Submitted Successfully!
To reward your contribution, here is a gift for you: A free trial for our video production service.
Thank you for your contribution! You can also upload a video entry or images related to this topic.
Version Summary Created by Modification Content Size Created at Operation
1 + 1520 word(s) 1520 2021-02-19 10:47:39 |
2 Format correct Meta information modification 1520 2021-02-22 03:58:47 |

Video Upload Options

Do you have a full video?


Are you sure to Delete?
If you have any further questions, please contact Encyclopedia Editorial Office.
Mason, E.J. Breast-Conserving Surgery. Encyclopedia. Available online: (accessed on 24 April 2024).
Mason EJ. Breast-Conserving Surgery. Encyclopedia. Available at: Accessed April 24, 2024.
Mason, Elena Jane. "Breast-Conserving Surgery" Encyclopedia, (accessed April 24, 2024).
Mason, E.J. (2021, February 21). Breast-Conserving Surgery. In Encyclopedia.
Mason, Elena Jane. "Breast-Conserving Surgery." Encyclopedia. Web. 21 February, 2021.
Breast-Conserving Surgery

Breast-conserving surgery’s main goal is to fully remove the tumor with clear margins, while avoiding resection of healthy breast tissue in order to achieve better cosmetic results. 

breast cancer breast-conserving surgery image-guided localization

1. Introduction

Breast cancer (BC) is the most commonly diagnosed cancer and the leading cause of cancer-related death among women [1]. A successful BC treatment is based on a multidisciplinary use of surgery, chemotherapy and radiation therapy, with surgery as the central component of treatment for early-stage breast cancer [2][3]. Breast-conserving surgery (BCS) followed by adjuvant radiotherapy, known as breast conservation therapy (BCT), has become the alternative treatment to mastectomy for early stage breast cancer because of equivalent survival and lower morbidity [4][5][6].

Local recurrence after BCS is strongly correlated to the surgical margin status, as demonstrated by a large number of follow-up studies [7][8][9][10][11]. The main goal of BCS is to fully remove the tumor with clear margins, while avoiding resection of healthy breast tissue in order to achieve better cosmetic results. Image-guided preoperative localization is mandatory for guiding surgery of non-palpable lesions or surgically relevant extension of palpable lesions to improve both oncological and cosmetic outcomes [12][13]. Over the last decade, methods for preoperative localization of breast lesions for BCS have evolved rapidly due to innovative techniques and discovery of novel agents. However, cooperation and communication between breast surgeons and radiologists still play a crucial role.

Different image guided localization techniques are variably used in different institutions depending on personal choices, skills and available technologies. As a general rule, the method chosen should be the most precise to localize the lesion or marker left after biopsy, thus improving free margin rates and decreasing operative time, and possibly cause little to no discomfort to the patient. Preoperative breast lesions localization techniques currently available are wire localization, carbon marking, radio-guided occult lesion localization (ROLL), radioactive seed localization (RSL), magnetic seed localization and non-radioactive radar localization, intraoperative ultrasound and preoperative skin tattoo localization (Table 1). In this article, we provide an overview of current literature of all commercially available techniques. The aim of this review is to educate practicing radiologists and breast surgeons so they can knowingly select new techniques to improve patient care.

Table 1. Comparison of different localization techniques. Abbreviations: ROLL = radio-guided occult lesion localization; RSL = radioactive seed localization; Magseed = magnetic seed localization; IOUS = intraoperative ultrasound; Skin tattoo = preoperative localization with skin tattoo; OR = operating room; US = ultrasound; MRI = magnetic resonance imaging. * Success is defined as removal of target lesion. ** Authors’ experience.

