biopsy. The observation group underwent digital tungsten molybdenum double-target three-dimensional stereotactic indwelling guide wire biopsy. The patient inclusion criteria include (1) no lesions were found on clinical palpation, and lesions such as psammomatous calcifications, tiny suspicious tufted calcifications, structural distortions, asymmetric dense, and suspicious nodules were found only on molybdenum target radiography; and (2) patients with BI-RADS-4 and some BI-RADS-3 categories (who required localization biopsy due to their own concerns about the lesion) according to the Breast Imaging Reporting and Data System (BI-RADS) classification criteria established by the American College of Radiology [9]. The patient exclusion criteria include (1) BI-RADS-0 undetermined category requires further imaging examination; BI-RADS-1, 2 categories of normal and benign lesions; and (2) BI-RADS-5 category confirmed breast cancer.

2.2 Test instrument and test method

2.2.1 Test instrument

Tungsten molybdenum dual-target digital mammographic DR machine (manufacturer FUJIFILM; model AMULET f) is additionally equipped with three-dimensional positioning system in addition to scanning frame and operating console. 21G needle is used as positioning. The tip of stylet is equipped with fishhook-like barb.

2.2.2 Test method

Patients in both groups underwent conventional molybdenum target axial, standard lateral and mediolateral oblique radiography preoperatively. The control group underwent gross localization biopsy, and the observation group underwent digital tungsten molybdenum dual-target three-dimensional stereotactic indwelling guide wire to guide surgical resection biopsy.

Gross localization: Each breast is regarded as a clock disc. According to the preoperative routine molybdenum target X-ray axial and standard lateral images, it is generally judged which quadrant the lesion is in and the range of several o’clock corresponding to the clock disc. The body surface position of the lesion is roughly circled with the body surface localization guide wire. The distance from the lesion to the nipple on the imaging image is measured with computer software. The report form is filled in for the reference of the surgeon during biopsysurgery.

Digital tungsten molybdenum double-target three-dimensional stereotactic indwelling guide wire: three-dimensional stereotactic indwelling guide wire first starts the digital breast DR machine, runs the three-dimensional positioning system and corrects the system, and starts the guide wire cutting inspection after normal. The location of the lesion was judged by imaging films (Fig. 1), the appropriate resection site was selected, and the radiography was compared with the location of the lesion on the previous mammography to confirm that the location of the lesion was anastomosed and continued to be radiographed at±15°. The X, Y, and Z values of the lesion localization were obtained after the three radiography images were processed in the system, and the compression plate was adjusted again to compress the lesion in the center of the compression plate, the resection site was routinely disinfected, and lidocaine was locally anesthetized. For three-dimensional stereotactic guidewire localization and cutting, after anesthesia, 21G needle with guidewire was used to penetrate the lesion perpendicular to the skin direction at the positioning site, radiography was performed at±15°oblique position to determine that the needle completely passed the lesion after the cutting needle accurately reached the located lesion, the needle core guidewire was gently pushed (Fig. 2), the anterior barb of the guidewire was opened to hook the lesion, the needle was quickly withdrawn, and then the guidewire was located in part of the patient ‘s body for fixation (Fig. 3), the guidewire was ensured not to be displaced during the fixation of the guidewire, axial radiography was performed to observe whether the guidewire barb was located in the lesion, the compression plate was released and lateral radiography was performed, and the lesion resection was performed by the surgeon according to the guidelines of the guidewire after the guidewire was processed, and molybdenum target radiography of the cut specimen was used to determine whether the lesion was completely removed and sent for pathological examination (Fig. 4).

Fig. 1

Breast calcification in the positioning frame. Patients were required to be seated. A puncture rack was installed, and the lesion puncture was placed into the placement box, radiography was assessed and the lesions in the operational range were adjusted and fixed by oppression.

Fig. 2

The positioning needle was inserted, and the needle tip is located in the focal region. The position of the needle tip was calibrated, and the coordinates were 0.- axis Z. Perturbation of +15° and –15° film was determined in the digital spot mammography, the target lesions display system was selected, and the puncture point x, y and z axes were accurately calculated by computer to determine the needle point and needle depth. Regular disinfection, and local anesthesia, were used and the needle puncture was inserted, and radiography confirmed the correct position.

Fig. 3

Indwelling double hook wires in the lesion area. The needle sheath, and indwelling double hook wire was pulled out, and the body part of the guide wire was excised and fixed by ligule tape winding.

Fig. 4

Postoperative specimen shows a one-time completed resection of lesions. At the general location of the lesion, the surgeons made incisions according to the focus range provided by the radiologists. For the lesions localized by 3D stereo wire, the surgeons followed guided wire localization to excise the lesion biopsy; with surgical resection being generally in the range of 20 mm around the tip of localization wires. If the lesion size, quantity, and scope were consistent with previous X-ray film, it was considered completely removed, and the needle head was inserted into the pathological lesions.

