Radioactive Seed Localization Breast Biopsy and Lumpectomy: Can Specimen Radiographs Be Eliminated?

Background: Wire localization (WL) is the current standard for surgical diagnosis of nonpalpable breast lesions. Many disadvantages inherent to WL are solved with radioactive seed localization (RSL). This trial investigated the ability of RSL to reduce the need for specimen radiographs and operating room delays associated with WL.Methods: A total of 134 women were entered onto an institutional review board–approved study. RSL was performed by placing a titanium seed containing .29 to 20 mCi of iodine-125 to within 1 cm of the suggestive breast lesion. The surgeon used a handheld gamma detector to locate and excise the iodine-125 seed and the lesion.Results: Specimen radiographs were eliminated in 98 (79%) of 124 patients. Surgical seed retrieval was 100% in 124 patients. No seed migration occurred after correct radiographical placement. A total of 26 (21%) of 124 patients required a specimen radiograph; 22 (85%) of these 26 were performed for microcalcifications.Conclusions: After surgical removal, RSL can eliminate specimen radiographs when the radiologist accurately places the seed and the pathologist grossly identifies the lesion. If small microcalcifications are noted before surgery, then specimen radiographs may be necessary. RSL reduced requirements for specimen radiographs, decreased OR time, improved incision placement, and improved resections to clear margins.     

A multi-site validation trial of radioactive seed localization as an alternative to wire localization

Abstract:  This study aims to validate radioactive seed localization (RSL) as an alternative to wire localization (WL) in the operative excision of nonpalpable breast lesions. Eligible patients were recruited sequentially. A sample of 99 patients treated with WL was compared to the next 383 patients treated with RSL. Margins were considered "negative" if ≥2 mm from in-situ and invasive disease. Pain and convenience scores were recorded on a 10-point scale. Patient characteristics and histology were similar. The lesion and localization device were retrieved in all patients. Margins of the first specimen were negative in 73% of RSL patients, versus 54% of WL patients (p < 0.001). A second operation was required in 8% of RSL patients to achieve negative margins, versus 25% of WL patients (p < 0.001). Pain scores were not statistically different. However, the RSL group had higher convenience scores (p = 0.015). RSL is safe, effective, and compared to WL, reduces the rates of intraoperative re-excision and reoperation for positive margins by 68%. Patient satisfaction is improved with RSL. We strongly favor RSL over WL.     

Radioactive seed vs wire localization for nonpalpable breast lesions: A single institution review

The aim of this study was to compare wire localization (WL) and radioactive seed localization (RSL) for nonpalpable breast lesions with regard to margin status, re‐excision rate, procedure length, and complications related to localization. A retrospective review of the electronic health records at a single institution was performed. There was no difference in re‐excision rate, margin positivity, volume of tissue removed, and complication rate for RSL vs WL (P = 0.9934, P = 0.9934, P = 0.6645, and P = 0.4716 respectively). The only difference was a longer OR time, RSL = 104.408 minutes vs WL = 82.386 minutes. (P = 0.0163). RSL and WL are comparable techniques for localization of nonpalpable breast lesions.     

Radioactive seed localization of nonpalpable breast lesions is better than wire localization

BACKGROUND: The current study sought to validate radioactive seed localization (RSL) as an alternative to wire localization (WL) to facilitate the operative excision of nonpalpable breast lesions. METHODS: One hundred consecutive patients underwent preoperative WL and the next 100 RSL. Margins were considered negative if > or =2 mm from in situ and invasive disease. RESULTS: RSL resulted in 100% retrieval of the seeds and lesions. Sixty-eight percent of patients underwent RSL at least 1 day before surgery. RSL resulted in a 35% relative improvement in the rate of negative margins in the first specimen (P = 0.01) and a 62% relative improvement in the rate of reoperation for positive margins (P = 0.01). The sentinel lymph node (SLN) identification rate was 100% in both groups. CONCLUSIONS: RSL is effective and safe, and this procedure significantly improved the rate of negative margins in the first specimen and the rate of reoperation for positive margins compared to WL. We highly favor RSL over WL.     

Current status of radioactive seed for localization of non palpable breast lesions

Background

Wire-localized breast biopsy (WLBB) remains the standard method for the surgical excision of nonpalpable breast lesions. Because of many of its shortcomings, most important a high microscopic positive margin rate, alternative approaches have been described, including radioactive seed localization (RSL). This review highlights the literature regarding RSL, including safety, the ease of the procedure, billing, and oncologic outcomes.