Technique Materials/Procedures Advantages Disadvantages Success * Rate Clear Margins Rate
Wire localization Wire
Preloaded needle introducer
Different kinds of image-guidance
Wire migration
Scheduling difficulties
Limits surgical decisions
97.5% [14] 70.8–87.4% [15]
Carbon marking Diluted charcoal powder Simple
Different kinds of image-guidance
Cannot dislodge
Scheduling flexibility
Carbon can distort or obscure lesion
Unfit for large breasts
Unfit for multifocal or extensive lesions
99% [16] 61–85% [17][18]
ROLL Nuclear radiotracer
Technetium 99
Gamma ray probe
Different kinds of image-guidance
Does not limit surgeon
Scheduling difficulties
95–99% [19] 92% [20][21]
RSL Iodine 125 seed
Preloaded needle introducer
Gamma probe set for I-125
Scheduling flexibility
Does not limit surgeon
Different kinds of image-guidance
Not repositionable after deployment
100% [22][23] 73.5–96.7% [22][23]
Magseed Paramagnetic seed
Preloaded needle introducer
Scheduling flexibility
No radiation
Does not limit surgeon
Not repositionable after deployment
Non magnetizable surgical equipment
MRI artifacts
99.86% [24][25][26][27] 88.75% [24]
Radiofrequency identification tags Radiofrequency reflector
Needle introducer
Scheduling flexibility
No radiation
Does not limit surgeon
Depth limit
Not repositionable after deployment
Interference with halogen lights in the OR
97–100% [28][29] 85–100% [28][29][30]
IOUS Portable or OR-stationed US machine and sterile transducer cover Scheduling flexibility
No radiation
Does not limit surgeon
Unemployable in US-invisible lesions
Surgeon learning curve
Interference with air during dissection
100% [31][32][33][34][35] 81–97% [32][34]
Skin tattoo Dermographic marker
Lead markers
Simple and safe
Different kinds of image-guidance
Does not limit surgeon
Scheduling difficulties
Inability to depict marker
99.5% ** 95.9% **

2. Preoperative Localization with a Skin Tattoo

Preoperative localization with a skin tattoo is a simple and safe technique amply utilized in our centre, as it is easily performed, extremely well tolerated by patients and effective in terms of successful excision and clear margin rates. This method can be carried out by acquiring either sonographic or mammographic images, depending on the type of lesion, but ultrasounds are employed whenever possible because the procedure is easier. In this case, patients lie in the supine position with their arms extended to mimic the position held during surgery. The tumor is located, and its distance from the skin surface is measured taking care not to apply pressure with the probe, so as to report accurately the depth of the tumor in relation to the skin surface [36]. The distance between the lesion, the nipple and the pectoralis major muscle is also measured, as is the distance between separate lesions in case of multifocal or multicentric disease [37][38]. Radiologists with experience in this technique visualize the tumors at their largest diameter to achieve the optimal correspondence between the lesion and the skin markers. The tumor’s projection on the skin surface is pinpointed with a dermographic skin marker and the drawing is covered to avoid accidental erasure (Figure 1). The whole procedure, performed by an experienced radiologist, takes 5–10 min and provides minimum patient discomfort. Limitations include poor results in case of sonographically invisible lesions, microcalcifications or biopsy markers, but are easily overcome by implementing this technique with a mammographic approach. Stereotactic-guided skin marking is also a non-invasive technique, albeit it provides a little more discomfort to the patient due to breast compression. Mammograms are acquired in double projection and measurements are performed on the images to determine the distance between the lesion and the nipple, the skin surface and the fascia.

Figure 1. Preoperative skin tattoo. Transverse sonogram showing hypoechoic, round shaped multifocal masses with indistinct margins in the upper outer quadrant of the right breast (a,b, arrows). The distance between separate lesions is measured (c). The dermographic skin markers of the tumor’s projection on the skin surface (d).

The radiologist then estimates the projection of the tumor on the skin surface and positions a lead marker in the corresponding spot. In case of bigger lesions, such as extensive microcalcifications, or multifocal disease, multiple lead markers can be employed to determine lesion margins. A second stereotactic pair of images is acquired to confirm the correct localization, and in case of inaccurate positioning, the lead markers can be repositioned more accurately and confirmed by a further mammogram [39] (Figure 2). At the end of the procedure the lead markers are removed, and the skin tattoo is drawn in their place. In the operating room, the mark is exposed and retraced with a specific marker resistant to antiseptic solutions, and painting and draping procedures are carried out carefully without wiping out the ink. Our centre strongly advocates pursuit of the maximum aesthetic result achievable with oncological safety, and because this localization technique employs only a temporary skin tattoo, the surgeon is granted total liberty in choice of incision and oncoplastic technique. The skin flap is dissected in the direction of the tattoo, then the incision is deepened and a lumpectomy is carried out taking into account tumor depth measured during the preoperative localization. In some cases, a non-palpable lesion becomes palpable after dissection of the skin flap, allowing the surgeon to easily complete the excision, however in most cases the excision has to be conducted by reassessing the original position of the skin mark from time to time. Once the excision is completed, metallic clips are placed on the orienting sutures in different numbers, so as to recognize margins in the specimen X-ray. The sample is then placed into a transparent plastic bag and sent to the Radiology Department, and mammograms are acquired in double projection. The tumor is usually visible as a radiopaque nodule, and its position inside the lumpectomy specimen is described as either well centered or close to one or more surgical margins, and reported to the operating surgeon. In dense, glandular specimens the nodule can be difficult to distinguish from the surrounding mammary parenchyma: in these cases, the exam can be completed with a specimen ultrasound [40] (Figure 3). If close margins are detected in either technique the surgeon can acquire further cavity shave margins on the affected border.