2.3 Outcome measures and statistical data analysis

The success rate of complete resection of the lesion at one time was counted, and the degree of coincidence between the radiography findings and the pathological findings after surgical resection was analyzed.

In this study, SPSS 26.0 software was used for statistical analysis. Normality tests for quantitative data were performed using the K-S test (α= 0.05), quantitative data that conformed to the normal distribution were expressed as mean±standard deviation ( $\bar{x}$ ±s) and maximum and minimum values (min, Max), and t-test was used for comparison between groups; qualitative data were expressed as n (%), and chi-square test or Fisher’s exact test was used for comparison between groups. P < 0.05 was considered to indicate a statistically significant difference.

3 Results

3.1 Basic information and characteristics

A total of 168 patients who met the criteria were included, 84 in the observation group and 84 in the control group. There were no significant differences in age and molybdenum target X-ray findings between the two groups (P > 0.05). General data are comparable as shown in Table 1.

Table 1
Comparison of basic information and characteristics between the observation group and the control group

Variable Observation group Control group T/X² P value

(n = 84) (n = 84)

Age 2.356 0.453

$\bar{x} \pm s$ 44.5±2.3 45.6±3.0

Min, Max 24,63 23,62

Molybdenum target X-ray results 0.623 0.960

Psammomatous calcification 40(47.6) 42(50.0)

Small suspected tufted calcification 20(23.8) 16(19.0)

Distorted or disorganized structure 10(11.9) 12(14.3)

Asymmetric compaction 8(9.5) 6(7.1)

Solitary nodule 6(7.1) 8(9.5)

Variable	Observation group	Control group	T/X²	P value
Age			2.356	0.453
$\bar{x} \pm s$	44.5±2.3	45.6±3.0
Min, Max	24,63	23,62
Molybdenum target X-ray results			0.623	0.960
Psammomatous calcification	40(47.6)	42(50.0)
Small suspected tufted calcification	20(23.8)	16(19.0)
Distorted or disorganized structure	10(11.9)	12(14.3)
Asymmetric compaction	8(9.5)	6(7.1)
Solitary nodule	6(7.1)	8(9.5)

3.2 Comparison of the success rate of complete resection at one time

In the control group, 66 lesions were completely resected at one time, and the success rate of complete resection at one time was 78.6%; 12 lesions were partially resected and underwent a second total resection after the radiologist informed the orientation; 6 lesions were still not cut and needed to be repositioned and resected half a year later.

In the observation group, 80 cases of lesions were completely resected at one time, and the success rate of complete resection at one time was 95.2%; 4 cases had secondary resection after the radiologist informed the orientation due to excessive movement range of the patient before surgical biopsy, resulting in guide wire movement and incomplete resection of the lesion.

The success rate of one-time complete resection of the lesion in the two groups was significantly higher in the observation group than in the control group, and the difference had statistical significance (χ² = 5.126, P = 0.024) as shown in Table 2. Therefore, the patients who received digital tungsten dual-target three-dimensional stereotactic indwelling guide wire had a significantly higher success rate than gross localization biopsy.

Table 2
Comparison of success rate of one-time complete resection of lesions

Variable Observation group Control group X ² P value

n = 84 n = 84

Single complete resection 80(95.2%) 66(78.6%) 5.126 0.024

Secondary resection 4(4.8%) 12(14.3%) 2.211 0.137

Resection after repositioning required 0(0.0%) 6(7.1%) 3.111 0.780

Variable	Observation group	Control group	X ²	P value
Single complete resection	80(95.2%)	66(78.6%)	5.126	0.024
Secondary resection	4(4.8%)	12(14.3%)	2.211	0.137
Resection after repositioning required	0(0.0%)	6(7.1%)	3.111	0.780

3.3 Mammography findings and pathological diagnosis after surgical resection in the observation group

In the observation group, 34 cases (40.5%, 34/84) were malignant lesions, including 22 cases (64.7%) of invasive ductal carcinoma and 6 cases of intraductal carcinoma. There were 6 cases of medullary carcinoma. There were 50 cases of benign lesions, accounting for 59.5% (50/84), including 16 cases (32%) of lobular hyperplasia of the breast, 18 cases (36%) of cystic hyperplasia of the breast, 10 cases of fibroadenoma, 2 cases of papilloma, and 4 cases of chronic inflammation. The corresponding relationship between the diagnostic results of cases and mammographic findings is shown in Table 3. Although the proportion of pathologically confirmed malignant lesions was relatively low in the observation group, this technique provides an important method for the pathological detection of the palpation-negative and breast microcalcifications.

