Radioguided breast surgery for occult lesion localization – correlation between two methods
© Moreno et al; licensee BioMed Central Ltd. 2008
Received: 17 May 2008
Accepted: 15 August 2008
Published: 15 August 2008
The detection of sub-clinical breast lesions has increased with screening mammography. Biopsy techniques can offer precision and agility in its execution, as well as patient comfort. This trial compares radioguided occult lesion localization (ROLL) and wire-guided localization (WL) of breast lesions. We investigate if a procedure at the ambulatorial level (ROLL) could lead to a better aesthetic result and less postoperative pain. In addition, we intend to demonstrate the efficacy of radioguided localization and removal of occult breast lesions using radiopharmaceuticals injected directly into the lesions and correlate radiological and histopathological findings.
One hundred and twenty patients were randomized into two groups (59 WL and 61 ROLL). The patients were requested to score the cosmetic appearance of their breast after surgery, and a numerical rating scale was used to measure pain on the first postoperative day. Clearance margins were considered at ≥ 10 mm for invasive cancer, ≥ 5 mm for ductal carcinoma in situ, and ≥ 1 mm for benign disease. Patients were subsequently treated according to the definitive histological result. When appropriate, different statistical tests were used in order to test the significance between the two groups, considering a P value < 0.05 as statistically significant.
WL and ROLL located all the occult breast lesions successfully. In the ROLL group, the specimen volume was smaller and there were more cases with clear margins (P < 0.05). There were significant differences in mean time of hospital stay between WL and ROLL (21.42 vs. 2.56 hours), but not in operative time (39.4 vs. 29.9 minutes). There were significant differences in the subjective ease of the procedures as rated by the patients (cosmetic outcomes and postoperative pain).
ROLL is an effective method for the excision of non-palpable breast lesions. It enables more careful planning of the cutaneous incision, leading to better aesthetic results, less postoperative symptoms, and smaller volumes of excised tissue.
The diagnosis of breast cancer has changed over the last years. Previously, about 50 to 70% of breast cancers were diagnosed through physical examination . The detection of subclinical lesions has increased with screening mammography . Thus, the need arose to develop minimally invasive techniques of locating and histological confirming small alterations [3, 4]. Wire localization (WL) is a well-known technique in breast surgery where a malleable needle with a spear at its distal extremity is used to locate a lesion. Under mammography or ultrasound visualization, a needle is placed directly into an area suspicious as per the nature of the lesion [3, 4]. There is a risk of needle displacement during the period between its positioning and retreat, mainly in breasts with a predominant fatty component [2, 4]. This can represent an important complication in patients with mammary prosthesis, for example. In dense breasts, difficulty in positioning the needle localization device can occur. Cases of transected needles, pneumothorax, and other accidents have been described [2, 5]. Needle localization of occult lesions is usually done under general anesthesia due to patient discomfort when the needle localization device is manipulated [5–7].
Radioguided occult lesion localization (ROLL) is a method that has been used since 1996 . It was developed at the European Institute of Oncology in Milan, and is currently the standard of care in many breast surgery services. In this procedure, a radioactive labeling substance is used at the suspect site (under ultrasound or mammography guidance). The gamma-detecting probe guides the localization of a suspicious opacity or microcalcification cluster during the surgical procedure [6, 9]. The cutaneous incision can be planned with better aesthetic results. In this method, a spear is not used; instead, a small portion of liquid makes the process less traumatic for patients. Local anesthesias for ROLL and patients' opinions as to the pain and postoperative aesthetic results have not been previously studied for effectiveness and patient acceptability [7, 9].
The goal of this paper is to show the feasibility of performing the ROLL technique in an ambulatory setting, with shorter operative time and less patient morbidity, through careful surgical planning and the extraction of a smaller mammary sample. Therefore, these advantages make it the preferred method for occult breast lesion localization with diagnostic intention.
Clinical and radiological characteristics of WL and ROLL groups.
Number of patients
Mean of age (yr)
Micro-Calcifications + Stromal deformity
Comparison of surgical and pathological features of WL and ROLL groups.
Local of cutaneous incision
Carcinoma in situ
Size of specimen (mean in cm3)
Invasive and not invasive carcinomas
Period of hospital stay (mean in hours)
Time of procedure (mean – min)
Margins of all lesions
Postoperative wound infection
Dependent variables on the patient opinion.
Pain (mean of numerical scale)
Nowadays, the diagnosis of subclinical breast lesions is very common due to easy access to standard mammography in most places. Many techniques, such as core biopsy, fine needle aspiration, and mammotomy are used for the histological study of clinically occult breast lesions. Sometimes it is necessary to excise all occult lesions in order to choose the adequate treatment. WL is a method used in many places as standard preoperative localization of non-palpable lesions. However, the problems reported with this technique are well known: wire transection, difficulties in wire repositioning in dense or fatty breasts, dislodgement, interference with the surgical approach, and patient discomfort during wire positioning and during patient transportation from the radiological center to the operating room [2, 9, 12].
Since 1996, when the first paper presented the advantages of ROLL, other authors have reported the same findings and have documented some characteristics of this technique: it is a radiologically and surgically easier procedure to perform, and the lesion can be identified in three dimensions affording greater flexibility in making a cosmetic incision . ROLL is also appropriate for combination with sentinel lymph node mapping in which the occult breast cancer and sentinel lymph node can be excised in the same procedure [9, 14, 15]. Until now, the methodology for evaluation of postoperative pain has not mentioned the ROLL procedure, despite some works reporting postoperative pain when the WL is carried out [6, 8, 14, 16]. The evaluation of pain on the first postoperative day and of the cosmetic outcomes was used as a parameter for comparing patients' opinions about both procedures, and there was a difference between the two groups. This is due to a better choice of an incision site (radioguided) and the fact that the size of the ROLL specimen is smaller. Hospital stay was shorter in the ROLL group due to the ambulatory characteristics of this procedure. Moreover, with the WL procedure, the patient needed a time to recover from general anesthesia. The failure rate of the wire guided technique (i.e. incomplete cancer resection) has been reported in the range of 40–50% . The duration of the procedure was shorter in the ROLL procedure, which could be explained by better radioguided planning of the method; however, there were no significant findings (p > 0.05). The specimen size (mean in cm3) was smaller in patients submitted to ROLL and there were more cases with compromised margins with the WL procedure (p < 0.05), which again reflects better planning to include all lesions at the same time, and the specimen excised is the smallest possible. This difference, however, could affect the results for rates of cases with involved margins due to the different criteria of histological categories. To date, there have been no descriptions of a comparison between the use of local anesthesia in the ROLL procedure and use of general anesthesia in WL, especially comparing them as to aesthetic results and pain measurement.
ROLL can provide diagnosis or treatment of the breast lesion with a shorter hospital stay, shorter operative period, less breast tissue excised, and consequently, better aesthetic outcomes and fewer procedure-related symptoms. It can result in lower costs and a better acceptance on the part of patients.
Conflict of interests
The authors declare that they have no competing interests.
List of Abbreviations
Radioguided Occult Lesion Localization
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