Abstract
Introduction
Impalpable breast lesions generally require image‐guided localisation for breast‐conserving surgery. A standard technique is to place a hook wire (HW) within the lesion. Radioguided occult lesion localisation using iodine seeds (ROLLIS) involves inserting a 4.5 mm iodine‐125 seed (seed) into the lesion. We hypothesised that a seed could be more precisely positioned in relation to the lesion than a HW and that this may be associated with a lower re‐excision rate.
Methods
Retrospective review of consecutive participant data from three ROLLIS RCT (ACTRN12613000655741) sites. Participants underwent preoperative lesion localisation (PLL) with seed or HW between September 2013 and December 2017. Lesion and procedural characteristics were recorded. Distances between (1) any part of the seed or thickened segment of the HW (‘TSHW’) and the lesion/clip (‘distance to device’ DTD) and (2) centre of the TSHW/seed and centre of the lesion/clip (device centre to target centre ‘DCTC’) were measured on immediate postinsertion mammograms. Pathological margin involvement and re‐excision rates were compared.
Results
A total of 390 lesions (190 ROLLIS and 200 HWL) were analysed. Lesion characteristics and guidance modality used were similar between groups. Ultrasound‐guided DTD and DCTC for seed were smaller than for HW (77.1% and 60.6%, respectively, P‐value < 0.001). Stereotactic‐guided DCTC for seeds was 41.6% smaller than for HW (P‐value = 0.001). No statistically significant difference in the re‐excision rates was found.
Conclusion
Iodine‐125 seeds can be more precisely positioned for preoperative lesion localisation than HW, however, no statistically significant difference in re‐excision rates was detected.
Keywords: Accuracy, breast, iodine‐125 seed, preoperative localisation, ROLLIS
Preoperative localisation of impalpable breast lesions using iodine 125 seeds is more precise than hook wire, irrespective of proceduralist seniority. Seeds were positioned closer to the lesion, particularly when ultrasound guidance is used.
Introduction
Breast cancer is the most commonly diagnosed cancer in Australian women 1 with approximately 53 women diagnosed every day in 2019. 2 Breast‐conserving surgery requires women with impalpable breast cancers to undergo image‐guided preoperative lesion localisation (PLL). Until recently, the standard technique has been to insert a hook wire (HW) with a 2‐cm‐long thickened segment (modified Kopans wire) so that the thickened segment of the wire (TSHW) lies within or alongside the lesion. 3
Previous literature has shown that accurate preoperative localisation is important. Jackman et al. 4 demonstrated a higher likelihood of successful excision if the TSHW traverses a lesion in two mammographic planes. Furthermore, Abrahamson et al. 5 found that the placement of a wire within 5 mm of the lesion was a significant predictor of successful lesion removal and increased wire‐to‐lesion distance was associated with increased breast excision biopsy failure. However, whether a more precise PLL of impalpable breast cancer might be associated with lower rates of pathologically inadequate margins and a need for re‐excision remains unanswered.
HW localisation is associated with many disadvantages, including the need for insertion on the day of surgery as the wire extends onto the skin, with movement after placement considered a common complication. 6 , 7 , 8 , 9 Radioguided occult lesion localisation using iodine‐125 seeds (ROLLIS) is an alternative technique that has been fully described previously 10 , 11 involving insertion of a 4.5 mm × 2 mm titanium seed containing low‐dose radioactive material into a lesion under imaging guidance, with the seed visible on X‐ray and MRI. By changing a switch on the handheld gamma probe used for radioisotope‐guided sentinel node excision, the surgeon can detect the 27 keV energy emitted by the iodine‐125, with the seed acting as a continuous point of reference for lesion excision. The seed can be inserted multiple days prior to surgery, decoupling the localisation and surgical procedures. Other advantages of seed localisation include lower levels of discomfort and stress 12 and improved ease of use by both surgeons and radiologists; 10 however, the seeds are a sealed source of radioactivity and are therefore subject to handling protocols and location tracking between insertion and retrieval. 11 Once the seed is inserted, it remains within the breast and clinically significant movement (arbitrarily defined as a maximum clip‐to‐lesion distance >10 mm) 13 , 14 , 15 is thought to be rare, 11 , 13 , 14 , 15 , 16 having been reported in 1 in 1000 cases by McGhan et al. and in 0 of 48 cases by Alderleistein et al.
