A comparison of stereotactic and tomosynthesis‐guided localisation of impalpable breast lesions

Abstract

Introduction Impalpable breast cancers require precise pre‐operative lesion localisation to minimise re‐excision rates. Conventional techniques include hookwire insertion using stereotactic guidance. Newer techniques include the use of tomosynthesis guidance and the use of iodine‐125 seeds. This study compares the accuracy of lesion localisation with hookwire or seed insertion using prone stereotactic or upright tomosynthesis guidance. Methods This registered quality improvement activity did not require formal ethics approval. The post‐localisation images for 116 lesions were reviewed. The distance from the lesion or breast biopsy marker to the hookwire or seed was measured on post‐insertion mammograms. The relative placement accuracy of hookwire or seed using prone stereotactic or upright tomosynthesis guidance was compared. A lesion to seed or wire distance > 10 mm was considered technically unsatisfactory. Results 94.8% of the seeds and wires inserted via prone stereotactic guidance were accurately placed, compared with 89.6% of those inserted via upright tomosynthesis. There were twice as many technically unsatisfactory insertions under upright tomosynthesis guidance. The majority of the unsatisfactory insertions using upright tomosynthesis occurred when the lesion was at or below the level of the nipple and the insertion was performed craniocaudally. Conclusion The degree of accuracy of pre‐operative localisation of impalpable breast lesions is significantly higher with the use of prone stereotactic rather than upright tomosynthesis guidance. This was most evident with the placement of I‐125 seeds, and in cases where the target lesion was located below the level of the nipple.

Localisation accuracy with iodine‐125 seed versus wire guidance for breast cancer surgery

“…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.…”

“…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.…”

“…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 …”

Positive Predictive Value for the Malignancy of Mammographic Abnormalities Based on the Presence of an Ultrasound Correlate

“…Some surgeons perform blind wide lumpectomy with the aid of intraoperative fluoroscopy. Tomosynthesis does not usually improve the accuracy of marker placement [12].…”

Image-Guided Localization Techniques for Surgical Excision of Non-Palpable Breast Lesions: An Overview of Current Literature and Our Experience with Preoperative Skin Tattoo

“…In case of bigger lesions, such as extensive microcalcifications, or multifocal disease, multiple lead markers can be employed to determine lesion margins. A second stereotactic pair of images is acquired to confirm the correct localization, and in case of inaccurate positioning, the lead markers can be repositioned more accurately and confirmed by a further mammogram [ 67 ] ( Figure 5 ). At the end of the procedure the lead markers are removed, and the skin tattoo is drawn in their place.…”