Methods

Medline and PubMed were searched using the terms “radioactive seed” and “breast.” All peer-reviewed studies were included in this review.

Conclusions

RSL is a promising approach for the resection of nonpalpable breast lesions. It is a reliable and safe alternative to WLBB. RSL is at least equivalent compared with WLBB in terms of the ease of the procedure, removing the target lesion, the volume of breast tissue excised, obtaining negative margins, avoiding a second operative intervention, and allowing for simultaneous axillary staging.     

A Multicentered, Randomized, Controlled Trial Comparing Radioguided Seed Localization to Standard Wire Localization for Nonpalpable, Invasive and in situ Breast Carcinomas

Background

Studies suggest radioguided seed localization (RSL) yields fewer positive margins than wire-guided localization (WL). The goal of this study is to determine whether RSL is superior to WL.

Methods

Women with confirmed invasive or ductal carcinoma in situ (DCIS) undergoing localization and breast conserving surgery were enrolled. Outcomes measured include positive margin and reoperation rates, specimen weight, operative and localization times, and surgeon and radiologist ranking of procedural difficulty.

Results

Randomization was centralized, concealed, and stratified by surgeon with 153 patients in the WL group and 152 in RSL group. Localizations were performed using either ultrasound (70%) or mammographic guidance (30%). Pathology was either DCIS (18%) or invasive carcinoma (82%). Procedures were performed at 3 sites, by 7 surgeons. Only difference found for patient and tumor characteristics was more multifocal disease in RSL group. Using intention-to-treat analysis, there were no differences in positive margins rates for RSL (10.5%) and WL (11.8%), (P = .99) or for positive or close margins (<1 mm) (RSL 19% and WL 22%; P = .61). Mean operative time (minutes) was shorter for RSL (RSL 19.4 vs WL 22.2; P < .001). Specimen volume, weight, reoperation and localization times were similar. Surgeons ranked the seed technique as easier (P = .008), while radiologists ranked them similarly. Patient’s pain rankings during wire localization were higher (P = .038).

Conclusions

In contrast to other trials positive margin and reoperation rates were similar for RSL and WL. However, for RSL operative times were shorter, and the technique was preferred by surgeons, making it an acceptable method for localization.     

Radioactive Seed Localization Compared to Wire Localization in Breast-Conserving Surgery: Initial 6-Month Experience

Background

Wire localization (WL) of nonpalpable breast cancers on the day of surgery is uncomfortable for patients and impacts operating room efficiency. Radioactive seed localization (RSL) before the day of surgery avoids these disadvantages. In this study we compare outcomes of our initial 6-month experience with RSL to those with WL in the preceding 6 months.

Methods

Lumpectomies for invasive or intraductal cancers localized with a single ¹²⁵iodine seed (January–June 2012) were compared with those using 1 wire (July–December 2011). Surgeons and radiologists did not change. Positive and close margins were defined as tumor on ink and tumor ≤1 mm from ink, respectively. Demographic and clinical characteristics and outcomes were compared between RSL and WL patients.

Results

There were 431 RSL and 256 WL lumpectomies performed. Clinicopathologic characteristics did not differ between groups. Most seeds (90 %) were placed before the day of surgery. Positive margins were present in 7.7 % of RSL versus 5.5 % of WL patients, and 16.9 % of RSL versus 19.9 % of WL had close margins (p = 0.38). The median operative time was longer for lumpectomy and sentinel lymph node biopsy (SLNB) in the RSL group (55 vs. 48 min, p < 0.0001). There was no significant difference in the volume of tissue excised between groups.

Conclusions

In the first 6 months of RSL, operative scheduling was simplified, while rates of positive and close margins were similar to those seen after many years of experience with WL. Operative time was slightly longer for RSL lumpectomy and SLNB; we anticipate this will decrease with experience.     

