Breast Surgery Techniques: Preoperative Bracketing Wire Localization By Surgeons/DISCUSSION

Written By: Sam Savage

Published Date: August 3, 2007 Last Edited: August 3, 2007

By Burkholder, Hans C Witherspoon, Laura E; Burns, R Phillip; Horn, Jeffrey S; Et al

With the development of expertise in image guidance for breast surgery, many surgeons now perform preoperative wire localization themselves. Use of a single wire versus multiple wires to bracket a radiographic breast abnormality has previously been described, although benefits of this technique based on clinical outcomes such as margin status, tissue volume removed, and re-excision rates have not been established. This study is a retrospective analysis of wire- localized breast biopsies performed by 14 surgeons over 29 months; stereotactic and ultrasound guidance were used. During this time, 489 wire localizations were done, of which 159 used multiple wires. Two hundred eleven of these biopsies were done for malignant disease, 86 using multiple wires. After controlling for tumor node metastases stage, single and multiple wire placements were compared using endpoints of margin status, need for re-excision, and total volume of tissue removed. Neither margin status nor re-excision was related to the number of wires placed. However, the number of wires placed was significantly related to the total volume of tissue removed. Use of more than one localizing wire was associated with greater volume of tissue removal (measured in centimeters cubed) in benign disease (46 vs 25, P 80) surgeons did not differ in the type or stage of breast pathology treated. Surgeons with high case volumes were more likely to place multiple localizing wires (P

Methods other than traditional mammogram-guided wire localization guidance have since been developed for localizing breast lesions. Other imaging modalities have been used, including stereotactic, sonographic, or magnetic resonance imaging (MRI) guidance.5-1 ‘Other localization techniques have been developed, including radioactive seed, encircling guide wire, and cryo-assisted localization.12-17

Although initial preoperative wire localizations were done using a single localizing wire, Silverstein et al.18- 19 in the late 1980s recommended the use of bracketing wires. This technique involves placing multiple wires around a lesion to better define the target resection area. Silverstein recommended that this technique be used to outline the borders of larger, more comPlex lesions- He suggested that that this would allow these patients to undergo breastconserving procedures instead of a mastectomy, and that it would also result in fewer re-excision lumpectomies than if a single wire were used. 18

Several studies have subsequently described results obtained using bracketing wires in breast surgery.20-22 Liberman et al’ s20 prospective nonrandomized study evaluated the results of bracketing wire localization performed by radiologists in 103 patients. Positive histologic margins, with negative margins being defined as >/= 1 mm, were obtained in 56 per cent of malignant lesions in which this localization technique was used. The only predictor of positive margin status in their study was the density of the breast, with more dense breasts being more likely than mild or moderately dense breasts to have positive margins after use of bracketing wires for breast biopsy.

Wallace et al.” reported on the use of MRI-guided placement of bracketing wires in a retrospective analysis of 26 patients. In their study, 43 per cent of malignant lesions in which this technique was used had positive histologic margins. They defined a negative margin as >/=3 mm for malignant disease and >/=5 mm for ductal carcinoma in situ (DCIS). Younger patient age and increasing size of the breast lesion were associated with the need for re- excision, whereas breast density was not.

None of these prior studies have compared the outcomes of breast biopsies performed using bracketing wires with those performed with a single localizing wire. The purpose of this study was to compare clinical outcomes of these two techniques in terms of margin status, tissue volume excised, and re-excision rates. It is also the first study to report results of bracketing wire placement by surgeons.

Methods

We retrospectively reviewed wire localizations done by 14 surgeons during a 29-month time interval extending from January 2003 through May 2006. Potential study participants were identified from the University Surgical Associates billing records by current procedural terminology (CPT) codes for wire localization. Patients were excluded from the study if their breast biopsy was not done as part of a breast-conserving procedure. Approval for the study was obtained from the Institutional Review Board at the University of Tennessee College of Medicine, Chattanooga Unit.

All wire localizations were done preoperatively by a surgeon using sonographic or stereotactic guidance. Needle localizations were done with a Kopans wire system. The number of wires placed and imaging technique used were obtained from the procedure note dictated by the surgeon at the time of wire placement. The distance to the closest margin was recorded in the pathology report and for purposes of this study were considered close or positive if =3 mm.

Results were analyzed using logistic regression, analysis of variance, and chi-squared test. All data recording tissue volumes were converted to the logarithm to the base 10 before performing statistical tests. The data were recorded and analyzed using SPSS 13.0 for Windows (SPSS, Chicago, IL).

