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.     

Breast‐Specific Gamma Imaging Influences Surgical Management in Patients with Breast Cancer

Breast‐specific gamma imaging (BSGI) is a physiologic breast imaging modality that provides more sensitive detection of breast lesions than mammography or ultrasound, and appears to have greater specificity than breast MRI. The purpose of this study was to evaluate how often BSGI changed surgical management in patients with breast cancer. Charts were reviewed from 218 consecutive eligible patients who had preoperative evaluation with BSGI or MRI before surgery for breast cancer from January 2008 to May 2010. Patients who were initially considered eligible for breast‐conserving therapy (BCT) were evaluated to determine how many ultimately had mastectomies. Patients who underwent mastectomy because of personal choice or ineligibility for BCT were excluded. Management was changed to mastectomy in 11.9% of those who had BSGI and 28.9% of those who had MRI. Review of pathology demonstrated that all patients who underwent mastectomies were not candidates for breast conservation. 15.4% of patients who underwent BCT based on BSGI findings required a single re‐excision due to positive surgical margins. 14.4% required mastectomy. In the MRI group, 18.8% required a single re‐excision, and 6.3% required mastectomy. Evaluation with BSGI changed management to mastectomy in a substantial proportion of patients believed to be eligible for BCT following standard imaging. BSGI is effective in evaluation of extent of disease in patients with breast cancer, and is comparable to MRI in terms of its influence on surgical management.     

Diagnostic and therapeutic aspects of fine-wire localization biopsy for impalpable breast cancer.

During the first 2 years (July 1989 to July 1991) of the Avon Breast Screening Service, fine-wire localization biopsy was indicated in 213 impalpable breast lesions. A total of 144 lesions were benign and 69 malignant. Only four of 213 lesions (1.9 per cent) were not excised at the first localization. Factors influencing reoperation in the 69 patients with malignant impalpable lesions were examined. There was a significant association (P < 0.001) between parenchymal disturbances on mammography and invasive carcinoma, and between non-invasive carcinoma and microcalcification (P < 0.001). In 31 patients the localization biopsy was the only surgical procedure. Thirty-eight patients required further surgery: 12 underwent further local excision and 26 mastectomy. Reoperation was more frequent in patients with calcification than in those with parenchymal disturbance (P < 0.001). The most frequent indications for mastectomy were inadequate excision of widespread comedo ductal carcinoma in situ or invasive ductal carcinoma combined with extensive ductal carcinoma in situ. Fine-wire localization biopsy was a combined therapeutic and diagnostic procedure in 31 of 69 women with impalpable screen-detected lesions. The majority of patients required further surgery because radiological abnormalities underestimated the extent of disease.     

Rates for mastectomy are lower in women attending a breast-screening programme

Background: Mammographic screening for breast cancer facilitates earlier recognition of lesions, thus potentially allowing for breast‐conserving surgery. Few studies have compared the final surgical outcomes of women presenting through breast screening programmes with those presenting via other sources. Are breast cancer patients presenting through BreastScreen more likely to undergo breast‐conserving surgery than those presenting from other sources? Methods: Using the Royal Perth Hospital (RPH) Multidisciplinary Breast Service Database, the final surgical outcomes were reviewed for 723 women treated for breast cancer at RPH between January 2000 and August 2002. During this period, 397 patients were referred to the RPH Multidisciplinary Breast Clinic from BreastScreen WA, and 326 were referred from other sources. Results: Of all patients undergoing surgery for breast cancer, 58% in the screen group and 36% in the non‐screen group had breast‐conserving surgery (P < 0.0001). When surgical outcomes for women in the BreastScreen target age range of 50?69 years were analysed, 59.5% in the screen group and 42.3% in the non‐screen group had breast‐conserving surgery (P < 0.001). Patient choice was second only to disease extent as a factor determining the outcome of mastectomy. In both cohorts, more than 40% of patients who underwent re‐excisional surgery for positive margins, after initial breast‐conserving surgery, had residual invasive or in situ disease present. Conclusions: At RPH, BreastScreen patients were more likely to undergo breast‐conserving surgery than those who presented from other sources. A significant proportion of women with positive margins after initial breast‐conserving surgery had residual in situ or invasive disease. Re‐excision for positive margins was thus warranted.     

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.     

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.     

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.     

Identifying Factors and Techniques to Decrease the Positive Margin Rate in Partial Mastectomies: Have We Missed the Mark?