When performing preoperative localisation of a lesion (without bracketing), the radiologist aims to place the reference point of the localising device within or as close as possible to the lesion or accurately sited marker clip (clip ≤10 mm of lesion site) if the lesion is no longer visible. For ROLLIS, the reference point is the 4.5 mm titanium seed, whereas, for HWL, the reference point is the 2 cm thickened segment of the hook wire (TSHW).
Given the inherent physical differences between the seed and wire, we hypothesised that the degree of precision with which a seed could be placed in PLL would be superior to that of an HW. We also hypothesised that greater precision might be associated with a lower rate of inadequate pathological margins and re‐excision.
Methods and Materials
This substudy was part of an institutional Ethics Committee‐approved trial, in which women with impalpable breast cancers were randomised to undergo image‐guided PLL with either HW or ROLLIS (The ROLLIS Trial, ACTRN12613000655741). The full trial methodology and primary outcome results have recently been published. 10
The breast imaging and pathology data of consecutive ROLLIS RCT participants from three of the eight study centres who underwent PLL with either seed or HW between September 2013 and December 2017 were reviewed. Study inclusion criteria were females aged over 18 years, with at least one biopsy‐proven invasive carcinoma or ductal carcinoma in situ (DCIS) lesion, who were considered suitable for breast‐conserving surgery and had given written informed consent to participate in the trial.
Participants were randomised for localisation devices (hook wire or seed) using centrally concealed computer‐generated block randomisation via a secure online database. The low‐dose radioactive seeds (with an activity of ≤3.7 MBq of iodine‐125) were inserted up to 8 days prior to surgery, decoupling the localisation and surgical procedures. These parameters were set to ensure that the effective radiation dose received by a trial participant did not exceed a 5 mSv threshold that would have required specific approval from the local Radiation Council. Randomisation was stratified according to study site and the core biopsy histopathology of the index lesion (ductal carcinoma in situ (DCIS) only vs. other malignant pathology) of the index lesion. 10
The exclusion criteria were lesions bracketed with more than one device, mammographically occult lesions (with no marker clip or suboptimal marker clip position) and lesions where no postlocalisation mammogram was available. Suboptimal marker clip position was assessed by comparing marker clip location in relation to the lesion site when viewing the equivalent projections from the pre‐ and postbiopsy mammograms. Clip position was considered suboptimal if the largest clip‐to‐lesion distance was >10 mm. If multiple attempts at localisation had been performed, only the initial attempt was assessed.
Lesion type, size, localisation device (wire or seed), guidance modality and proceduralist seniority were reviewed. The lesion size was calculated by taking the sum of the maximal measurement of the lesion in the craniocaudal (CC) view and the mediolateral oblique (MLO) or lateromedial (LM) view immediately after PLL and then dividing by 2 (to give an arithmetic mean). In lesions deemed mammographically occult, but with a marker clip in situ (marker clip only), lesion size was taken from ultrasound measurements.
The appearances of the lesions on mammography were classified using descriptors that were common to all three study centres: localised increased stroma (LIS), stromal distortion (SDI), solitary mass noncalcified (SMN), solitary mass with calcification (SMC), stellate opacity (SOP), localised cluster of calcification (LCC) (for calcifications measuring <25 mm), widespread calcification (WCA) (for calcifications measuring ≥25 mm) or marker clip only.
ROLLIS involved inserting an iodine‐125 seed (ADVANTAGE, IsoAid LLC, Port Richey, FL, USA) into the lesion. For HWL, a modified Kopans hook wire (Cook, Bloomington, IN, USA) was inserted through the lesion, aiming to place the thickened segment of the HW (TSHW) within it (Fig. 1).
Figure 1.
(A) Seed compared with HW with introducing needles for both. (B) Magnified image of seed compared with HW in terms of size, with ruler markings in centimetres.
Guidance modality for PLL (ultrasound, stereotactic or tomosynthesis) was chosen by the radiologist based on equipment availability and the modality on which the lesion and/or marker clip had been best visualised. Stereotactic guidance was performed on a Lorad‐prone table (Hologic, Bedford, MA). Tomosynthesis‐guided procedures (available towards the end of the trial) were performed using a vertical add‐on device (Selenia Dimensions, Hologic, Bedford, MA, USA). Proceduralists were classified as either Junior (Radiology Registrar or Breast Radiology Fellow) or Senior (a Consultant Breast Radiologist).