Figure 2. Lead marker positioning during mammographic technique. Metallic marker (a). Craniocaudal (b) and mediolateral oblique (c) views confirm the appropriate marker (arrow) placement on the microcalcifications’ (circle) projection on the skin surface. Specimen X-ray contains the microcalcifications (d).

Figure 3. Radiograph of a dense, glandular specimen with scarcely recognizable nodules (a). Subsequent specimen ultrasound demonstrates successful removal of two masses (arrows) (b,c).

This technique is quick, easily performed by breast radiologists and extremely cost-effective. It does not require equipment that is not normally present in any breast surgery department, and is therefore feasible even with scarce resources. Limitations include accurate scheduling to time the procedure before surgery thus avoiding accidental mark erasure, and a certain degree of experience by the surgeon in reassessing the tumor’s position based on the skin mark during dissection. Reports on this technique are widely deficient in the literature, however a preliminary analysis of the data from our high-volume centre examining the outcome of 199 lumpectomies performed for non-palpable breast tumors between August and December 2019 identified a global success rate of 99.5% (198/199) and a clear margins rate of 95.9% (192/199). As these rates did not differ significantly from other localization techniques, this method appears safe and especially ideal in the case of limited resources or spending reviews.


  1. Sharma, R. Breast cancer incidence, mortality and mortality-to-incidence ratio (MIR) are associated with human development, 1990–2016: Evidence from Global Burden of Disease Study 2016. Breast Cancer 2019, 26, 428–445.
  2. Moo, T.-A.; Sanford, R.; Dang, C.; Morrow, M. Overview of breast cancer therapy. PET Clin. 2018, 13, 339–354.
  3. Franceschini, G.; Terribile, D.; Fabbri, C.; Magno, S.; D’Alba, P.; Chiesa, F.; Di Leone, A.; Masetti, R. Management of locally advanced breast cancer. Mini-review. Minerva Chir. 2007, 62, 249–255. Available online: (accessed on 8 November 2020).
  4. Fisher, B.; Anderson, S.; Bryant, J.; Margolese, R.G.; Deutsch, M.; Fisher, E.R.; Jeong, J.-H.; Wolmark, N. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N. Engl. J. Med. 2002, 347, 1233–1241.
  5. Veronesi, U.; Cascinelli, N.; Mariani, L.; Greco, M.; Saccozzi, R.; Luini, A.; Aguilar, M.; Marubini, E. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N. Engl. J. Med. 2002, 347, 1227–1232.
  6. Sanchez, A.M.; Franceschini, G.; D’Archi, S.; De Lauretis, F.; Scardina, L.; Di Giorgio, D.; Accetta, C.; Masetti, R. Results obtained with level II oncoplastic surgery spanning 20 years of breast cancer treatment: Do we really need further demonstration of reliability? Breast J. 2020, 26, 125–132.
  7. Peterson, M.E.; Schultz, D.J.; Reynolds, C.; Solin, L.J. Outcomes in breast cancer patients relative to margin status after treatment with breast-conserving surgery and radiation therapy: The University of Pennsylvania experience. Int. J. Radiat. Oncol. Biol. Phys. 1999, 43, 1029–1035.
  8. Singletary, S.E. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am. J. Surg. 2002, 184, 383–393.
  9. Corsi, F.; Sorrentino, L.; Bossi, D.; Sartani, A.; Foschi, D. preoperative localization and surgical margins in conservative breast surgery. Int. J. Surg. Oncol. 2013, 2013, 793819.
  10. Park, C.C.; Mitsumori, M.; Nixon, A.; Recht, A.; Connolly, J.; Gelman, R.; Silver, B.; Hetelekidis, S.; Abner, A.; Harris, J.R.; et al. Outcome at 8 years after breast-conserving surgery and radiation therapy for invasive breast cancer: Influence of margin status and systemic therapy on local recurrence. J. Clin. Oncol. 2000, 18, 1668–1675.
