Lessons Learned from 210 Concomitant Image-guided Biopsy with Preoperative Localization Procedures: Surgery Outcomes and Imaging Findings from a High-volume Community Practice

Background: Breast imaging plays a pivotal role in the diagnosis, staging, and short and long-term surveillance of cancer patients. Patients who present with suspicious breast or axillary lymph node lesions, strongly predicted to require both needle biopsy (Bx) and preoperative localization (Loc) to guide surgery may benefit from a single-step concomitant image-guided Biopsy with Localization (Bx-Loc). The wire-free localization device serves as both a biopsy tissue clip marker and localizer. It remains inert until activated and ideally allows for pre- and post-operative assessment of the lesion and adjacent tissue via US, MG, PET/CT, and MRI.

Learning Objectives: Using examples from our 5-year clinical experience with concomitant Bx-Loc, this pictorial will review:
1) which lesions might be managed with concomitant Bx-Loc procedure
2) preoperative imaging options throughout the neoadjuvant treatment period
3) how surgical management options are maintained in Bx-Loc patients
4) follow-up imaging of non-surgical patients throughout longer-duration Loc periods (300-1,239 days)

Abstract Content/Results: Institutional Review Board waived consent for retrospective review of 160 female patients who had 210 concomitant Bx-Loc of suspicious breast or axillary lesions between August 29, 2016 – May 19, 2021.
This pictorial review includes 10 clinical examples to reflect patient age 20-89 (mean 53.9) years, lesion site (105 breast, 104 axilla, 1 chest wall), time interval from Bx-Loc to surgery 1-417 (mean 128) days and includes standard-of-care preoperative planning and surveillance images including MRI (111 exams) of patients who did (122) and did not (38) complete surgery to date. Although no supplementary wire localization was required, this pictorial includes examples of supplementary wire localizations (2 breast, 2 axilla, 1 chest wall) performed per surgeon preference. All Loc devices were excised without complications. The review includes examples of patients (21) who are not expected to proceed to surgery [stage IV (7), benign (7), refused (5), myeloma (1), high risk (1)] who proceeded to in-vivo imaging surveillance up to 1,239 days with no device complication, migration, or MRI artifact.

Conclusion: This pictorial review includes clinical examples of patients who presented with suspicious lesions that were strongly predicted to require both needle Biopsy and Localization to guide surgery and who were clinically assessed to potentially benefit from single-step Bx-Loc. Our surgical outcomes and long-term imaging surveillance experience demonstrate how surgical oncology treatment options and preoperative surveillance with MRI is preserved, how downstream redundant needle localization procedures are avoided for some patients, and demonstrates why some patients may proceed to imaging surveillance without surgery.