Following PLL, two‐view mammography (consisting of a craniocaudal (CC) and either a lateromedial (LM) or mediolateral oblique (MLO) projection) of the affected breast was performed to assess the position of the localising device in relation to the lesion or marker clip. In the absence of a mammographically visible residual lesion, an accurately sited marker clip (i.e. clip ≤10 mm of lesion site) was used as the lesion surrogate. The choice of LM or MLO projection was based on the view that had been obtained during the initial assessment and on which the lesion had been visible during work‐up.
Two types of measurements were made to assess lesion localisation accuracy (Fig. 2), with examples of measurements in different mammographic lesion types provided (Fig. 3A–C).
Figure 2.
Examples of device‐to‐target distance (DTD) and device centre‐to‐target centre (DCTC) measurements (marked in red) performed with HW and seed.
Figure 3.
Examples of how the DTD and DCTC measurements for HW and seed were obtained for different lesion types: (A) method used for LCC. (B) method used for SDI. (C) method used for LIS. The distances measured are marked in red.
The ‘device to target distance’ (DTD) was the minimum distance between any part of the TSHW or seed and any part of the lesion or marker clip and was used to assess the number of localisation devices traversing any part of the lesion.
The ‘device centre to target centre’ (DCTC) was the distance between the centre of the TSHW/seed and the centre of the lesion/clip and was used to assess the number of localisation devices traversing the centre of the lesion.
DTD and DCTC measurements were taken for each lesion on both the MLO or LM and CC views. The largest measurement between the MLO or LM and CC views was used in the statistical analysis. All measurements were categorised as <2; ≥2 and <5 mm; ≥5 and <10; and ≥10 mm. These intervals were chosen to take into account the often small size of impalpable lesions and to correspond with the ASTRO and SSO Consensus guidelines for acceptable pathological margins. 17 , 18
Intraoperative specimen radiographs and macroscopic radiographic margins
As per standard of care, all specimens underwent an Intraoperative Specimen Radiograph (IOSR) to confirm excision of the lesion (and seed if applicable), position of the localisation device and assessment of radiographic margins.
Specimens were radiographed with the deep resection margin face down on the detector to profile the radial margins; the latter were labelled using sutures and radio‐opaque markers, according to site‐specific protocols. The smallest and largest radial margins (measured from the edge of the lesion (or marker clip) to the edge of the specimen) were recorded. Radiographic clear margins were defined as ≥5 mm. An immediate IOSR report was telephoned to the surgeon in theatre; cavity margin re‐excision was performed if indicated.
Concentricity
The degree to which a lesion was centred within the surgical specimen (‘concentricity’) 19 was used to estimate potentially unnecessary tissue excision. This variable was calculated by subtracting the size of the smallest radiographic margin (from the lesion to the edge of the specimen) from the largest margin (Fig. 4). Marker clip‐only lesions with a clip in situ were excluded from concentricity analysis.
Figure 4.
Seed and lesion type solitary mass noncalcified (SMN): Single‐head white arrows – minimal excess tissue, concentricity of 2 mm (10 mm minimum and 12 mm maximum IOSR margins); Double‐head white arrows – significant excess tissue, concentricity 32 mm (10 mm minimum and 42 mm maximum IOSR margins).
Final pathology reports were reviewed to obtain the radial margin widths. The closest margin was classified as clear (≥2 mm), close (>0 and <2 mm) or involved (0 mm, ‘tumour on ink’). 17 , 18 Individualised decisions regarding re‐excision based on lesion, patient and surgical factors were made during multidisciplinary meetings.
Statistical analysis
A lesion‐level analysis was performed. The number of lesions localised with seed and HW in each DTD and DCTC measurement category were compared and summarised using mean and standard deviation (SD), median and first‐to‐third quartiles (Q1, Q3) or counts and proportions as appropriate. Lesion size with DTD and DCTC distances in millimetres was log‐transformed and summarised with a geometric mean due to the nature of their skewed distribution (a distribution which shows asymmetry, as opposed to normal distribution which shows symmetry). A significant portion of accuracy distances was 0, requiring the addition of an arbitrary amount (1 mm) to all distances in order to retain the whole sample in calculating the geometric mean.
