For those unfamiliar, preoperative wire localization is the procedure performed on the overwhelming majority of patients undergoing lumpectomy or excisional biopsy prior to surgery. The general idea is that one or more needles and wires are inserted into the area in question before surgery with imaging guidance to assist the surgeon in removing the correct area of the breast that could not otherwise be felt or seen by the surgeon. The procedure remains essentially unchanged from its development in the 1970s and has been performed on millions of women and thousands of men across the United States. Although without question this method is cheap, reliable, and effective, it also suffers from some limitations.
One limitation is that the wire must be inserted on the day of the procedure, most often immediately before surgery. This not only creates an inconvenient rate-limiting step for all parties working the patient through the modern day surgical process, but more importantly it can become a safety issue. The pressure to rapidly move patients through the procedure on the day of surgery can be a source of latent errors. I have witnessed at least one sentinel event root cause analysis committee list an impatiently waiting surgical team and “time-crunch” as a reason for the wrong area of the breast being localized and subsequently removed.
Another important limitation often overlooked is patient comfort. At best, following the procedure a wire (and sometimes needle) is left dangling out of the breast with an awkward tape-job which sometimes includes a styrofoam cup or other device taped to the patients’ chest in order to secure the wire and or needle in an attempt to keep them from becoming dislodged and out of site. In patients requiring more than one wire for surgical planning, it can leave the patient looking like some awkward form of radio-frequency receiver. Both cases leave the patient feeling uneasy, sometimes even grossly nauseated while looking at their breast with wires hanging out of it prior to surgery. Quite simply the look and feel from the patient perspective is “barbaric.”
Throughout the years there have been numerous devices and procedures to improve on the traditional needle localization, but none have ever taken root in mainstream clinical practice patterns. There is a newer method however, which appears in my mind to potentially hold enough promise to prompt change from years of habit it in the breast imaging and surgical community. Specifically, the new device implants special reflectors in the breast that allows for radar localization. This allows for placement many days before surgery if needed and does not make the patient feel as uncomfortable. This month, original research was published about this method in the journal of Radiology that examined the effectiveness of this method using the Scout device in 100 women over the course of a year. The results showed that it was effective for localizing breast lesions even when reflectors were placed closely together to “bracket” the lesions.
Given this evidence and the above considerations, I think this is an excellent time for the breast imaging and surgical community to start seriously considering changes or at least alternatives to the traditional wire localization procedure.
Ryan Polselli, M.D.
Fellowship Trained, Breast Imaging Radiologist