Results

During the study interval, 511 wire localizations were performed. Of these 5 1 1 wire localizations, 489 met study criteria and were included. Twelve wire localizations were excluded because of the localization being performed at the time of another unrelated procedure such as reduction mammoplasty. Ten wire localizations were excluded because of the inadequacy of available information relative to study parameters. Of the 489 wire localizations that met study criteria, 159 (32.5%) used more than one localizing wire. Of the 489 wire localizations, 21 1 (43.1%) were done for malignant disease. The remaining 278 wire localizations were done for benign or premalignant conditions. Follow-up time for all study patients ranged from 1 to 41 months, with a mean of 14.4 months and a standard deviation of 11.0 months.

Two hundred fifty-four wire localizations were done for benign disease, and 24 were done for premalignant conditions. Of the 254 biopsies done for benign disease, 63 (24.8%) used multiple localizing wires. Core biopsies had been done preoperatively in 132 (52.0%) of the patients whose final pathology demonstrated benign disease. Of the 24 biopsies done for premalignant disease, 10 (41.7%) of which were performed using multiple localizing wires, 19 (79.2%) had preoperative core biopsies. Only 22.5 per cent of patients with preoperative core biopsies demonstrating benign disease had multiple localizing wires placed compared with 44.7 per cent of patients with a preoperative core biopsy demonstrating nonbenign disease (P

Of the 278 patients with benign or premalignant disease, a total of three patients had a second surgical procedure. Two of these patients had premalignant disease and one had benign disease. Of the two patients with premalignant disease, one patient had lobular carcinoma in situ (LCIS) and the other had atypical lobular hyperplasia. Both of these women requested bilateral mastectomies. The patient with benign disease had pain and a palpable lump at the previous lumpectomy site. The pathology from her re-excision lumpectomy also demonstrated benign disease.

Of the 211 procedures done for malignant disease, 86 (40.8%) used multiple localizing wires. Preoperative core biopsies were done in 179 (84.8%) of these patients. After controlling for tumor node metastases stage, outcomes of single and multiple wire placements were compared. Endpoints of analysis were histologic margin status, whether another operation was done, and the total volume of tissue removed (Table 1). Of the 21 1 patients with malignant disease, 45 (21.3%) had positive margins, and 56 (26.7%) had a second operation including re-excision lumpectomy and mastectomy. Positive histologic margins were present in 25.6 per cent of biopsies using a single wire, and 17.4 per cent of biopsies using bracketing wires, but this difference did not reach statistical significance (P = 0.11). Having positive margins was related to tumor node metastases stage, with higher stage lesions being more likely to have positive margins (P = 0.01). The number of localizing wires did not affect whether another operation was performed. Twentyeight per cent of patients with single wire localization had another surgical procedure compared with 25.6 per cent of patients with two or more wires (P = 0.66). Of the 56 patients with malignant disease who had a second surgical procedure, 23 (41.1%) had a re-excision lumpectomy and 33 (58.9%) had a mastectomy. In these patients requiring a second procedure, 52.6 per cent were done because of DCIS at the histologic margin, and 35.1 per cent were performed because of invasive carcinoma at the margins. The remaining 12.3 per cent of the patients who underwent a second procedure had negative histologic margins, but opted to have a mastectomy rather than undergo radiation therapy.

Most wire placements in malignant disease were done stereotactically with 59.6 per cent of single wires and 96.5 per cent of multiple wires being placed using this method. The method of wire placement, whether sonographic or stereotactic, was not related to margin status or whether a second surgery was performed (P = 0.73).

The number of wires placed was significantly related to the total volume of tissue removed as measured in cubic centimeters (Fig. 1). In benign disease, the use of more than one localizing wire was associated with greater volume of tissue removal (46 vs 25 cm^sup 3^, P

Table 1. Outcomes and Number of Localizing Wires in Malignant Disease

FIG. 1. Number of wires and volume of tissue removed.

Based on the number of cases performed during the study period, surgeons were divided into low- (1-40), medium- (41-80), and high- volume (>80) groups. Of the 14 surgeons included in the study, 10 were in the low-volume group (2-40 cases), 2 were in the medium- volume group (49 and 66 cases), and 2 were in the high- volume group (84 and 156 cases). The high-, medium-, and low-volume surgeons did not differ in the type or cancer stage of breast pathology treated (P = 0.20).

Multiple localizing wires were placed more frequently by high- volume surgeons (41.7%) than by medium- (22.8%) and low- (24.6%) volume surgeons (P

TABLE 2. Surgeon Case Volume and Outcomes

Conclusions

Several other studies have previously described the results of breast biopsies done using bracketing wires.1 1, 20-22 Our study is larger than any of the previous studies, and is also the first to compare outcomes using multiple wires with outcomes using a single localizing wire. It is also unique in that it describes results of bracketing wires when placed by surgeons rather than radiologists.

