Implementation of Intraoperative Ultrasound Localization for Breast-Conserving Surgery in a Large, Integrated Health Care System is Feasible and Effective

Abstract

Background Intraoperative ultrasound (IUS) localization for breast cancer is a noninvasive localization technique. In 2015, an IUS program for breast-conserving surgery (BCS) was initiated in a large, integrated health care system. This study evaluated the clinical results of IUS implementation. Methods The study identified breast cancer patients with BCS from 1 January to 31 October 2015 and from 1 January to 31 October 2019. Clinicopathologic characteristics were collected, and localization types were categorized. Clinical outcomes were analyzed, including localization use, surgeon adoption of IUS, day-of-surgery intervals, and re-excision rates. Multivariate logistic regression analysis was performed to evaluate predictors of re-excision. Results The number of BCS procedures increased 23%, from 1815 procedures in 2015 to 2226 procedures in 2019. The IUS rate increased from 4% of lumpectomies (n = 79) in 2015 to 28% of lumpectomies (n = 632) in 2019 (p < 0.001). Surgeons using IUS increased from 6% (5 of 88 surgeons) in 2015 to 70% (42 of 60 surgeons) in 2019. In 2019, 76% of IUS surgeons performed at least 25% of lumpectomies with IUS. The mean time from admission to incision was shorter with IUS or seed localization than with wire localization (202 min with IUS, 201 with seed localization, 262 with wire localization in 2019; p < 0.001). The IUS re-excision rates were lower than for other localization techniques (13.6%, vs 19.6% for seed localization and 24.7% for wire localization in 2019; p = 0.006), and IUS predicted lower re-excision rates in a multivariable model (odds ratio [OR], 0.59). Conclusions In a high-volume integrated health system, IUS was adopted for BCS by a majority of surgeons. The use of IUS decreased the time from admission to incision compared with wire localization, and decreased re-excision rates compared with other localization techniques.

Ultrasound Guided Intraoperative Wire Localization Under General Anesthesia in Breast-Conserving Surgery

“…Various localization methods have obtained negative margins, including palpation-guided, radio-guided, or wire-guided. Our technique aimed to combine an intraoperative ultrasound to guide surgeon-performed wire localization and removal of the breast lesion throughout one procedure under general anesthesia [ 5 , 6 ].…”

Technique of intraoperative ultrasound‐guided excision of impalpable breast lesions

“…Several reviews and meta-analyses of reports from centres around the world have demonstrated that IOUS excision of breast cancers is associated with improved margins of excision, lower reoperation rates and smaller volumes of tissue being excised resulting in better cosmetic outcomes. [7][8][9] The technique is also favoured by patients who are able to avoid a painful preoperative procedure such as insertion of a hookwire, and as a result, patients experience less preoperative anxiety and can spend less time in the hospital environment. 2 Other advantages of the IOUS technique include the ability to assess margins of excision on table immediately following the resection, so that if required, additional tissue can be taken at the time thus avoiding the need to return to theatre for reexcision and reduced operating theatre time as on-table specimen sonography obviates the need to send the specimen to the radiology department for confirmation.…”

“…Worldwide, the practice of IOUS localisation to excise impalpable breast lesions is being increasingly utilised and recognised as an appropriate, safe and economically efficient technique . Several reviews and meta‐analyses of reports from centres around the world have demonstrated that IOUS excision of breast cancers is associated with improved margins of excision, lower reoperation rates and smaller volumes of tissue being excised resulting in better cosmetic outcomes 7–9 …”

The Beneficial Impact of Intraoperative Ultrasound on Resection Margin Status during Breast Conserving Surgery

“…The implementation of radioactive seeds needs to be one day before surgery. It is also an invasive procedure that has a high financial cost [ 9 ]. Likewise, wire localization needs to be done in a separate setting before surgery, and it is associated with increased patient anxiety [ 10 ].…”

“…IOUS of the excised surgical specimen could be used to ensure appropriate margins surrounding the whole specimen. If a deficient margin is detected the surgeon is informed and a re-excision of the infiltrated region is performed within the same primary setting [ 9 , 14 ].…”