  11. Franceschini, G.; Sanchez, A.M.; Di Leone, A.; Magno, S.; Moschella, F.; Accetta, C.; Natale, M.; Di Giorgio, D.; Scaldaferri, A.; D’Archi, S.; et al. Update on the surgical management of breast cancer. Ann. Ital. Chir. 2015, 86, 89–99.
  12. Hayes, M.K. Update on preoperative breast localization. Radiol. Clin. N. Am. 2017, 55, 591–603.
  13. Jeffries, D.O.; Dossett, L.A.; Jorns, J.M. Localization for breast surgery: The next generation. Arch. Pathol. Lab. Med. 2017, 141, 1324–1329.
  14. Jackman, R.J.; Marzoni, F.A. Needle-localized breast biopsy: Why do we fail? Radiology 1997, 204, 677–684.
  15. Bick, U.; Trimboli, R.M.; Athanasiou, A.; Balleyguier, C.; Baltzer, P.A.T.; Bernathova, M.; Borbély, K.; Brkljacic, B.; Carbonaro, L.A.; Clauser, P.; et al. Image-guided breast biopsy and localisation: Recommendations for information to women and referring physicians by the European Society of Breast Imaging. Insights Imaging 2020, 11, 1–18.
  16. Riedl, C.C.; Pfarl, G.; Helbich, T.H.; Memarsadeghi, M.; Wagner, T.; Rudas, M.; Fuchsjäger, M. Comparison of wire versus carbon localization of non-palpable breast lesions. RöFo 2002, 174, 1126–1131.
  17. Rose, A.; Collins, J.; Neerhut, P.; Bishop, C.; Mann, G.B. Carbon localisation of impalpable breast lesions. Breast 2003, 12, 264–269.
  18. Tran, Q.; Mizumoto, R.; Tran, M.; Reintals, M.; Gounder, V. Carbon-track localisation as an adjunct to wire-guided excision of impalpable breast lesions: A retrospective cohort study. Int. J. Surg. Open 2019, 21, 7–11.
  19. Öcal, K.; Dag, A.; Turkmenoglu, M.O.; Günay, E.C.; Yûcel, E.; Duce, M.N. Radioguided occult lesion localization versus wire-guided localization for non-palpable breast lesions: Randomized controlled trial. Clinics 2011, 66, 1003–1007.
  20. De Cicco, C.; Pizzamiglio, M.; Trifirò, G.; Luini, A.; Ferrari, M.; Prisco, G.; Galimberti, V.; Cassano, E.; Viale, G.; Intra, M.; et al. Radioguided occult lesion localisation (ROLL) and surgical biopsy in breast cancer. Technical aspects. Q. J. Nucl. Med. 2002, 46, 145–151.
  21. Luini, A.; Zurrida, S.; Paganelli, G.; Galimberti, V.; Sacchini, V.; Monti, S.; Veronesi, P.; Viale, G. Comparison of radioguided excision with wire localization of occult breast lesions. BJS 1999, 86, 522–525.
  22. Gray, R.J.; Salud, C.; Nguyen, K.; Dauway, E.; Friedland, J.; Berman, C.; Peltz, E.; Whitehead, G.; Cox, C.E. Randomized prospective evaluation of a novel technique for biopsy or lumpectomy of nonpalpable breast lesions: Radioactive seed versus wire localization. Ann. Surg. Oncol. 2001, 8, 711–715.
  23. Rao, R.; Moldrem, A.; Sarode, V.; White, J.; Amen, M.; Rao, M.; Andrews, V.; Euhus, D.; Radford, L.; Ulissey, M. Experience with seed localization for nonpalpable breast lesions in a public health care system. Ann. Surg. Oncol. 2010, 17, 3241–3246.
  24. Gera, R.; Tayeh, S.; Al-Reefy, S.; Mokbel, K. Evolving role of magseed in wireless localization of breast lesions: Systematic review and pooled analysis of 1,559 procedures. Anticancer. Res. 2020, 40, 1809–1815.
  25. Endomag. Available online: (accessed on 11 November 2020).
  26. Zacharioudakis, K.; Down, S.; Bholah, Z.; Lee, S.; Khan, T.; Howe, M.; Maxwell, A.; Harvey, J. Is the future magnetic? Magseed localisation of non palpable breast cancer—A multicentre comparative cohort study. Breast 2019, 44, S112.