In the previous studies of bracketing wires, positive margin rates of 43 per cent to 58 per cent were described using stereotactic or MRI wire placement for breast lesions that were malignant. Our positive margin rate of 17.4 per cent when bracketing wires were used is lower than in these previous studies. However, it is difficult to compare the results of these studies given the differences in definition of a positive margin ranging from 1 to 5 mm.

Our positive margin rate of 21 .4 per cent overall, as well as the 25.6 per cent rate found with single wire placement, compare favorably with published rates. In similar studies, positive margin rates ranging from 24 per cent to 60 per cent are described.12, 17, 20, 23, 24

Wire-localized breast biopsies have a false-negative rate that is quoted as 2 per cent or less.23- 25- 26 During the follow-up period, two lesions that had been missed at the time of the original wire localization were identified. In both patients, mammographie findings 6 months after the wire-localized breast biopsy were similar to preoperative findings, suggesting that the lesion had been missed. Final pathology on one patient demonstrated a mucinous carcinoma, and the other had DCIS. Our false-negative rate is therefore 1 per cent.

These findings confirm that surgeons do well when performing wire localizations themselves. Although our study was not designed to examine this, there are benefits to wire localization being performed by the operating surgeon. Increased familiarity with the mammographie findings and choice of directional approach for wire placement may lead to more adequate excision.

Our study did not demonstrate an advantage for bracketing wire placement in outcomes such as positive histologic margins and reoperation rates. However, as Fig. 1 shows, less tissue volume was removed in malignant disease when multiple wires were used. This decrease in excised tissue volume was done without sacrificing margin status. Although we did not measure cosmetic outcomes in this study, previous studies have demonstrated an improved cosmetic outcome with decreasing volumes of tissue excised.27, 28 This suggests that use of bracketing wires may facilitate a superior cosmetic result.

In benign breast disease, the use of bracketing wires resulted in an increased volume of tissue excised compared with use of a single localizing wire. It is likely that this resulted from a higher index of suspicion at the time of wire placement that the lesion was malignant. Where preoperative core biopsy showed benign breast disease, single wire placement was more common.

This study is retrospective and the decision about number of wires placed was made by the individual surgeon. This decision was influenced by preoperative core biopsy findings or lesion characteristics on ultrasound or mammography. The results of bracketing wire placement from this study cannot be extrapolated to sonographic placement because the majority of bracketing wires were placed stereotactically.

A number of British studies have demonstrated management differences as well as survival benefits for breast cancer patients based on the case volume of their surgeon, with higher volume surgeons having better outcomes.29-32 Although our study did not demonstrate differences between surgeons in terms of achieving negative histologic margins, it did demonstrate that surgeons managed breast lesions differently based on their case volumes. Surgeons who performed a higher volume of breast cases were less likely to perform a second procedure, and were more likely to perform a breast-conserving procedure in those cases where they did do a second procedure. In addition, higher volume surgeons were more likely to use bracketing wires.

This study demonstrates that bracketing wires can be used to significantly reduce the volume of breast tissue removed in malignant disease without sacrificing margin status or increasing the need for future procedures. Further research with a prospective randomized study is needed to define the patient population for whom this technique is most beneficial.

REFERENCES

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17. Tafra L, Fine R, Whitworth P, et al. Prospective randomized study comparing cryo-assisted and needle-wire localization of ultrasound-visible breast tumors. Am J Surg 2006;192:462-70.

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HANS C. BURKHOLDER, M.D.,* LAURA E. WITHERSPOON, M.D., F.A.C.S.,* R. PHILLIP BURNS, M.D., F.A.C.S.,* JEFFREY S. HORN, M.D.,* MICHAEL D. BIDERMAN, Ph.D.[dagger]

From the * Department of Surgery, University of Tennessee, College of Medicine, Chattanooga Unit, Chattanooga, Tennessee; [dagger] Department of Psychology, University of Tennessee at Chattanooga, Chattanooga, Tennessee

Presented at the Annual Scientific Meeting and Postgraduate Course Program Southeastern Surgical Congress, Savannah, GA, February 10-13, 2007.

Address correspondence and reprint requests to L.E. Witherspoon, M.D., F.A.C.S., 979 East Third Street, Suite 401, Chattanooga, TN 37403.

DISCUSSION

GEORGE M. FUHRMAN, M.D. (Atlanta, GA; Opening Discussion): The title of the paper “Preoperative Wire Localization by Surgeons” is controversial. The controversy is not focused on the procedure, but which specialist performs the procedure. I am going to focus my comments on the controversy and ignore the specifics of the technique.