A Randomized Prospective Comparison of Patient‐Assessed Satisfaction and Clinical Outcomes with Radioactive Seed Localization versus Wire Localization

Radioactive seed localization (RSL) has emerged as an alternative to wire localization (WL) in patients with nonpalpable breast cancer. Few studies have prospectively evaluated patient satisfaction and outcomes with RSL. We report the results of a randomized trial comparing RSL to WL in our community hospital. We prospectively enrolled 135 patients with nonpalpable breast cancer between 2011 and 2014. Patients were randomized to RSL or WL. Patients rated the pain and the convenience of the localization on a 5‐point Likert scale. Characteristics and outcomes were compared between groups. Of 135 patients enrolled, 10 were excluded (benign pathology, palpable cancer, mastectomy, and previous ipsilateral cancer) resulting in 125 patients. Seventy patients (56%) were randomized to RSL and 55 (44%) to WL. Fewer patients in the RSL group reported moderate to severe pain during the localization procedure compared to the WL group (12% versus 26%, respectively, p = 0.058). The overall convenience of the procedure was rated as very good to excellent in 85% of RSL patients compared to 44% of WL patients (p < 0.0001). There was no difference between the volume of the main specimen (p = 0.67), volume of the first surgery (p = 0.67), or rate of positive margins (p = 0.53) between groups. RSL resulted in less severe pain and higher convenience compared to WL, with comparable excision volume and positive margin rates. High patient satisfaction with RSL provides another incentive for surgeons to strongly consider RSL as an alternative to WL.     

Radioactive Seed Localization for Nonpalpable Breast Lesions: Review of 1,000 Consecutive Procedures at a Single Institution

Introduction  

Radioactive seed localization (RSL) is an alternative to wire localization for nonpalpable breast lesions, with reported lower rates of positive surgical margins.     

Radiocolloid in Combination with Methylene Dye Localization, Rather Than Wire Localization, is a Preferred Procedure for Excisional Biopsy of Nonpalpable Breast Lesions

Background

Wire localization (WL) is traditionally performed before excisional biopsy for patients with nonpalpable breast lesions, but it has several disadvantages. Our current study examines whether the method of radiocolloid combined with methylene dye localization (RCML) has an advantage over WL.

Materials and Methods

From August 2006 to May 2009, 157 patients with nonpalpable breast lesions classified as BI-RADS category 5 were enrolled in our study. Of the 157 patients, 78 were assigned to WL and 79 to RCML. The status of surgical margins, weight of specimens, length of incisions, and duration of operation were compared between these two groups.

Results

All patients were diagnosed after first excisional biopsy. The patients with malignancy accounted for 55.1% in WL group, and 53.2% in RCML group. For malignant lesions, fewer patients undergoing RCML had close or involved surgical margins than did those who had WL (19.0% vs. 39.5%, P = .038). The mean weight of specimen was 45.2 g in WL group and 39.0 g in RCML group (P < .001). The mean length of incision was 44.8 mm in WL group and 36.3 mm in RCML group (P < .001). The mean time of operation was 16.3 min for WL and 14.7 min for RCML (P = .001).

Conclusions

RCML provides precise identification of the site of the nonpalpable lesion and a visible marker to the lesion for surgeons and allows rapid, easy, and accurate excision of nonpalpable breast lesions. Therefore, RCML is a promising alternative to WL.     

Localizing High-Risk Lesions for Excisional Breast Biopsy: A Comparison Between Radioactive Seed Localization and Wire Localization

Background

Improved resolution and utilization of screening breast imaging has increased identification of nonpalpable high-risk lesions (HRL) and subsequent excisional breast biopsies (EBBs). Wire localization (WL), used most commonly for EBBs, may have shortcomings, including wire displacement, patient discomfort, limitations with incision planning and scheduling logistics. Radioactive seed localization (RSL) may overcome these drawbacks. The purpose of this study was to compare WL and RSL for EBBs for HRLs.

Methods

All single-site EBBs for HRL performed by four breast surgeons were retrospectively reviewed over two consecutive 1-year periods. Patients with cancer on percutaneous core biopsy (CB) were excluded. Clinicopathologic information, operative time, targeted lesion retrieval rate, and upstage rate were collected.

Results

A total of 324 EBBs for HRL were performed: 196 using WL and 128 using RSL. CB pathology was atypical hyperplasia in 56 % of WLs and 62 % of RSLs. The remaining pathologies were radial scar, papilloma, atypical papilloma or lobular carcinoma in situ. Mean age was 54 years. OR time was 27 ± 8 min for WL and 27 ± 7 min for RSL (p = 0.9). Upstage rate was 6 and 5 % for WLs and RSLs, respectively (p = 0.5). Targeted lesions were retrieved in 98 % of WL and 99 % of RSL (p = 0.5). SV was 37.2 ± 32.8 cm³ and 25.7 ± 22.3 cm³ for WL and RSL, respectively (p = 0.001).

