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  • Review Article
  • Published:

Surgical treatment of nonpalpable primary invasive and in situ breast cancer

Nature Reviews Clinical Oncology volume 12, pages 645–663 (2015)Cite this article

Subjects

Key Points

  • A range of alternative techniques to wire-guided localization are available for localization of neoplastic lesions prior to surgical management of nonpalpable breast cancer

  • The use of radioguided localization is supported by data from meta-analyses; however, overall utilization of this technique has been poor owing to the logistical and legislative issues associated with radioisotope use

  • More than 95% of localization procedures include ultrasonography, making intraoperative ultrasonography a logical alternative, but this method requires evidence from randomized controlled trials and implementation of training programmes for surgeons

  • Techniques that use the principles of radioguided localization, but that are radioisotope free, could form the basis of future therapeutic options and warrant investigation in adequately powered clinical trials

  • Non-invasive surgery using high-intensity focused ultrasound is in its infancy, but could potentially enable real-time visualization and therapy of lesions as an outpatient procedure

Abstract

Breast cancer is the most-common cancer among women worldwide, and over one-third of all cases diagnosed annually are nonpalpable at diagnosis. The increasingly widespread implementation of breast-screening programmes, combined with the use of advanced imaging modalities, such as magnetic resonance imaging (MRI), will further increase the numbers of patients diagnosed with this disease. The current standard management for nonpalpable breast cancer is localized surgical excision combined with axillary staging, using sentinel-lymph-node biopsy in the clinically and radiologically normal axilla. Wire-guided localization (WGL) during mammography is a method that was developed over 40 years ago to enable lesion localization preoperatively; this technique became the standard of care in the absence of a better alternative. Over the past 20 years, however, other technologies have been developed as alternatives to WGL in order to overcome the technical and outcome-related limitations of this technique. This Review discusses the techniques available for the surgical management of nonpalpable breast cancer; we describe their advantages and disadvantages, and highlight future directions for the development of new technologies.

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Figure 1: Radioguided occult-lesion localization.
Figure 2: Radioactive-seed localization.
Figure 3: Magnetically guided localization.
Figure 4: Intraoperative ultrasound.
Figure 5: Non-invasive localized surgery using HIFU (Echopulse® device, Theraclion, France).

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Authors and Affiliations

  1. Division of Cancer Studies, Research Oncology, King's College London, 3rd Floor, Bermondsey Wing, Guy's Hospital, Great Maze Pond, London, SE1 9RT, UK

    Muneer Ahmed & Michael Douek

  2. Breast Surgical Unit, Breast Cancer Centre, Hospital Universitario Vall d'Hebron, Paseo Vall d'Hebron 119-129, Barcelona, 08035, Spain

    Isabel T. Rubio

  3. Department of Surgery, Medisch Spectrum Twente, Haaksbergerstraat 55, Enschede, 7513 ER, Netherlands

    Joost M. Klaase

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  1. Muneer Ahmed
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  4. Michael Douek
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All authors researched the data for the article, provided substantial contributions to discussions of its content, wrote the article and undertook review and/or editing of the manuscript before submission.

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Correspondence to Michael Douek.

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Competing interests

M.A. and M.D. receive research grants from Theraclion Ltd (Malakoff, France) for the HIFU-F trial and have received equipment support for the MagSNOLL trial from Endomagnetics Ltd. All of these trials have been academically run and sponsored by King's College London. The other authors declare no competing interests.

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Ahmed, M., Rubio, I., Klaase, J. et al. Surgical treatment of nonpalpable primary invasive and in situ breast cancer. Nat Rev Clin Oncol 12, 645–663 (2015). https://doi.org/10.1038/nrclinonc.2015.161

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