Analyses were adjusted for multiple lesions from within the same patient with robust standard error estimation (a method by which standard errors of parameter estimates in modelling are computed) wherever possible. DTD and DCTC measurements were modelled separately using a negative binomial regression model to allow for overdispersion; the maximum of the two views was modelled. An interaction term for PLL method and guidance modality was tested to allow for PPL comparisons within each guidance modality separately; the seniority of the proceduralist was also tested as a potential confounder. Statistical analysis was performed using Stata v.16 20 and statistical significance was set at a P‐value of <0.05.
Results
Patients, lesions and proceduralists
After exclusions, 384 patients with 390 lesions were reviewed: 190 lesions in the ROLLIS and 200 in the HWL group (Fig. 5). Bilateral lesions were present in six patients, three patients had HWL and two had ROLLIS. The remaining patient had asynchronous bilateral lesions, the first was localised with ROLLIS and subsequent cancer with HWL.
Figure 5.
Study flow diagram.
Preoperative chemotherapy was undertaken in 11 patients (11 lesions): 5 in the ROLLIS and 6 in the HWL group. Multiple attempts at localisation were required for 18 lesions: 8 within the ROLLIS and 10 within the HWL groups.
There were no identifiable differences in lesion size, mammographic lesion type or guidance modality between the two intervention groups (Table 1). Juniors inserted a higher proportion of HW than seeds (25.5% compared with 11.2%, respectively), however, on testing for the proceduralists' seniority, no statistically significant association with DTD and DCTC measurements (P‐value = 0.969, P‐value = 0.570, respectively) was found.
Table 1.
Lesion characteristics, localisation type and proceduralist data.
| ROLLIS n = 190 (%) | HWL n = 200 (%) | |
|---|---|---|
| Breast side | ||
| Right | 81 (42.6) | 101 (50.5) |
| Left | 109 (57.4) | 99 (49.5) |
| Mean lesion size (mm) | 10.8 | 10.6 |
| Mammographic types | ||
| LIS | 24 (12.6) | 21 (10.5) |
| SDI | 9 (4.7) | 15 (7.5) |
| SMN | 28 (14.7) | 43 (21.5) |
| SMC | 11 (5.8) | 10 (5) |
| SOP | 63 (33.2) | 56 (28) |
| LCC | 51 (26.9) | 47 (23.5) |
| WCA | 1 (0.5) | 2 (1) |
| Marker clip only | 3 (1.6) | 6 (3) |
| Guidance modality | ||
| Ultrasound | 130 (68.4) | 134 (67) |
| Mammography | ||
| Stereotactic | 56 (29.5) | 61 (30.5) |
| Tomosynthesis | 4 (2.1) | 5 (2.5) |
| Proceduralist seniority | ||
| Senior | 169 (88.9) | 149 (74.5) |
| Junior | 21 (11.1) | 51 (25.5) |
LCC, Localised Cluster of Calcifications; LIS, Localised Increased Stroma; SDI, Stromal Distortion; SMC, Solitary Mass Calcified; SMN, Solitary Mass Noncalcified; SOP, Stellate Opacity; WCA, Widespread Calcifications.
The DTD and DCTC measurements used to assess lesion localisation accuracy are shown in Information Table S1.
Influence of guidance modality on precision of lesion localisation
Localisation modality proved to be a significant confounder in its interaction with PLL method (P < 0.001) and so we report the PLL method comparison (HW vs. seed) for each guidance modality separately (Table S1). Accuracy was found to be similar across proceduralist seniorities while conditioning on guidance modality.
For ultrasound‐guided procedures, the DTD for seeds was on average 77.1% smaller than for HW (95% CI: 59.5%–87.1%, P‐value < 0.001) and the DCTC for seeds was on average 60.6% less than that for HW (95% CI: 53.7%–66.5%, P‐value < 0.001).
For stereotactically guided procedures, there was no difference in DTD between seeds and HWs (P‐value 0.861). The DCTC for seeds was on average 41.6% smaller than for HW (95% CI: 19.5%–57.6%, P‐value = 0.001).