Conclusions

RSL is comparable to WL for EBB of HRLs with similar OR times and upstage rates. SV is significantly decreased with RSL and may translate into improved cosmetic outcomes without sacrificing the diagnostic accuracy of the EBB.     

Radioactive iodine-125 seed localization as an aid in reoperative neck surgery

BackgroundScarring and disrupted tissue planes add to already-complex neck anatomy and make localization of nonpalpable pathology difficult in cervical endocrine reoperations. We describe the use of radioactive iodine-125 seed localization (RSL) in 6 patients with metastatic papillary thyroid carcinoma (PTC) and 2 with recurrent hyperparathyroidism.MethodsEight patients had 2-D ultrasound-guided RSL of the target lesion, 0–3 days preoperatively. Intraoperative gamma probe (Neoprobe) was used to plan incision placement and localize the implanted seed. Recorded operative variables included: number of lymph nodes (LNs) harvested, estimated blood loss (EBL), operative time, length of stay (LOS) and RSL and operative complications.ResultsAll patients had successful resection of the targeted area and removal of the radioactive seed. There was no seed migration. Two complications occurred in the thyroid group.ConclusionRadioactive iodine 125 seeds facilitate successful localization of endocrine pathology during reoperative cervical procedures.     

Indocyanine green fluorescence‐guided lumpectomy of nonpalpable breast cancer versus wire‐guided excision: A randomized clinical trial

The use of wire localization (WL) for excisions of nonpalpable breast cancer (NBC) has several disadvantages. The purpose of this study was to evaluate the use of indocyanine green‐guided nonpalpable breast cancer lesion localization (INBCL) and to compare it with WL. A total of 62 patients with a preoperative histological diagnosis of NBC lesions that could be visualized with ultrasound and mammography were randomized to INBCL or WL. Patients with preoperatively diagnosed primary ductal carcinoma in situ and multifocal disease were excluded from the study. Significance was considered at P < 0.05. Of all 62 excision, 32 (51.6%) were guided by INBCL and 30 (48.4%) by WL. Both techniques resulted in 100% retrieval of the lesions. The rate of clear margins was significantly higher in the INBCL group (87.5%; 28/32) compared to the WL (63.3%, 19/30) (P = 0.026), reducing the requirement of re‐excision. When results of the excised tissue are taken into account, the mean volume of the INBCL specimen was 56 cm³ less than that of the WL group, although this was not significantly different (P = 0.058). INBCL for NBCs was more accurate than WL, because it optimized the surgeon's ability to obtain clear margins. A smaller volume of the tissue may be excised by using INBCL technique. Therefore INBCL is an attractive alternative to WL.     

The introduction of radioactive seed localisation improves the oncological outcome of image guided breast conservation surgery

IntroductionRadioactive seed localisation (RSL) has become increasingly popular for localisation of non-palpable breast tumours. This is largely due to advantages it offers in terms of practicality and convenience when compared to guide wire localisation (WL). This institute switched from using WL to RSL in September 2014. The primary aim was to assess whether this change improved the accuracy of excision with regards to inadequate margin rates and weight of excision specimens. The secondary aim was to establish whether there is a “learning curve” associated with RSL technique.MethodsRetrospective data collection was performed for 333 consecutive cases of unifocal non-palpable invasive breast cancers undergoing excision with WL or RSL. An inadequate margin was defined as tumour <1 mm from an inked radial margin. Patient demographics, tumour characteristics and clinical outcomes were compared between WL and RSL cases.Results100 WL and 233 RSL cases were included. Patient demographics and tumour characteristics were similar for both groups. Inadequate margin rates were 18% with WL and 8.6% with RSL (p = 0.013). Median specimen weights were 33.3 g with WL and 28.7 g with RSL (p = 0.014). Subdividing the RSL group into the first 100 cases performed (RSL1) and the subsequent 133 cases (RSL2), inadequate margin rates were 13.0% and 5.3% respectively (p = 0.037). Mean specimen weights were similar.ConclusionSwitching from WL to RSL results in a significant reduction in both inadequate margin rates and specimen weights. A procedure-specific learning curve is present on first implementation of RSL and following this, inadequate margin rates are further reduced.     