Table 3
Comparison of mammography findings and pathological diagnosis results in 84 patients in the observation group

Pathological diagnosis Mammary X-ray manifestations (n) Total

Gravel microcalcification Small suspicious cluster-like calcification Structural distortion or disorder Asymmetric densification Solitary nodule

Malignant

Invasive ductal carcinoma 10 4 4 2 2 22

Intraductal carcinoma 4 2 0 0 0 6

Medullary carcinoma 0 4 0 2 0 6

Benign

Mammary gland lobular hyperplasia 8 2 2 2 2 16

Cystic hyperplasia of mammary glands 12 2 2 0 2 18

Fibroadenoma 4 2 2 2 0 10

Papilloma 0 2 0 0 0 2

Chronic inflammation 2 2 0 0 0 4

Total 40 20 10 8 6 84

Pathological diagnosis	Mammary X-ray manifestations (n)	Total
Malignant
Invasive ductal carcinoma	10	4	4	2	2	22
Intraductal carcinoma	4	2	0	0	0	6
Medullary carcinoma	0	4	0	2	0	6
Benign
Mammary gland lobular hyperplasia	8	2	2	2	2	16
Cystic hyperplasia of mammary glands	12	2	2	0	2	18
Fibroadenoma	4	2	2	2	0	10
Papilloma	0	2	0	0	0	2
Chronic inflammation	2	2	0	0	0	4
Total	40	20	10	8	6	84

4 Discussion

Breast cancer is the most common malignant tumor in women worldwide, and the annual incidence of breast cancer in China is 169,000, accounting for 12.25% of the total global incidence, second only to the United States (182,000), and with the change of people’s lifestyle, its incidence and mortality show an increasing trend year by year [10]. The number of breast cancer patients with negative palpation in breast cancer screening has increased, most of whom are patients with early breast cancer, and most of them have a good prognosis due to early detection and treatment [11]. Molybdenum target-guided three-dimensional stereotactic resection is the gold standard for the diagnosis of palpation negative lesions, and accurate resection of suspicious lesion tissues can not only preserve the beautiful shape of the breast, but also achieve the early diagnosis of breast cancer and help to improve the prognosis [12, 13].

In addition, due to the tiny and occult nature of the lesion, it is clinically inaccessible, conventional ultrasound-guided resection has been unable to assist in the diagnosis and treatment, three-dimensional stereoscopic guidance to determine calcifications has become an effective diagnosis and treatment method, which is the key to the accurate localization and resection of microcalcifications. As far as we know, there are few research on digital tungsten-molybdenum dual target three-dimensional positioning indwelling guide wire excision biopsy. In our study, we found that patients who received digital tungsten dual-target three-dimensional stereotactic indwelling guide wire had a significantly higher success rate than gross localization biopsy. Our study further proves the accuracy and safety of digital tungsten dual-target three-dimensional stereotactic indwelling guide wire in clinical practice and provides important reference value for the promotion of its clinical application.

According to domestic and foreign literatures in recent years, X-ray molybdenum target puncture localization for palpation of occult microcalcifications, the specificity of the diagnosis of breast cancer is 95% to 97%, and the sensitivity can reach 91% to 97% [14 –16]. In this study, among 84 patients who underwent successful resection by digital tungsten molybdenum dual-target three-dimensional stereotactic guidewire localization, malignant lesions accounted for 40.5% (34/84), of which invasive ductal carcinoma accounted for 64.7%; benign lesions accounted for 59.5% (50/84), of which cystic hyperplasia of the breast accounted for 36% (18/50). Consistent with the results reported in the relevant literature [17, 18]. In this study, psammomatous calcification accounted for 48.8% (41/84), which was consistent with relevant literature reports [19]. Calcified lesions have always been a difficult point for clinicians to remove by biopsy because calcifications are difficult to palpate during surgery and are easily missed when they are widely distributed [20]. In this paper, mammographic findings are collated to help better compare with pathological findings. Research review reports: Breast microcalcification is a calcium deposition that is considered to be a powerful marker of breast cancer in mammography, and understanding its molecular and structural development is helpful for the detection and treatment of breast lesions [21].

In this study, the success rate of one-time complete resection was as high as 95% in the observation group, which was inseparable from the characteristics of accurate localization of digital tungsten molybdenum double-target three-dimensional stereotactic indwelling guide wire biopsy. It shows that it is an ideal method for the diagnosis of small breast lesions, which not only solves the problem of localization of small breast lesions by surgeons, but also solves the problem of false negative results of blind surgical resection or needle biopsy in the past [22]. At the same time, because biopsy surgery can remove the entire lesion, the diagnosis and treatment of lesions with surgical indications are completed at one time. Both definite diagnosis and timely treatment have been obtained, and some lesions also remove the risk of carcinogenesis.

