Intraoperative Ultrasound-Guided Excision of Non-Palpable and Palpable Breast Cancer: Systematic Review and Meta-Analysis

Maggie Banys-Paluchowski; Isabel T. Rubio; Güldeniz Karadeniz Cakmak; Antonio Esgueva; Natalia Krawczyk; Peter Paluchowski; Ines Gruber; Mario Marx; Sara Y Brucker; Nana Bündgen; Thorsten Kühn; Achim Rody; Lars Hanker; Markus Hahn

doi:10.1055/a-1821-8559

Ultraschall in der Medizin - European Journal of Ultrasound, Table of Contents

Ultraschall Med 2022; 43(04): 367-379
DOI: 10.1055/a-1821-8559

Review

Intraoperative Ultrasound-Guided Excision of Non-Palpable and Palpable Breast Cancer: Systematic Review and Meta-Analysis

Intraoperative Sonographie zur Entfernung von nicht-palpablen und palpablen Mammakarzinomen: systematisches Review und Meta-Analyse

Authors

Maggie Banys-Paluchowski

¹Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany

²Medical Faculty, Heinrich Heine University Düsseldorf, Dusseldorf, Germany (Ringgold ID: RIN9170)
Isabel T. Rubio

³Breast Surgical Unit, Clinica Universidad de Navarra, Madrid, Spain
Güldeniz Karadeniz Cakmak

⁴General Surgery Department, Breast and Endocrine Unit, Zonguldak BEUN The School of Medicine, Kozlu/Zonguldak, Turkey
Antonio Esgueva

³Breast Surgical Unit, Clinica Universidad de Navarra, Madrid, Spain
Natalia Krawczyk

⁵Department of Obstetrics and Gynecology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany (Ringgold ID: RIN9170)
Peter Paluchowski

⁶Department of Gynecology and Obstetrics, Regio Klinikum Pinneberg, Pinneberg, Germany
Ines Gruber

⁷Department for Women’s Health, University of Tübingen, Tübingen, Germany
Mario Marx

⁸Department of Plastic, Reconstructive and Breast Surgery, Elblandklinikum Radebeul, Radebeul, Germany
Sara Y Brucker

⁷Department for Women’s Health, University of Tübingen, Tübingen, Germany
Nana Bündgen

¹Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
Thorsten Kühn

⁹Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany (Ringgold ID: RIN15004)
Achim Rody

¹Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
Lars Hanker

¹Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein Campus Lübeck, Lübeck, Germany
Markus Hahn

⁷Department for Women’s Health, University of Tübingen, Tübingen, Germany

Abstract

Wire-guided localization (WGL) is the most frequently used localization technique in non-palpable breast cancer (BC). However, low negative margin rates, patient discomfort, and the possibility of wire dislocation have been discussed as potential disadvantages, and re-operation due to positive margins may increase relapse risk. Intraoperative ultrasound (IOUS)-guided excision allows direct visualization of the lesion and the resection volume and reduces positive margins in palpable and non-palpable tumors. We performed a systematic review on IOUS in breast cancer and 2 meta-analyses of randomized clinical trials (RCTs). In non-palpable BC, 3 RCTs have shown higher negative margin rates in the IOUS arm compared to WGL. Meta-analysis confirmed a significant difference between IOUS and WGL in terms of positive margins favoring IOUS (risk ratio 4.34, p < 0.0001, I2 = 0%). 41 cohort studies including 3291 patients were identified, of which most reported higher negative margin and lower re-operation rates if IOUS was used. In palpable BC, IOUS was compared to palpation-guided excision in 3 RCTs. Meta-analysis showed significantly higher rates of positive margins in the palpation arm (risk ratio 2.84, p = 0.0047, I2 = 0%). In 13 cohort studies including 942 patients with palpable BC, negative margin rates were higher if IOUS was used, and tissue volumes were higher in palpation-guided cohorts in most studies. IOUS is a safe noninvasive technique for the localization of sonographically visible tumors that significantly improves margin rates in palpable and non-palpable BC. Surgeons should be encouraged to acquire ultrasound skills and participate in breast ultrasound training.

Zusammenfassung

Drahtlokalisation stellt die am häufigsten verwendete Lokalisationsmethode bei nicht palpablen Mammakarzinomen dar. Zu potenziellen Nachteilen der Technik gehören eine niedrige Rate an R0-Resektionen, die Invasivität und das Risiko der Drahtdislokation. Des Weiteren ist die Notwendigkeit einer Re-Operation mit einem erhöhten Rezidivrisiko assoziiert. Intraoperative Sonografie (IOUS) erlaubt eine direkte Visualisierung der Läsion und des Resektionsvolumens und reduziert die Rate an positiven Rändern bei palpablen und nicht palpablen Tumoren. Wir führten ein systematisches Review der Studien zur IOUS durch. Die randomisierten Studien wurden in 2 Metaanalysen ausgewertet. In nicht palpablen Mammakarzinomen zeigten3 randomisierte Studien höhere R0-Resektionsraten im IOUS-Arm, verglichen mit Drahtlokalisation. Der signifikante Unterschied konnte in der Metaanalyse bestätigt werden (Risk Ratio 4,34, p < 0,0001, I2 = 0%). Die meisten der 41 Kohortenstudien mit 3291 Patientinnen zeigten höhere R0-Resektionsraten und niedrigere Nachresektionsraten bei Verwendung von IOUS. Eine Metaanalyse von 3 randomisierten Studien bei palpablem Mammakarzinom zeigte signifikant höhere Raten an positiven Rändern im Palpations-Arm (Risk Ratio 2,84, p = 0,0047, I2 = 0%). In 13 Kohortenstudien mit 942 Patientinnen mit palpablem Mammakarzinom, waren die R0-Resektionsraten meist höher und die Gewebsvolumina niedriger, bei Verwendung von IOUS. IOUS ist eine sichere nicht invasive Technik zur Lokalisation von sonografisch sichtbaren Tumoren und verbessert R0-Resektionsraten bei palpablem und nicht palpablem Mammakarzinom. Sonografische Weiterbildung für Brustoperateure erscheint empfehlenswert.

Keywords

breast cancer - intraoperative ultrasound - wire-guided localization - resection margins - reoperation rate

Full Text

References

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