Abstract
PurposeMammographic screening programmes have increased detection rates of non-palpable breast cancers. In these cases, wire-guided localization (WGL) is the most common approach used to guide breast conserving surgery (BCS). Several RCTs have compared WGL to a range of novel localization techniques. We aimed to perform a network meta-analysis (NMA) of randomized controlled trials (RCTs) comparing methods of non-palpable breast cancer localization.MethodsA NMA was performed according to PRISMA-NMA guidelines. Analysis was performed using R packages and Shiny.Results24 RCTs assessing 9 tumour localization methods in 4236 breasts were included. Margin positivity and reoperation rates were 16.9% (714/4236) and 14.3% (409/2870) respectively. Cryo-assisted localization had the highest margin positivity (28.2%, 58/206) and reoperation (18.9%, 39/206) rates. Compared to WGL (n = 2045 from 24 RCTs) only ultrasound guided localization (USGL) (n = 316 from 3 RCTs) significantly lowered margin positivity (odds ratio (OR): 0.192, 95% confidence interval (CI): 0.079–0.450) and reoperation rates (OR: 0.182, 95%CI: 0.069–0.434). Anchor-guided localization (n = 52, 1 RCT) significantly lowered margin positivity (OR: 0.229, 95%CI: 0.050–0.938) and magnetic-marker localization improved patient satisfaction (OR: 0.021, 95%CI: 0.001–0.548). There was no difference in operation duration, overall complications, haematoma, seroma, surgical site infection rates, or specimen size/vol/wt between methods.ConclusionUSGL and AGL are non-inferior to WGL for the localization of non-palpable breast cancers. The reported data suggests that these techniques confer reduced margin positivity rates and requirement for re-operation. However, caution when interpreting results relating to RCTs with small sample sizes and further validation is required in larger prospective, randomized studies.
Highlights
The establishment of mammographic breast cancer screening pro grammes and enhancement of diagnostic strategies for breast cancer have facilitated an increase in the detection of non-palpable breast le sions [1]
The results of this analysis suggest overall margin positivity and reoperation rates are similar for conventional wire-guided localization (WGL) and the 8 other novel localization methods, the crude numbers illustrate a difference in these outcome measures which is likely to be clinically relevant: We observed an absolute reduction of almost 75% in margin positivity for those undergoing ultrasound guided localization (USGL) (USGL: 5.4% vs. WGL: 20.1%), as well as an estimated 80% estimated relative reduction in margin positivity (OR: 0.192) and the requirement for reoperation (OR: 0.182) respectively
Previous meta-analyses have been undertaken in attempt to address the most effective method of breast tumour localization, including a network meta-analysis (NMA) of 18 randomized controlled trials (RCTs) performed by Athanasiou et al which highlighted reduced margin positivity rates when using USGL (OR: 0.19), [25]
Summary
The establishment of mammographic breast cancer screening pro grammes and enhancement of diagnostic strategies for breast cancer have facilitated an increase in the detection of non-palpable breast le sions [1]. WGL of non-palpable cancers have been reported to have positive margin rates as high as 17.0%, often requiring reoperation, and conferring an increased risk of local recurrence [5,6]. WGL is currently the most common approach used to guide the localization of non-palpable breast cancer, there are a number of limitations to be considered with this approach: WGL may be compli cated by the displacement of the guide-wire prior to or during the operation, and inaccurate placement of the wire in relation to the tumour may negatively impact clear margin rates. The wire acts as a guide for the operating surgeon This indicates that with the aid of pre-operative imaging, a judicial approximation of the extent of the entire tumour volume is made intraoperatively, which may result in human error. Efforts to enhance breast cancer localization are imperative in the current breast cancer surgery paradigm
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