Adequacy of invasive and in situ breast carcinoma margins in radioactive seed and wire-guided localization lumpectomies

Image-guided preoperative localizations help surgeons to completely resect nonpalpable breast cancers. The objective of this study is to compare the adequacy of specimen margins for both invasive breast cancer (IBC) and ductal carcinoma in situ (DCIS) after radioactive seed localization (RSL) vs wire-guided localization (WGL). We retrospectively reviewed 600 cases at a single Canadian academic center from January 2014 to September 2017, comparing surgical margins, re-excisions and reoperations, localization accuracy and major complications (migration, accidental deployment, vasovagal reaction), as well as operative duration between RSL and WGL cases. IBC margins were positive in 7% of RSL and 6% of WGL cases (P = .57). Tumor size (P = .039) and association with DCIS (P = .036) predicted positive margins in invasive carcinoma. DCIS margins were positive in 6% and 8%, and close (≤2 mm) in 37% and 36% of cases (P = .45) for RSL and RSL cases respectively. The presence of extensive intraductal component predicted positive DCIS margins (P < .0001). There was no significant difference between intraoperative re-excisions (P = .54), localization accuracy (P = .34), and operation duration (P = .81). Reoperation for lumpectomies and mastectomies was marginally higher for WGL than RSL (P = .049). There were 11 (4%) WGL and no RSL complications (P = .03). Overall, positive margins for IBC, close or positive margins for DCIS, intraoperative re-excision, localization accuracy, and operation duration were similar between RSL and WGL. The reoperation rate was higher in WGL than RSL, which may reflect practice changes over time. RSL was safer than WGL with lower complication rates.     

Radioactive seed localization of breast lesions: an adequate localization method without seed migration

Preoperative localization is important to optimize the surgical treatment of breast lesions, especially in nonpalpable lesions. Radioactive seed localization (RSL) using iodine-125 is a relatively new approach. To provide accurate guidance to surgery, it is important that the seeds do not migrate after placement. The aim of this study was to assess short-term and long-term seed migration after RSL of breast lesions. In 45 patients, 48 RSL procedures were performed under ultrasound or stereotactic guidance. In the first 12 patients, the lesion was localized with two markers: an iodine-125 seed and a reference marker. In 33 patients, 36 RSL procedures were performed using a single iodine-125 seed. All patients received control mammograms after seed placement and prior to surgery. In the patients with two markers, migration was defined as the difference in the largest distance between the markers observed in the mammograms. For single-marked lesions, migration was assessed by comparing distances between anatomical landmarks in the mammograms. RSL was successful in all patients. Seeds were in-situ for 59.5 days on average (3-136 days). The detection rate during surgery was 100%. Overall, an average seed migration of 0.9 mm (standard deviation 1.0 mm) was observed. Neither differences in lesion type, nor days in situ, type of surgery or radiologic localization method were found to have impact on seed migration. RSL is an accurate preoperative localization method for breast lesions with negligible seed migration, independent of time in-situ.     

Surgeon performed continuous intraoperative ultrasound guidance decreases re-excisions and mastectomy rates in breast cancer

BackgroundIntraoperative ultrasound guided (IUG) breast conserving surgery (BCS) is being increasingly embraced by breast surgeons worldwide. We aimed to compare the efficacy of IUG-BCS for palpable and nonpalpable breast cancer with respect to margin status, re-excision rate, tissue sacrifice and cost-time analysis.MethodsIntraoperative localization protocol includes intraoperative ultrasound prior to excision to localize the lesion and guide the initial resection. The excised specimen was then examined visually and by palpation and the specimen and cavity was examined with ultrasound. Frozen sections were obtained routinely from a portion of all six faces of the resected specimen, and shaved cavity margins were sent for permanent histology.ResultsOf the 208 patients, 57.2% had nonpalpable tumors. The sensitivity of ultrasound localization was 100%. Negative margins were achieved in 92.43% of nonpalpable and 91.01% of palpable lesions at initial procedure. The involved margins were correctly identified by the surgeon via specimen sonography in 95.4% of cases. Final positive margin rate was 2.4%. Calculated resection ratio and time analysis revealed nothing significant.ConclusionIUG-BCS is an invaluable and effective modality for obtaining clear surgical margins with optimum resection volumes and reducing re-operations. Furthermore, by means of this algorithm, in case of shaving cavity margins of the tumor bed for permanent analysis, frozen section evaluation might be omitted.     

