Intraoperative ultrasound is accurate for guiding breast conservative surgery in non-palpable ductal breast carcinoma

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Published: 24 Nov 2022
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Dr Antonio Esgueva - Clinica Universidad de Navarra, Madrid, Spain,

Dr Antonio Esgueva speaks to ecancer about his study regarding intraoperative ultrasound for guiding breast conservative surgery in non-palpable ductal carcinoma in situ of the breast.

The research involved 108 people who were diagnosed with DCIS. Forty-one were treated with IOUS-guided surgery while 67 were treated with surgery guided by wire localisation.

The study results showed that using ultrasound to guide surgery for patients with ductal carcinoma in situ (DCIS) gives better results than the standard technique of using a wire inserted into the breast.

De Esgueva concludes by discussing the impact these results can have on the future treatment of breast cancer.

Read the full story here.

Hello, this is Antonio Esgueva. I am a breast surgeon from Clinica Universidad de Navarra in Madrid, Spain. The idea of talking here with you is about the results of our latest study which is about the use of intraoperative ultrasound for DCIS, which is ductal carcinoma in situ of the breast. Ductal carcinoma in situ of the breast is a pre-malignant lesion that, if left untreated, most of the time has a high risk of developing as a breast cancer. At the moment most surgeons will perform the surgery. I know there are several studies running right now about not doing any type of surgery but anyway we are going to centre on the surgical part of it.

The problem with DCIS is that mostly it presents as microcalcifications on the mammogram and most of these microcalcifications are not seen under ultrasound. So we can’t perform an ultrasound if we don’t know what to excise. The good news is that there are ultrasound visible clips that we can place at the area of the calcifications and that way it can help us in the guidance of the surgery. We see the clip and then with the mammogram we can create our pattern, we can create what we want to excise. That’s the idea of this study because for breast cancer, for non-palpable breast cancer, we use it either by seeing the cancer itself on the ultrasound or by placing a clip and we have really good results, not only similar results to the wire but it has even better volumes, even less positive margins and patients are happier because they avoid the wire.

Then we have developed this study which was to compare the patients that underwent surgery with intraoperative ultrasound and the patients who underwent surgery with the wire. The wire is really uncomfortable because it is placed the day of the surgery in the radiology department, it’s a needle, you have to place it, you have to check it’s in place then if it’s not you have to move it and it’s really uncomfortable for the patient. With the ultrasound the moment we perform the biopsy we place the clip that we can see it and that’s all. The patient goes directly to the OR without the need of going through the radiology department.

For that we have included 108 patients, 41 of them at the intraoperative ultrasound, 67 had the wire localisation. Then we wanted to check the surgical volume and the rate of positive margin because if we get a positive margin that means that we have ductal carcinoma in situ cells on the surface of our specimen then it’s a second surgery in order to make sure that we don’t leave any residual disease in the breast.

So that was the idea of the study and we were quite happy with the results because we have seen that in the intraoperative group we have less than 5% of positive margins while in the wire group we have more than 10% of positive margins. That means that less than 5% of second surgeries in the intraoperative group and more than 10% of second surgeries in the wire group which is something interesting.

Then about surgical volumes, which is something that we wanted to see. In the intraoperative group the volumes tended to be smaller compared to the wire group. Not only this, we have checked with the calculated resection rate which is a mathematical formula that permits us to evaluate the excess of healthy breast tissue that resected. This is a bit tricky to understand but in an ideal world we would excise the DCIS with just a couple, 1-2mm, of healthy tissue around, this is in an ideal world. In real life it’s almost impossible to perform that type of surgery so we always excise a bit more of healthy breast tissue than the ideal minimum. Then if we compare our two techniques we find that in the ultrasound group, in the intraoperative ultrasound group, we excise half of the healthy breast tissue compared with the wire group. That, we hope, may have an impact on cosmetics and also for patient satisfaction. 

Those are the main results of this study. It’s much more comfortable, less rates of positive margins, less second surgeries and less healthy breast tissue resected compared to the wire.

How can these results impact the future screening and treatment of breast cancer?

It’s for DCIS, for ductal carcinoma in situ, the idea is to get rid of the wire. As we were saying before, it’s really uncomfortable for the patient. You know you have a surgery that very day, before the surgery you need to go to the radiologist then he will get a needle, a long needle, he will put it in your breast, he may be moving it and it’s really, really, really, really stressing, it creates a lot of anxiety. Even the wire can move and that way the surgeon won’t be performing a proper surgery. 

With the ultrasound we get rid of that and, not only this, we excise less tissue and with lower amounts of positive margins which means less second surgery that, at the end of the day, is less money because we don’t need to perform the surgery on a woman that maybe with the ultrasound would have only needed one surgery.