Intraoperative Ultrasound: Is it the Method of Choice for the Detection of Breast Lesions?

We have read with interest the publication by Medina Fernández et al.¹ about resection margins in conservative surgery for breast cancer. The paper is a synopsis of the problem posed in conservative breast surgery and the presence of positive margins in between 20 and 40% of surgical specimens that are removed. This confirms that our objective should be to achieve free resection margins and absence of residual tumor. The authors describe it as “rigorous conservative breast cancer surgery”, and we could not agree more.

The authors analyze the literature on predictive factors for positive margins in resection specimens. They comment on an experimental study, emphasizing the impact of formalin preservation of the surgical specimen, which could alter the measurement of the tumor margins. Last of all, they analyze the different intraoperative methods for locating tumors. Harpoons, radioguided occult lesion localization (ROLL) and intraoperative ultrasound (IOUS) are currently the 3 basic pillars with extensive, corroborated studies. They also mention other methods such as the cryoprobe and manual probes for positron detection, both of which are unthinkable in our hospital for financial reasons. The results of IOUS, ROLL and harpoons are similar, although IOUS and ROLL seem to be superior in comfort of use, positive margin rate and re-operations.¹

In our hospital, we started using IOUS 18 months ago because of its availability, easy handling, non-invasive nature and reliability in the hands of surgeons dedicated to breast pathologies in collaboration with the radiologist from the Breast Unit. The surgeon also reviews the surgical specimen ex vivo with the ultrasound before it is sent for further ultrasound and mammography studies by the radiologist. The harpoon technique that we used previously has been relegated to use in lesions that are not visible on ultrasound, as well as microcalcifications due to non-calcified ductal carcinoma in situ or multifocal invasive carcinoma. Ultrasound-guided surgery can significantly reduce the rate of resection margin involvement by reducing the need for re-excision.²

The ROLL technique requires our patients to go to another hospital with a Nuclear Medicine Unit either the day before or the same day of the procedure, with consequently higher costs and involvement of a greater number of specialists.³

We have recently published our data with IOUS in non-palpable lesions and, although the series is still small, there has been a re-intervention percentage of malignant lesions of 15.4%.⁴

The breast ultrasound starts in the breast consultation and turns into IOUS with the breast surgeon. In small hospitals like ours that lack “cutting-edge” technology, we should continue to offer the diagnostic–therapeutic options upheld by the literature.