• Currently, wire localization (WL):
  • Is the most commonly used technique for guiding excision of nonpalpable lesions in the breast:
    • It may also be used to localize a clipped axillary node
• However, WL may require coordination of scheduling in the operating room and radiology, result in patient discomfort, and the wire may potentially become dislodged or malpositioned
• Localization devices that do not require wires are increasing in popularity to overcome some of these issues:
  • For both techniques, the localization device, such as a radioactive seed, is implanted via mammographic or sonographic guidance prior to surgery:
    • Although initially used mostly for non-palpable breast lesions, use of these techniques is increasing in localization of lymph nodes, especially after neoadjuvant chemotherapy
• The use of neoadjuvant chemotherapy in node-positive breast cancer patients:
  • Can result in clinical downstaging of the axilla:
    • Allowing for de-escalation of axillary surgery with use of sentinel node biopsy rather than axillary dissection
  • Marking previously biopsied nodes and excision at time of breast surgery:
    • Has been shown to reduce false negative rates of sentinel node biopsy:
      • 6.8% vs. 19.8% without excision of clipped node
        • This is recommended by the National Comprehensive Cancer Network
• Radioactive seed placement has not been shown to interfere with the isotope utilized in sentinel node mapping

References

1. Lovrics PJ, Goldsmith CH, Hodgson N, et al. A multicentered, randomized, controlled trial comparing radioguided seed localization to standard wire localization for nonpalpable, invasive and in situ breast carcinomas. Ann Surg Oncol. 2011;18(12):3407-3414.

2. Cox CE, Russell S, Prowler V, et al. A prospective, single arm, multi-site, clinical evaluation of a nonradioactive surgical guidance technology for the location of nonpalpable breast lesions during excision. Ann Surg Oncol. 2016;23(1):3168-3174.

3. Caudle AS, Yang WT, Mittendorf EA et al. Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial. JAMA Surg 2015;150(2):137-143.

4. Boughey JC, Ballman KV, Le-Petross HT et al. Identification and resection of clipped node decreases the false-negative rate of sentinel lymph node surgery in patients presenting with node-positive breast cancer (T0-T4, N1-N2) who receive neoadjuvant chemotherapy: results from ACOSOG Z1071 (Alliance). Ann Surg. 2016;263(4):802-807.

5. Diego EJ, McAuliffe JF, Soran A, et al. Axillary staging after neoadjuvant chemotherapy for breast cancer: a pilot study combining sentinel lymph node biopsy with radioactive seed localization of pre-treatment positive axillary lymph nodes. Ann Surg Oncol. 2016;23(5):1549-1553.