The occurrence and development of breast cancer is a complicated process involving many causes and factors. Genomics, proteomics and chemokines are all hot topics and mainstream research directions in the pathogenesis of breast cancer. However, surgery is still the main treatment method for nonpalpable primary breast cancer, in which digital tungsten molybdenum double target three-dimensional positioning indwelling guide wire plays an important role. The results of this study showed that the success rate of one-time complete resection of the lesion in the observation group was significantly higher than that in the control group, and the difference had statistical significance (95.2% vs 78.6%, P = 0.024). Possible reasons are that the related studies have shown that imaging findings of palpation negative breast lesions are poorly specific and difficult to differentiate benign from malignant [23, 24]. Therefore, before the introduction of 3D stereotaxic system, for lesions with negative palpation that can only be visualized on molybdenum target films, traditional gross localization methods are clinically used to provide surgeons with the gross location of the lesion.

However, gross localization requires a higher technical level for radiologists and surgeons, with a larger localization range and a larger extent of surgical resection. At the same time, due to the difference between the body position at the time of surgery and the body position at the time of radiography, in addition to the compression image of the breast during radiography, the location of the lesion will produce positioning deviation during surgery, which brings some difficulties to accurately remove the lesion in clinical surgery. Currently, some hospitals use molybdenum target two-dimensional guidewire positioning technology. The so-called two-dimensional guide wire positioning can only provide the coordinates of X and Y axis of target lesion, while the judgment on the coordinate value of Z axis of needle insertion depth depends on the experience of radiologist, which is bound to cause the distance deviation between needle tip and target lesion and expand the surgical range [25]. Although the relative accuracy of two-dimensional guidewire localization technique is much higher than that of gross localization, three-dimensional stereotaxic accuracy is not achieved because the depth of needle insertion is easily affected by subjective factors. Two-dimensional guidewire positioning has been shown to be less accurate and less comfortable for patients than three-dimensional guidewire positioning [26].

Additionally, the three-dimensional stereotaxic system is developed based on the localization of two-dimensional guide wire. It adds the coordinates of a dimension on a two-dimensional basis. The three-dimensional coordinates of the target lesion can be accurately calculated by the computer. After placing the guide wire, the surgeon can be guided to perform the resection of the lesion. The localization is more accurate, the resection range is smaller, and the damage to the normal breast tissue is also smaller [26]. Through molybdenum target-guided three-dimensional guidewire localization technique, the lesions that are negative in early palpation and can only be found in X-ray examination can be guided by guidewire localization to guide clinicians to perform resection and pathological examination, which is of great value for accurate resection of lesions and can further improve the early diagnosis rate and accurate resection rate of breast cancer or breast lesions [27]. Therefore, satisfactory aesthetic effect can be obtained through this technique.

As the precision requirements of digital tungsten molybdenum double target three-dimensional positioning indwelling guide wire localization technique are higher, authors suggest that in the course of the operation the following points remain to be clarified: 1) after fixing the lesions, patients should remain stationary during operation; 2) To avoid the vagal reaction of patients before and during surgery because of nervousness, communication should be constant with the patient in order to relieve the tension; 3) since breast compression is needed for the guide wire localization, it is not appropriate to use this for patients with extremely small and thin breasts; and 4) Guide wire localization technique should also not be used for patients with coagulation dysfunction.

Technology still has some limitations. This technology is performed on the day of surgery to avoid the risk of wire migration, which can negatively affect the operating-theatre schedules owing to the requirement for radiology support on the day of surgery [28]. Several complications are related to wire insertion, including wires becoming dislodged or transected, and wires migrating from the site of original placement, which can on rare occasions cause thoracic injuries [29]. Technical issues arising intraoperatively include potential needlestick injuries, diathermy burns, and limitations in incision placement with an adverse effect on cosmetic outcome [30]; The relatively high cost of digital tungsten molybdenum double target three-dimensional positioning indwelling guide wire localization technique compared with other techniques has been proven [31 –33].

There are some shortcomings in this study. First, due to the limitation of the sample size of cases, the pathological types covered are not comprehensive enough. Second, this study focuses on clarifying the pathological diagnosis of calcifications, and no further analysis is made for the X-ray image distribution, size, and morphological characteristics of resected calcifications. And for a wide range of lesion localization, molybdenum target localization may not be as simple as ultrasound localization, therefore, more meticulous studies can be made on the formation mechanism of microcalcifications in early breast cancer in the future.

5 Conclusion

In conclusion, the digital tungsten molybdenum dual-target three-dimensional stereotactic indwelling guide wire biopsy has an important diagnostic value for the palpation-negative and breast microcalcifications, as it has a high success rate, and has the advantages of high safety, which can play a greater role in the early diagnosis of breast cancer and is worthy of clinical application and promotion.

Statement of ethics

This study is conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of No. 6 Hospital of Shanxi Medical University, and written informed consent was obtained from all participants.

Conflict of interest statement

Author has no personal, financial, commercial, or academic conflicts of interest separately.

Funding sources

N/A.

Data availability statement

The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.

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