Intraoperative Ultrasound-Guided Excision of Nonpalpable Breast Lesions

In order to determine if intraoperative ultrasound (US)-guided excision is a feasible procedure, we prospectively studied 15 female patients between July 1996 and December 1998 for US-detected nonpalpable breast lesions. Intraoperative US was used by the operating surgeon to identify the lesion, guide its excision, and evaluate the specimen to document complete removal. A control group of 15 female patients with mammographically detected nonpalpable lesions was used for comparison. These patients underwent preoperative needle localization, excision of the lesions, and specimen radiographs. Age, size of the lesion, total excised tissue volume, and operative time were documented in all cases. Fifteen patients aged 20-83 years (mean 51) underwent US-guided excision, which adequately localized all lesions, and excision was successful in all patients. Specimen US documented the lesion in all cases. Lesion size ranged from 0.7 to 2 cm (mean 1.1) and the total excised tissue volume averaged 30 cc. Mean operative time was 53 minutes (range 30-75 minutes). The 15 patients of the control group ranged in age from 32 to 82 years (mean 61). Excision was successful in all cases. Lesion size ranged from 1 to 2.5 cm (average 1.5) and the average excised tissue volume was 35 cc. Mean operative time was 50 minutes (range 30-75 minutes). There were no statistically significant differences between the two groups with regard to age (p = 0.2), operative time (p = 0.5), and total excised tissue volume (p = 0.5). The size of the lesions did have a statistically significant difference (p = 0.01). There were no perioperative complications. In conclusion, US-guided excision of nonpalpable breast lesions is a feasible and effective technique. US documents results immediately, is of minimal discomfort to the patient, avoids the need for preoperative localization, allows the entire procedure to be performed in the operating room, does not require radiation, and provides the surgeon with a useful alternative in selected cases.     

Intraoperative Ultrasound Localization of Nonpalpable Breast Lesions

Background: The use of preoperative wire localization (PWL) for excision of nonpalpable breast lesions has several disadvantages. The purpose of this study was to evaluate the use of intraoperative ultrasound localization (IUL) and to compare it with PWL.Methods: Twenty-nine patients (22 with cancer) underwent IUL in a solo surgical practice over a 21-month period. They were compared to 22 patients with cancer in the same practice who underwent PWL in a similar time period. Parameters analyzed included accuracy of lesion removal, margin involvement, extent of disease-free margin, and the amount of tissue removed.Results: The targeted lesions were accurately removed 100% of the time, and disease-free margins were obtained at the first operation in 82% of patients in both groups. An equivalent amount of disease-free margin (IUL, 6.6 mm; PWL, 6.7 mm) was obtained with IUL while removing a smaller (IUL, 62.6 cm³; PWL, 81.1 cm³) mean volume of tissue.Conclusions: IUL is an accurate method of localizing most nonpalpable mass lesions identified on mammography. Equivalent margin status can be achieved while removing no more tissue than with PWL. The trauma of wire localization in an awake patient is avoided.     

Analysis of residual cancer after diagnostic breast biopsy: An argument for fine-needle aspiration cytology

Background: Diagnostic breast biopsy (DxBx) requires an effective strategy for strategy for successful treatment of breast cancer by lumpectomy or mastectomy. Clearance of margins is required to achieve local control. Methods: We reviewed 844 malignant diagnostic biopsies. The strategy was to perform DxBx on all nonpalpable lesions and fine-needle aspiration (FNA) on all palpable lesions. When FNA was equivocal, DxBx was performed. After positive DxBx, either the biopsy cavity or FNA-positive breast mass was excised, and margins were documented with touch preparation cytology analysis (TPC) and frozen section (FS) as necessary to achieve negative margins. Results: Ourside institutions referred 430 excisional biopsies. Two hundred twenty-five (52.3%) were found to have residual cancer at surgical excision. Our institution performed 414 biopsies: 169 were performed on nonpalpable lesions in which 58% had residual tumor at resection; 245 were diagnosed by FNA of palpable lesions. Residual disease was found in 12 (5%). Conclusions: Of patients who undergo DxBx, >50% have residual breast cancer. It is recommended that (a) FNA be performed on all palpable masses or DxBx of nonpalpable masses; when cancer is diagnosed, proceed to surgical excision. (b) When lumpectomy is the option, margins should be reexcised and intraoperatively evaluated with TPC and FS at the time of axillary dissection.