Intraoperative ultrasound is an effective and preferable technique to localize non-palpable breast tumors

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Abstract

Introduction

Non-palpable breast tumors represent an increasing management problem in modern Breast Units. Therefore, a simple and accurate procedure to localize these lesions is needed. To date, the most commonly used technique is wire localization, but there are some disadvantages.

Methods

We conducted a prospective study on patients with malignant or benign non-palpable breast tumors who were surgically treated and underwent intraoperative ultrasound (IOUS) from May 2006 to June 2007. Margins of excision were inked and specifically assessed by the pathologist, and were considered positive if ≤1 mm.

Results

There were 77 patients (60 malignant and 17 benign lesions), with a median age of 54 years (36–87), and a median diameter of 9 mm (4–17). All lesions were correctly identified and localized by IOUS, and free margins of excision were obtained in 75/77 cases (97%). Only two patients required a re-excision, one for multifocal disease and one for margins of excision of 1 mm. In the remaining cases, the median distance from the tumor to the closest margins of excision, with exclusion of the posterior (fascial) and anterior (skin) margins, was 1.3 cm (0.3–3.2).

Conclusions

IOUS is a simple and accurate procedure that can be used to identify most non-palpable breast tumors, and has many advantages over the more commonly used wire-localization technique.

Introduction

Breast cancer screening has dramatically increased the diagnosis of suspicious, non-palpable lesions of the breast.1

Screening mammography can reduce mortality by 20% in women with breast cancer,2 and early diagnosis of small, non-palpable tumors is associated with both a lower stage of disease and a decreased incidence of lymph node involvement, compared with the palpable counterpart. This maximises breast conservation, allows minimally invasive surgery on the sentinel lymph node, and enhances acceptability and quality of life of patients with this disease.3

To date, wire localization (WL), either under ultrasound or stereotaxic guidance, has been the most common technique used for preoperative localization of these tumors. However, WL has some disadvantages such as pain and discomfort in some patients, and occasionally carries risks of complications including dislodgement of the wire, intraoperative wire transaction, retention of wire fragments, thermal injury with the use of cautery, hematoma and even syncope. The procedure is performed in most institutions as an additional step outside the operating room, with further organization and scheduling problems.

Therefore, a procedure with the same accuracy, a higher rate of free margins and less discomfort for the patient would seem preferable.

Intraoperative ultrasound localization (IOUS) of non-palpable breast lesions has been first described more than 10 years ago, and preliminary reports have been favourable.4, 5, 6

We report, herein, a prospective study and describe our experience with IOUS.

Section snippets

Patients

Consecutive patients with both benign or malignant non-palpable breast lesions, who underwent IUL, were prospectively studied in our Institution from May 2006 to June 2007.

All patients who had sonographically visible lesions, not necessarily noted by mammography, were included.

Patients with benign lesions were considered for surgery because they had growing breast lesions, because results of fine-needle aspiration biopsy were inconclusive, or because of patients' preference.

Intraoperative ultrasound technique

Esaote Technos MPX

Patients' characteristics

Seventy-seven patients were operated during the period of the study. The median age of the patients was 54 years (36–87), while the median diameter of the lesions was 9 mm (4–17). There were 60 malignant and 17 benign lesions (Table 1). Among the former group, there were 54 invasive ductal, 4 invasive lobular, and 2 pure ductal in situ (DCIS) cancers. All these patients underwent sentinel lymph node biopsy after intradermal injection of 0.6 mCi of Tc-99 filtered nanocolloid (Nanocoll – Nycomed

Discussion

In our experience, IOUS was an excellent tool to identify non-palpable breast lesions, to remove them with satisfactorily margins in almost all cases, while the re-excision rate was only 3%. This is a key factor to minimize both an undesirable return to the operating room and an associated decrease in the cosmetic result in the case of breast conservation.7 Furthermore, patients with breast cancer removed with clear margins at the first excision seem to have a decreased risk of local recurrence

Conflict of interest

There are no conflicts of interest to be reported by all authors of this manuscript. All authors contributed significantly to this paper.

Acknowledgements

This study was supported by a grant from the Prometeus Foundation, ONLUS, for the development of training and cancer research.

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