Lesion localisation using tomosynthesis was used in only nine cases (five with hook wire guidance and four with ROLLIS) (as shown in Table 1). While imaging modality is a potential confounder, the statistical analysis used separate estimates for differences between HW and seed for each modality in assessing DTD and DCTC. This means that the tomosynthesis group does not impact the analysis performed on the stereotactic and the ultrasound groups.
The proportion of lesions in each DTD and DCTC measurement category according to localisation device is shown in a traffic‐light diagram (Fig. 6) to facilitate comparison of the degree of precision of device placement.
Figure 6.
Traffic‐light diagram demonstrating DTD compared with DCTC measurements.
IOSR findings
Lesion concentricity and the number of lesions that underwent intraoperative cavity margin re‐excision were similar for both localisation methods (Table 2), with the rates of pathological margin involvement and subsequent re‐excision also shown in Table 2.
Table 2.
Intraoperative findings and postoperative findings.
| Intraoperative findings | ROLLIS | HWL |
|---|---|---|
| Mean concentricity (mm) | 17.2 | 17.7 |
| Intraoperative cavity margin re‐excision [n (%)] | 123 (65) | 126 (63) |
| Postoperative findings | ||
| Radial margin [n (%)] | ||
| Involved (0 mm) | 9 (5) | 12 (6) |
| Close (<2 mm) | 16 (8) | 19 (10) |
| Clear (≥2 mm) | 165 (87) | 168 (84) |
| Surgical outcome [n (%)] | ||
| One operation | 168 (88.4) | 165 (82.5) |
| Two or more operations | 22 (11.6) | 35 (17.5) |
Re‐excision rates and IOSR findings
There were no cases of failed lesion excision. The re‐excision rate with ROLLIS was 11.6% compared with 17.5% with HWL, however, this did not reach statistical significance.
The rates of intraoperative margin re‐excision were similar in both groups, and no differences in specimen concentricity according to localisation device were found. In the ROLLIS group, 16 of 22 lesions (72.7%) that required a second operation were noted to have had clear margins on the IOSR (one lesion was mammographically occult on preoperative imaging) and in the HW group, this was the case for 20 of the 35 lesions (57.1%) (two lesions were mammographically occult).
Discussion
This study has shown that the degree of precision of PLL is higher with seed than with HW.
The definitions used for an acceptable device‐to‐lesion distance for optimal preoperative lesion localisation vary. European Guidelines state that the HW should lie within 10 mm of the lesion in at least 95% of cases. 21 A subsequent paper by Mucci et al. suggested a more discriminatory benchmark of 90% of wires traversing the lesion in two planes, 22 while Madeley et al. proposed a device‐to‐target distance of <5 mm. 23
In this study, 96.8% of seeds versus 90.5% of HW met the European standard (<10 mm) 21 and 90.5% of ROLLIS compared with 79% of HWL met the more stringent (<5 mm) standard suggested by Madeley et al. 23 However, we were unable to meet the ambitious target set by Mucci et al. as only 70% of seeds and 60.5% of HW traversed the lesion in two planes. 22
The process of achieving precise HW placement in relation to a target lesion/marker clip is considered to be more technically challenging than that of placing a seed, and studies comparing radiologists' ease of PLL using iodine seeds and wires support this assertion. 10 During HWL, the radiologist usually aims to place the hook portion of the wire just distal to the lesion, ensuring that the barb gains purchase within the tissue, minimising the risk of wire movement between localisation and surgery. In addition, ideally, the TSHW should be placed within the lesion to provide the surgeon with a more specific reference to the position of the lesion along the length of the wire. Seed placement on the other hand only requires the radiologist to ensure the seed is deployed within the lesion, which mimics the process of marker clip insertion after a biopsy.
The use of ultrasound rather than mammographic guidance for PLL was associated with more precise placement of both seed and wire. The superiority of US guidance for HW insertion has been confirmed by others, 24 and is unsurprising given that this provides continuous three‐dimensional feedback and allows positioning of the localisation device to be optimally adjusted in real time. Even with real‐time guidance, however, precise placement of a HW compared with a seed can be more technically challenging, for reasons previously discussed.