Breast conservation therapy (BCT) has a reported incidence of positive margins ranging widely in the literature from 20% to 70%. Efforts have been made to refine standards for partial mastectomy and to predict which patients are at highest risk for incomplete excision. Most have focused on histology and demographics. We sought to further define modifiable risk factors for positive margins and residual disease. A retrospective study was conducted of 567 consecutive partial mastectomies by 21 breast and general surgeons from 2009 to 2012. Four hundred fourteen cases of neoplasm were reviewed for localization, intraoperative assessment, excision technique, rates, and results of re‐excision/mastectomy. Histologic margins were positive in 23% of patients, 25% had margins 0.1–0.9 mm, and 7% had tumor within 1–1.9 mm. Residual tumor was identified at—in 61 cases: 38% (disease at margin), 21% (0.1–0.9 mm), and 14% (1–1.9 mm). Ductal carcinoma in situ (DCIS) was present in 85% of residual disease on re‐excision and correlated to higher rates of re‐excision (p = <0.001), residual disease, and subsequent mastectomy. The use of multiple needles to localize neoplasms was associated with 2–3 times the likelihood for positive margins than when a single needle was required. The removal of additional margins at initial surgery correlated with improved rates of complete excision when DCIS was present. Patients must have careful analysis of specimen margins at the time of surgery and may benefit from additional tissue excision or routine shaving of the cavity of resection. Surgeons should conduct careful patient selection for BCT, in the context of multifocal, and multicentric disease. Patients for whom tumor localization requires bracketing may be at higher risk for positive margins and residual disease and should be counseled accordingly.     

Randomized prospective evaluation of a novel technique for biopsy or lumpectomy of nonpalpable breast lesions: radioactive seed versus wire localization

Background: Standard wire localization (WL) and excision of nonpalpable breast lesions has several shortcomings.Methods: Ninety-seven women with nonpalpable breast lesions were prospectively randomized to radioactive seed localization (RSL) or WL. For RSL, a titanium seed containing ¹²⁵I was placed at the site of the lesion by using radiographical guidance. The surgeon used a handheld gamma detector to locate and excise the seed and lesion.Results: Both techniques resulted in 100% retrieval of the lesions. Fewer RSL patients required resection of additional margins than WL patients (26% vs. 57%, respectively; P = .02). There were no significant differences in mean times for operative excision (5.4 vs. 6.1 minutes) or radiographical localization (13.9 vs. 13.2 minutes). There were also no significant differences in the subjective ease of the procedures as rated by surgeons, radiologists, and patients. All WLs were carried out on the same day as the excision, whereas RSL was performed up to 5 days before the operative procedure.Conclusions: RSL is as effective as WL for the excision of nonpalpable breast lesions and reduces the incidence of pathologically involved margins of excision. RSL also reduces scheduling conflicts and may allow elimination of intraoperative specimen mammography. RSL is an attractive alternative to WL.     

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.     

Initial experience of magnetic seed localization for impalpable breast lesion excision: First 100 cases performed in a single Irish tertiary referral centre

IntroductionWire guided localization has been widely utilized as the standard method of pre-operative localization of breast lesions. Magnetic seeds were developed to counter some of the disadvantages associated with wires. This aim of this study was to assess outcomes following the introduction of magnetic seeds at a tertiary specialist breast centre.MethodsA retrospective review of a prospective database of the first 100 patients who underwent magnetic seed (Magseed) guided breast surgery between November 2018 and November 2019. Data was collected from 17 wire guided cases completed during the trial phase for comparison. The primary outcome measures were successful excision of index lesion and retrieval of the magnetic seed. Secondary outcomes analyzed included time ready for theatre, post-operative complications and breast margin re-excision rate.ResultsOf these 100 cases, 85 patients underwent Magseed guided wide local excision for invasive or in-situ carcinoma and 15 underwent Magseed guided diagnostic excision. The primary lesion was excised, and Magseed was retrieved in all 100 cases. 54% of patients were ready to proceed as the first scheduled theatre case of the day, compared to 0% of wire-guided cases. Amongst therapeutic Magseed guided cases, the re-excision rate for margin clearance was 9.4%.ConclusionMagseed guided breast excision is a new technology that has been implemented with relative ease in our unit. We have shown that magnetic seed guided surgery reliably localizes lesions, is associated with low re-excision rates without an increase in patient morbidity or mortality and results in improvements in theatre planning and efficiency.     

Outcomes of multiple wire localization for larger breast cancers: when can mastectomy be avoided?