The one- versus two-wire approach is well described in the manuscript. The technique for wire localization is far less interesting than the controversy. We could have probably had the same discussion a decade or so ago in the vascular surgery community regarding angiography performed by the surgeon as opposed to the radiologist. Like preoperative wire localization of the breast, angiography was once exclusively under the domain of the radiologist. If surgeons plan to take on the radiologist for the opportunity to perform preoperative wire localization, what can we learn from our vascular colleagues about these turf battles?

My first question is a practical one. How did you gain the training and credentials in your hospital to perform wire localization? Do your graduates who enter practice perform their own wire localizations?

Second, if surgeons are going to perform or offer these services to perform procedures that are typically done by other specialties, then we must demonstrate proficiency. Can surgeons provide equivalent or perhaps even better care than our radiology colleagues in performing wire localization? So, what is your miss rate? You had a total of 278 patients with a benign diagnosis in which four of them required a reoperation. My calculation puts that as a 1 .5 per cent “miss” rate, which is consistent with radiology literature. The margin-negative excision rate is excellent at 83 per cent, but were there some patients in the malignant group that underwent wire localization where the index lesion was not excised?

My third question is also about the 278 patients with a benign diagnosis from your entire group. I am a little bit concerned that well over half of your patients who underwent wire localization were done for benign disease. With the availability of image-guided breast biopsy techniques to document the benign etiology of an abnormal mammogram, that number seems too high and I think requires explanation. I think we have to be careful not to extend the indications for wire localization incisional biopsy for benign lesions than can be optimally managed with core-biopsy documentation of their benign nature and surveillance.

You used a less than 3-mm margin as a definition of a negative margin. I would encourage you to re-examine this and simply use the definition of an adequate negative margin. How do you define a 1-mm negative margin that is posterior in the breast? When the pectoralis fascia is removed, there is no additional tissue other than the pectoralis muscle. Most surgeons would be satisfied that that was an adequate negative margin.

What about the reward? What is the reimbursement for wire localization placement?

Finally, tell me about your relationship with your radiology colleagues. Certainly, the practice of general surgery requires a working relationship with radiologists. How have you accomplished this in your institution?

ANEES CHAGPAR, M.D. (Louisville, KY): How many of the patients had their wire localization done by the surgeon under stereotactic guidance versus under ultrasound guidance? Was this done in advance of the surgical procedure or in the operative field itself? Many of us will use the expertise of our radiology colleagues in doing wire localization simply because we are busy in the operating room itself. If these were done under ultrasound guidance, then why is there a need for needle localization at all? I have enjoyed your presentation.

PATRICK GATMAITAN, M.D. (Johnstown, PA): Did patients have prior biopsy, perhaps stereotactically, before the wire localization incision? Of those patients who had the prior biopsy, who had malignant disease, DCIS, or atypia, and what was the positive margin rate for single wire versus the bracketing? Is there really a need to proceed with a wire localization biopsy if you have a stereotactic capability in your institution?

HANS BURKHOLDER, M.D. (Chattanooga, TN; Clos ing Discussion): In terms of credentialing, the faculty group purchased their own stereotactic machine in our office. After training, our surgeons performed their own wire localizations. Many of our graduates have chosen to perform their own wire localizations. In terms of a “missed” rate, we found two lesions of the patients who eventually wound up having malignant disease that were undetected of the 211, for a “missed” rate of under 1 per cent, which is in line with published data. You mentioned four patients who had benign disease and had reincisions. Two of these patients had premalignant conditions with adequately excised margins that desired bilateral mastectomies because they had previous biopsies and were tired of undergoing those. With two of the patients with benign disease, one had had a lumpectomy and desired re-excision of that because of pain at the site, and the other patient had a mastectomy because of disease on the contralateral side. None of those were misses.

Regarding the high number of excisions for benign disease, we agree that is higher than desirable. This is primarily a patient- driven process in that those with a mammographie abnormality in their breast are insistent that it be removed.

I do not know the reimbursement issues. In regard to the question about our relationship to our radiology colleagues, I have not sensed any hostility from them regarding this, and I think we have a good working relationship with them.

There was a question regarding the number of procedures performed using ultrasound guidance versus a stereotactic approach. There was a much higher number of ultrasonographic-guided wire placements in benign disease that reached 40 per cent of those patients. It was 4 per cent for the malignant patients. In our benign disease group, we ran statistical analyses that showed that the method of wire placement did not correlate with any of the outcomes. There was also a question regarding preoperative biopsies and how often they were performed. These were done in 50 per cent of the patients who had benign disease on their final pathology and in 85 per cent of the patients with malignant disease.

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