A further factor that may account for higher accuracy of localisation procedures performed with ultrasound rather than mammographic (stereotactic and tomosynthesis) guidance is that the latter requires the breast to be compressed. Following HW or seed deployment, release of compression is associated with breast re‐expansion and movement of the HW or seed in the plane of compression can occur. 25
The plane in which the localising device was separated from the lesion (or clip) was not specifically evaluated in this study, however, previous studies of marker clip displacement have shown that this occurs predominantly in the plane of insertion. Displacement in other planes can also occur (due to factors including the presence of a haematoma and surrounding low‐density fatty tissue), but is much less common. 26 , 27 , 28 , 29 It should also be noted that any clip/localiser placed at a separate time from the biopsy is likely to have a lower chance of migration – no biopsy tract and no haematoma.
The degree of precision of seed localisation with stereotactic guidance (based on the DCTC measurements) was higher for seed than wire. We hypothesise that this is because the ‘accordion effect’ is more likely to occur following insertion of a HW than a seed. In HWL (using a modified Kopans wire), the hook is placed distal to the lesion so that the TSHW is located within the lesion itself. Upon deployment, the hook opens and the tip of the wire is anchored in the tissue. As breast compression is released, the position of the lesion in the plane of compression may move, whereas the hook remains embedded at the depth it was placed. The position of the TSHW in relation to the lesion/clip can therefore change as the overlying tissues re‐expand. We hypothesise that this is less likely to occur with ROLLIS, as the radiologist aims to place the seed in its entirety within the lesion, and its position in relation to the lesion is less likely to be affected by re‐expansion of the surrounding tissues.
Despite showing that PLL using seed is significantly more precise than HW, we were unable to find a statistically significant difference in rates of pathologically inadequate margins or re‐excision in our cohort. This may be related to the relatively low rates of involved margins and re‐excision in the cohort and the relatively small sample size. In the complete ROLLIS study (659 participants), 10 a statistically significant reduction in re‐excision rate using seed compared with HW was observed.
IOSR has well‐known limitations in only demonstrating macroscopic and radiographically visible disease, 30 , 31 and the association between the need for re‐excision and the presence of more extensive malignant disease than anticipated with use of mammography and ultrasound has been previously documented. 3 , 32 Concentricity was assessed using the IOSR images as an indicator of the amount of tissue excised. 19 The amount of tissue excised has been shown to correspond with postoperative cosmesis and patient satisfaction, 33 with our results showing a similar volume of excised tissue between HW and seed‐localised lesions.
Study limitations
This study has compared the localisation of just one type of nonwire localisation device with that of HW. Many alternative seed‐like localisation devices are now available, including radar reflectors (Savi Scout), magnetic seeds (Magseed, Molli), radiofrequency ID tags (LOCalizer) and electromagnetic navigation (Smart Clip). While these devices are not subject to the radiation regulations or tracking requirements associated with ROLLIS, they do have other disadvantages including limited depth resolution, artefacts on MRI and considerably higher costs. 34
The observed tendency for a greater proportion of seeds to have been inserted by senior proceduralists was a recognised source of potential bias in this study. However, this has been accounted for in the statistical analysis, and no significant difference in either the DTD and DCTC measurements (P‐value = 0.969, P‐value = 0.570, respectively) between the junior and senior proceduralists was found.
Breast lesions can be inherently difficult to measure due to differences in morphology and shape, however, the use of a standardised measurement technique performed by a single investigator is considered to have given a consistent approach across the study.
Finally, the nature of this study meant it was impossible to blind the observer to the type of localisation device used, which may have resulted in observer bias.
Conclusion
PLL with insertion of seed rather than HW is more precise, with seeds positioned closer to the lesion, irrespective of proceduralist seniority and particularly when ultrasound guidance is used.
Funding Information
The State Health Research Advisory Committee, The Royal Perth Hospital Medical Research Foundation, The Cancer Council of Western Australia, The St John of God Foundation and The Ladybird Foundation.
Conflict of Interest
The author declares no conflict of interest.
Ethics Approval Statement
This study was approved by The Royal Perth Hospital Human Research Ethics Committee.
Supporting information
Table S1. Device‐to‐Target Distance (DTD) and Device Centre‐to‐Target Centre (DCTC) Measurement Frequencies.
Table S2. Geometric Means and Confidence Intervals by Guidance Modality and Seniority of Proceduralist.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1. Device‐to‐Target Distance (DTD) and Device Centre‐to‐Target Centre (DCTC) Measurement Frequencies.
Table S2. Geometric Means and Confidence Intervals by Guidance Modality and Seniority of Proceduralist.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.