BACKGROUND: Mastectomy is often recommended when mammography shows a breast cancer with extensive calcifications. We wished to determine whether the use of multiple localizing wires to guide lumpectomy in this setting was associated with increased rates of breast conservation. We also wanted to identify factors that predicted a poor chance of successful lumpectomy, to avoid multiple lumpectomy attempts in a patient who would ultimately require mastectomy. STUDY DESIGN: Records of 153 women with breast cancer who underwent lumpectomy for larger lesions that required multiple wire localization and 196 controls who required only single wire localization were reviewed retrospectively. The number of localizing wires, specimen volume, largest specimen dimension, number of surgical procedures, and rates of breast conservation were scored. RESULTS: Seventy-seven percent of patients requiring multiple wire localization had successful breast conservation, compared with 90% of those needing only single wire localization. Only 28% of multiple wire patients required more than 1 excision to achieve clear margins, compared with 36% of single wire patients (p < 0.01). CONCLUSIONS: Breast conservation is possible in the great majority of breast cancer patients whose mammographic lesions require multiple localizing wires for excision. The use of multiple wires can decrease the number of procedures required to obtain clear lumpectomy margins.     

Tumour involvement of the re-excision specimen following clear local excision of breast cancer with positive margins

Background: Breast conservation surgery and subsequent radiotherapy is an acceptable method of treating breast cancer. Complete excision of the primary tumour is important to minimize the risk of local recurrence. Re‐excision is usually carried out if the initial primary tumour excision shows positive margins. However, a significant proportion of re‐excision specimens are negative for tumour. The aim of the present study was to identify factors predicting a histologically positive re‐excision specimen. Methods: The case records of all patients with invasive and in situ breast cancer referred to the William Buckland Radiotherapy Centre between January 1996 and December 2001 were reviewed. The factors evaluated were patient age, whether or not tumours were detected by screening mammography, use of hook‐wire needle localization, whether tumours were marked with orientating sutures, histopathological characteristics of the tumour and involvement of axillary nodes. Univariate analysis was performed. Results: In the study period, a total of 1128 patients were reviewed. Of these, 742 underwent breast conservation surgery. Twenty‐nine (3.9%) of the 742 had positive surgical margins and underwent re‐excision. Data were insufficient for six, leaving 23 patients eligible for the study. The number of patients entering the study was small, limiting the statistical analysis. Of these, 21 patients had invasive cancer and two patients had ductal carcinoma in situ only. Of 23 re‐excisions, 11(48%) contained residual tumour. Univariate analysis of the data revealed no significant factors that were likely to predict tumour in the re‐excision specimen. The local recurrence after re‐excision in patients with positive margins was 4.3%. Conclusion: The results suggest that it is not possible to predict which patients will have tumour in the re‐excision specimen. However, approximately 50% of re‐excision specimens showed residual cancer. Therefore it is recommended that all excisions with positive margins need further surgery.     

Does Preoperative MRI Workup Affect Mastectomy Rates and/or Re‐excision Rates in Patients with Newly Diagnosed Breast Carcinoma? A Retrospective Review

The purpose of this study is to determine whether including breast magnetic resonance imaging (MRI) in the preoperative workup of patients with known breast cancer has an impact on mastectomy and/or re‐excision rates. This is an Institutional Review Board approved HIPAA compliant retrospective study reviewing the impact MRI has on mastectomy and re‐excision rates in patients with newly diagnosed breast cancer. Our study compares two groups: (i) 154 patients who did not receive preoperative MRIs and served as a control group and (ii) 96 patients who received preoperative breast MRIs. Patient race and age between the two populations were not statistically different. The difference in mastectomy rates between the two populations was 10.7%; although not statistically different, the p value of 0.10 suggests a trend toward significance. The re‐excision rates between the two populations, however, were significantly different (p < 0.001), with women in the control group having a higher re‐excision rate than those in the study group. The difference between involved and clear margins was significant as well (p = 0.002), with patients undergoing preoperative MRI more likely to have negative margins. Preoperative breast MRI significantly decreases the likelihood of involved margins as well as the need for surgical re‐excision. Preoperative breast MRI does not result in a statistically significant difference in mastectomy rates, although further investigation is required to determine whether there is a trend towards statistical significance.     

Loco‐regional Control After Neo‐adjuvant Chemotherapy and Conservative Treatment for Locally Advanced Breast Cancer Patients

