Intra-operative ultrasound versus wire-guided localization in the surgical management of non-palpable breast cancer

Indocyanine Green Fluorescence–Guided Lumpectomy of Nonpalpable Breast Cancer Versus Ultrasound-Guided Excision

Purpose

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 ultrasound localization (US).

Methods

We retrospectively reviewed 78 consecutive patients undergoing breast-conserving surgery for nonpalpable breast cancer (NBC). Of all 78 excisions, 42 cases were guided by INBCL and 36 by US.

Results

The rate of clear margins was 90.5% (38/42) in the INBCL group compared to the 83.3% (30/36) in the US ( P = .548). A comparison of the margins at first excision for both INBCL and US, in the INBCL series, 92.9% (39/42) of cases had a margin less than 5 mm, whereas for US series, it was 72.2% (26/36) ( P = .033). When results of the excised tissue are taken into account, the mean specimen volume for INBCL was 58 cm3, but for US it was 73 cm3, with difference in mean volume being 15 cm3 ( P = .062).

Conclusions

INBCL for NBCs was more accurate than US because a smaller volume of the tissue may be excised by using the technique, without compromising margin status in nonpalpable lesions.

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.

Intraoperative Margin Management in Breast-Conserving Surgery: A Systematic Review of the Literature

BACKGROUND

Breast surgeons have a wide variety of intraoperative techniques available to help achieve low rates for positive margins of excision, with variable levels of evidence.

METHODS

A systematic review of the medical literature from 1995 to July 2016 was conducted, with 434 abstracts identified and evaluated. The analysis included 106 papers focused on intraoperative management of breast cancer margins and contained actionable data.

RESULTS

Ultrasound-guided lumpectomy for palpable tumors, as an alternative to palpation guidance, can lower positive margin rates, but the effect when used as an alternative to wire localization (WL) for nonpalpable tumors is less certain. Localization techniques such as radioactive seed localization and radioguided occult lesion localization were found potentially to lower positive margin rates as alternatives to WL depending on baseline positive margin rates. Intraoperative pathologic methods including gross histology, frozen section analysis, and imprint cytology all have the potential to lower the rates of positive margins. Cavity-shave margins and the Marginprobe device both lower rates of positive margins, with some potential for negative cosmetic effects. Specimen radiography and multiple miscellaneous techniques did not affect positive margin rates or provided too little evidence for formation of a conclusion.

CONCLUSIONS

A systematic review of the literature showed evidence that several intraoperative techniques and actions can lower the rates of positive margins. These results are presented together with graded recommendations.

Ultrasound-guided breast-conserving surgery for early-stage palpable and nonpalpable invasive breast cancer: decreased excision volume at unchanged tumor-free resection margin

Ultrasound guidance (USG) during breast-conserving surgery improves tumor-free surgical resection margins. The objective of this study was to evaluate whether USG reduces resection volumes without compromising margin status. 134 patients with palpable or nonpalpable T1-2N0-1 invasive breast cancer were treated with USG and compared with a historical reference control group (CON) consisting of palpation-guided (PAG) or wire-guided localization (WIG) breast-conserving surgery. Primary outcomes were excess resection volume and clear margin status, and secondary outcome was re-excision rate. 66 patients underwent USG. In the CON group (n = 68), PAG was performed in 24 (35 %) and WIG in 44 (64 %) patients. Median excision volume [39 (IQR 20-66) vs 56 (38-94) cm(3); p = 0.001] and median calculated resection ratio [1.7 (1.0-2.9) vs 2.8 (1.4-4.6) (p = 0.005)] were significantly smaller in the USG than in the CON group. Median minimal distance to the resection margin [4 mm (IQR 2-5 mm) vs 2 mm (1-4 mm), p = 0.004] was significantly larger. Clear resection margins were achieved in 58 of the USG patients (88 %) and in 58 of the CON patients (86 %) (p = 0.91); this was true in patients with palpable as well as nonpalpable lesions. Reexcision was needed in 6.1 and 7.2 % respectively. Relative risk for re-excision in the USG group was 0.82 (95 % CI 0.23-2.93). In patients with palpable and nonpalpable breast cancers, USG allows for lower excision volume and reduced resection of healthy breast tissue, without increased re-excision rate.