  27. Thekkinkattil, D.; Kaushik, M.; Hoosein, M.; Al-Attar, M.; Pilgrim, S.; Gvaramadze, A.; Hyklova, L.; Jibril, A. A prospective, single-arm, multicentre clinical evaluation of a new localisation technique using non-radioactive Magseeds for surgery of clinically occult breast lesions. Clin. Radiol. 2019, 74, 974.e7–974.e11.
  28. Mango, V.L.; Wynn, R.T.; Feldman, S.; Friedlander, L.; Desperito, E.; Patel, S.N.; Gomberawalla, A.; Ha, R. Beyond wires and seeds: Reflector-guided breast lesion localization and excision. Radiology 2017, 284, 365–371.
  29. Mango, V.; Ha, R.; Gomberawalla, A.; Wynn, R.; Feldman, S. Evaluation of the SAVI SCOUT surgical guidance system for localization and excision of nonpalpable breast lesions: A feasibility study. Am. J. Roentgenol. 2016, 207, W69–W72.
  30. Cox, C.E.; Garcia-Henriquez, N.; Glancy, M.J.; Whitworth, P.; Cox, J.M.; Themar-Geck, M.; Prati, R.; Jung, M.; Russell, S.; Appleton, K.; et al. Pilot study of a new nonradioactive surgical guidance technology for locating nonpalpable breast lesions. Ann. Surg. Oncol. 2016, 23, 1824–1830.
  31. Jadeja, P.H.; Mango, V.; Patel, S.; Friedlander, L.; Desperito, E.; Ayala-Bustamante, E.; Wynn, R.; Chen-Seetoo, M.; Taback, B.; Feldman, S.; et al. Utilization of multiple SAVI SCOUT surgical guidance system reflectors in the same breast: A single-institution feasibility study. Breast J. 2018, 24, 531–534.
  32. Colakovic, N.; Zdravkovic, D.; Skuric, Z.; Mrda, D.; Gacic, J.; Ivanovic, N. Intraoperative ultrasound in breast cancer surgery—from localization of non-palpable tumors to objectively measurable excision. World J. Surg. Oncol. 2018, 16, 1–7.
  33. Haid, A.; Knauer, M.; Dunzinger, S.; Jasarevic, Z.; Köberle-Wührer, R.; Schuster, A.; Toeppker, M.; Haid, B.; Wenzl, E.; Offner, F. Intra-operative sonography: A valuable aid during breast-conserving surgery for occult breast cancer. Ann. Surg. Oncol. 2007, 14, 3090–3101.
  34. Fortunato, L.; Penteriani, R.; Farina, M.; Vitelli, C.E.; Piro, F. Intraoperative ultrasound is an effective and preferable technique to localize non-palpable breast tumors. Eur. J. Surg. Oncol. (EJSO) 2008, 34, 1289–1292.
  35. Ramos, M.; Díaz, J.C.; Ramos, T.; Ruano, R.; Aparicio, M.; Sancho, M.; González-Orús, J.M. Ultrasound-Guided Excision Combined with Intraoperative Assessment of Gross Macroscopic Margins Decreases the Rate of Reoperations for Non-Palpable Invasive Breast Cancer. Breast 2012, 22, 520–524. Available online: (accessed on 30 October 2020).
  36. Carlino, G.; Rinaldi, P.; Giuliani, M.; Rella, R.; Bufi, E.; Padovano, F.; Ciardi, C.; Romani, M.; Belli, P.; Manfredi, R. Ultrasound-guided preoperative localization of breast lesions: A good choice. J. Ultrasound 2019, 22, 85–94.
  37. Volders, J.H.; Haloua, M.H.; Krekel, N.M.A.; Meijer, S.; Van Den Tol, P.M. Current status of ultrasound-guided surgery in the treatment of breast cancer. World J. Clin. Oncol. 2016, 7, 44–53.
  38. Franceschini, G.; Visconti, G.; Sanchez, A.M.; Di Leone, A.; Salgarello, M.; Masetti, R. Oxidized regenerated cellulose in breast surgery: Experimental model. J. Surg. Res. 2015, 198, 237–244.
  39. Madeley, C.; Kessell, M.; Madeley, C.; Taylor, D.B. A comparison of stereotactic and tomosynthesis-guided localisation of impalpable breast lesions. J. Med. Radiat. Sci. 2019, 66, 170–176.
  40. Fusco, R.; Petrillo, A.; Catalano, O.; Sansone, M.; Granata, V.; Filice, S.; D’Aiuto, M.; Pankhurst, Q.; Douek, M. Procedures for location of non-palpable breast lesions: A systematic review for the radiologist. Breast Cancer 2012, 21, 522–531.
Subjects: Oncology
Contributor MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to :
View Times: 505
Revisions: 2 times (View History)
Update Date: 22 Feb 2021