Breast‐conserving treatment (BCT) has been validated for breast cancer patients receiving adjuvant chemotherapy. Our objective was to evaluate the difference in loco‐regional recurrence (LRR) rates between BCT and mastectomy in patients receiving radiation therapy after neo‐adjuvant chemotherapy (NCT). A retrospective data base was used to identify all patients with breast cancer undergoing NCT from 2002 to 2007. Patients with initial metastatic disease were excluded from this analysis. LRR was compared between those undergoing BCT and mastectomy. Individual variables associated with LRR were evaluated. Two hundred eighty‐four patients were included, 111 (39%) underwent BCT and 173 (61%) mastectomy. Almost all patients (99%) in both groups received postoperative radiation. Pathologic complete response was seen in 37 patients, of which 28 underwent BCT (p < 0.001). Patients receiving mastectomy had more invasive lobular carcinoma (p = 0.007) and a higher American Joint Committee on Cancer (AJCC) stage (p < 0.001) at diagnosis than those with BCT. At a median follow‐up of 6.3 years, the loco‐regional control rate was 91% (95% CI: 86–94%). The 10‐year LRR rate was similar in the BCT group (9.2% [95% CI: 4.9–16.7%]) and in the mastectomy group (10.7% [95% CI: 5.9–15.2%]; p = 0.8). Ten‐year overall survival (OS) rates (63% [95% CI: 46–79%] in the BCT group; 60% [95% CI: 47–73%] in the mastectomy group, p = 0.8) were not statistically different between the two patient populations. Multivariate analysis showed that AJCC stage ≥ III (HR: 2.6; 95% CI: 1.2–5.8; p = 0.02), negative PR (HR: 6; 95% CI: 1.2–30.6, p = 0.03), and number of positive lymph nodes ≥3 (HR: 2.5; 95% CI: 1.1–5.9; p = 0.03) were independent predictors of LRR. Ten‐year OS was similar in the BCT and in the mastectomy group (p = 0.1). The rate of LRR was low and did not significantly differ between the BCT and the mastectomy group after NCT. Randomized trials assessing whether mastectomy can be safely omitted in selected breast cancer patients (nonstage III tumors or those which do not require adjuvant hormone suppression) which respond to NCT are required.     

Intraoperative inking is superior to suture marking for specimen orientation in breast cancer

Margin status is an important indicator of residual disease after breast‐conserving surgery (BCS). Intraoperatively, surgeons orient specimens to aid assessment of margins and guide re‐excision of positive margins. We performed a retrospective review of BCS cases from 2013 to 2017 to compare the two specimen orientation methods: suture marking and intraoperative inking. Patients with ductal carcinoma in situ, T1/T2 invasive cancer treated with BCS were included. Rates of positive margins and residual disease at re‐excision were evaluated. 189 patients underwent BCS; 83 had suture marking, 103 had intraoperative inking and 3 had un‐oriented specimens. The incidence of positive margins was 29% (24 patients) in the suture marked group and 20% (21 patients) in the intraoperative inked group (P = .18). Among the 45 patients with positive margins, 60% of tumors were stage T1, 76% were node negative, 36% were palpable with median tumor size of 1.5 cm. Residual disease was identified on re‐excision in 21% of the suture marked specimens and 57% of intraoperative inked specimens (P = .028). The incidence of residual cancer at re‐excision for positive margins was higher for intraoperatively inked versus suture marked specimens. This finding suggests that intraoperative inking is more effective at guiding re‐excision of positive margins.     

Combined radioguided occult lesion and sentinel node localization for breast cancer

INTRODUCTION: The incidence of non-palpable breast lesions requiring intraoperative localization has greatly increased, particularly because of the widespread use of mammographic screening. These lesions have previously been localized preoperatively using hook-wire or carbon track techniques. In the era of increasing acceptance of sentinel node biopsy (SNB) a separate procedure would be required for sentinel node localization (SNL). The present study describes an experience with ultrasound guided radionucleotide occult lesion localization (ROLL) as a reliable alternative that enables SNL synchronously. METHODS: Twenty-two patients with proven breast malignancy on core biopsy were enrolled in the present study. Preoperatively, technetium-99m was injected around the lesion under radiological guidance. A gamma-probe was then used to locate the lesion and guide its surgical removal. Complete excision was then confirmed immediately by verifying minimal residual radioactivity in the cavity wall tissue. Appropriate SNB then proceeded. RESULTS: The primary breast lesion was identified in all cases except in one, where the radiotracer was injected into the wrong site, giving a miss rate of 1/22 (4.5%). The average size of the tumour was 13 mm (range 6-22 mm) and the closest margins ranged from 0 (1 patient) to 22 mm (mean 7 mm). Two patients had inadequate margins and required further excision giving a re-excision rate of 2/21 (9.5%). SNB specimens included a median of 3.7 nodes/patient. CONCLUSION: Radionucleotide occult lesion localization/SNL is a simple, accurate and reliable method of combining localization of impalpable breast lesions with the localization required for SNB. The miss and re-excision rates compare favourably with the needle-wire systems and carbon tracking techniques. There are significant resource efficiency and time advantages.     

