What is the recommended protocol for ultrasound wire localization for breast lesion removal?

Ultrasound Wire Localization Protocol for Breast Lesion Removal

For nonpalpable breast lesions requiring surgical excision, wire localization should be performed with precise placement using needle-hook wire (or combined with dye injection), with the wire positioned to guide the surgeon directly to the lesion, followed by mandatory intraoperative specimen radiography to confirm complete excision. 1

Pre-Localization Requirements

Imaging Documentation

• Obtain labeled craniocaudal and 90-degree lateral (or orthogonal) films showing the hook-wire position and send these to the operating room for surgeon orientation. 1
• Current diagnostic films should accompany the localization films to provide additional anatomic context for the surgeon. 1
• For ultrasound-visible lesions, wire localization can be performed under ultrasound guidance rather than stereotactic/mammographic guidance. 2, 3

Wire Placement Technique

• Localization must be precise and may require positioning of more than one wire for accurate triangulation. 1
• Place a radiopaque skin marker at the point of wire entry into the breast before obtaining final radiographs—this facilitates optimal incision placement. 1
• Methods include needle-hook wire alone, Evans blue dye injection, or combination of both techniques. 1

Surgical Approach

Incision Planning

• The incision must be placed directly over the lesion, NOT at the point of wire entry into the breast. 1
• The surgeon should assess exact location by triangulation based on wire position, depth of penetration, and angle, then place the incision closest to the wire tip for optimal cosmesis. 1
• Avoid tunneling—make the skin incision as close to the lesion as possible. 1
• Use curvilinear skin incisions for better cosmetic outcomes. 1
• Critical pitfall: Periareolar incisions are NOT appropriate for peripheral breast lesions as they provide inadequate exposure and compromise margin assessment. 1

Intraoperative Wire Management

• Dissect breast tissue until the wire is identified within the parenchyma, then stabilize the wire distally and bring it into the surgical field. 1
• Avoid traction on the wire at all times to prevent dislocation. 1
• The incision length must be sufficient to permit removal of the specimen in one piece—removal in multiple fragments is unacceptable as it precludes margin assessment and size determination. 1

Intraoperative Confirmation

Specimen Radiography (Mandatory)

• Obtain specimen radiograph in two dimensions (orthogonal projections) immediately after excision. 1
• Use magnification and compression of the specimen to increase radiographic resolution. 1
• The radiologist must interpret the specimen film without delay and communicate findings to the surgeon in the operating room BEFORE closing the excision site. 1
• The radiologist's report must indicate: (1) whether the mammographic abnormality is present in the specimen, (2) if it appears completely removed, and (3) proximity of the abnormality to resection edges. 1

Cavity Management

• Place titanium clips outlining the excision cavity to aid radiation therapy planning and demarcate the tumor bed for future imaging. 1
• Meticulous hemostasis is critical—hematoma formation creates long-lasting changes that complicate physical examination and may lead to unnecessary repeat biopsies. 1
• Avoid drains in the breast; allow the biopsy cavity to fill with serum for better cosmetic results. 1
• Close skin incisions with subcuticular technique. 1

Alternative Technique Considerations

Intraoperative Ultrasound-Guided Wire Placement

• Recent evidence suggests surgeon-performed intraoperative ultrasound with wire localization under general anesthesia can reduce wire dislocation (2/20 vs 9/20 cases, p=0.03) and eliminate accidental wire cutting (0/20 vs 5/20 cases, p=0.047). 4
• This combined approach (WUGL technique) may reduce re-excision rates compared to conventional preoperative wire placement. 4, 2
• However, this technique requires surgeon expertise in ultrasound and is not yet standard practice per established guidelines. 3

Critical Pitfalls to Avoid

• Never tunnel from wire entry point to lesion—this compromises cosmesis and margin assessment. 1
• Never remove the lesion in fragments—this makes margin evaluation and size determination impossible. 1
• Never close the excision site before receiving intraoperative specimen radiography confirmation—additional tissue may need immediate removal. 1
• Never use periareolar incisions for peripheral lesions—they provide inadequate exposure and compromise negative margin achievement. 1
• Always position the incision so it can be incorporated within a mastectomy specimen if negative margins cannot be achieved with breast conservation. 1