The effect of junior residents on surgical quality: a study of surgical outcomes in breast surgery

Background

Patients are often concerned about the participation of junior trainees in their operative treatment. Breast-conserving therapy (BCT) for nonpalpable breast lesions requires the use of localization devices and carries a significant risk for positive margins of excision. It was therefore hypothesized that the participation of junior residents in BCT operations for nonpalpable breast lesions could result in an increased rate of positive margins of excision.

Methods

Retrospective analysis of a prospective database of all patients with nonpalpable tumors who underwent BCT from August 1999 to August 2009 was performed. Patient and tumor characteristics and factors involved in resection were analyzed. A ≥2-mm margin of normal breast tissue beyond tumor was considered an adequate margin. Chi-square analysis and Student's t test were performed to determine relationships between independent variables and margin status.

Results

Of 308 BCT procedures for nonpalpable tumors, 241 (78%) were performed by attending surgeons and junior residents (group 1) and 67 (22%) by attending surgeons without resident assistance (group 2). The operations for group 1 took significantly longer than the operations for group 2 (mean, 130 vs 116 min, P = .006). Intraoperative reexcision of margins was performed for 37% of group 1 patients and 31% of group 2 patients (P = .249), and reoperation for inadequate margins was performed in 11% of group 1 patients and 13% of group 2 patients (P = .361).

Conclusions

Junior resident participation in BCT procedures was not associated with higher rates of inadequate margins of excision. Patients can be reassured that junior resident involvement in their BCT operations is safe and effective.     

Intraoperative Ultrasound Localization of Nonpalpable Breast Cancers

Background Preoperative localization of nonpalpable breast cancers requires good coordination between imaging and surgery departments, and insertion of a guide wire can be traumatic for the patient. This study was designed to evaluate the efficacy of intraoperative ultrasound localization of nonpalpable breast cancers directly by the surgeon. Methods This prospective study was conducted from June 2006 to October 2006 in 70 patients who underwent surgery for nonpalpable invasive breast cancer. Ultrasound was performed in the operating room by the surgeon with the patient in the operative position. Tumor identification, the correlation with tumor diameter on preoperative ultrasound, analysis of resection margins, and the need to perform surgical re-excision were analyzed. Results Intraoperative ultrasound identified the target in 67 (95.7%) of 70 patients. Two of the three lesions not detected by intraoperative ultrasound were ≤5 mm in diameter in patients with a body mass index of ≥25 (normal range, 19–24). The correlation with diagnostic ultrasound for tumor dimensions was satisfactory (correlation coefficient r = .80). Resection margins free of invasive lesions were obtained in 66 cases (94.3%). Three patients (4.3%) required surgical re-excision, one mastectomy due to multifocal cancer, and two lumpectomy due to positive resection margins. Conclusions Intraoperative ultrasound localization of nonpalpable breast cancers is feasible and effective, with a sensitivity of 98.3% for tumors >5 mm. It spares the patient the discomfort of a radiological and/or supplementary examination with insertion of a guide wire. It also saves time and money for hospital teams.     

Intraoperative ultrasonography‐guided surgery: An effective modality for breast conservation after neo‐adjuvant chemotherapy

Margin status is one of the significant prognostic factors for recurrence in breast‐conserving surgery (BCS). The issue that merits consideration for oncologic safety and cost‐effectiveness about the modalities to assure clear margins at initial surgical intervention remains controversial after neo‐adjuvant chemotherapy (NAC). The presented study aimed to assess the impact of intraoperative ultrasound (IOUS)‐guided surgery on accurate localization of tumor site, adequacy of excision with clear margins, and healthy tissue sacrifice in BCS after NAC. Patients who had IOUS‐guided BCS ater NAC were reviewed. No patient had preoperative localization with wire or radiotracer. Intraoperative real‐time sonographic localization, sonographic margin assessment during resection, macroscopic and sonographic examination of specimen, and cavity shavings (CS) were done as the standard procedure. No frozen assessment was performed. One hundred ninety‐four patients were included, in which 42.5% had pCR. IOUS‐guided surgery accomplished successful localization of the targeted lesions in all patients. Per protocol, all inked margins on CS specimens were reported to be tumor‐free in permanent histopathology. No re‐excision or mastectomy was required. For a setting without CS, the negative predictive value (NPV) of IOUS rate was 96%. IOUS was found to over and underestimate tumor response to NAC both in 2% of patients. IOUS‐guided surgery seems to be an efficient modality to perform adequate BCS after NAC with no additional localization method. Especially, when CS is integrated as a standard to BCS, IOUS seems to provide safe surgery for patients with no false negativity and a high rate of NPV.