| Wire-guided localization (WGL) |
Well-established Cost-effective Marker placement under radiographic, ultrasound or MRI guidance possible → suitable for localization of lesions visible only upon mammography (e.g., microcalcifications) or MRI Control mammogram or MRI after wire placement possible Reposition in case of some wires possible
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| Radioactive seed localization (RSL) |
Well-established Scheduling flexibility: localization can be performed several days/weeks before surgery or—in case of neoadjuvant therapy—before start of treatment Marker placement under radiographic or ultrasound guidance possible → suitable for localization of lesions visible only upon mammography (e.g., microcalcifications) Control mammogram after marker placement possible Can be combined with isotope-based sentinel node biopsy
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Procedure not authorized in some countries, requires complex radiation safety procedures Radiation exposure to patient and staff Invasive procedure for marker placement necessary In case of marker placement before neoadjuvant therapy signal loss possible in case of longer than planned duration of therapy Reposition after placement not possible Radiation safety concerns regarding MRI-guided localization (Geiger counter is MRI unsafe and cannot be used in case of seed loss in Zone IV) Very low risk of seed rupture or transection, resulting in emergency treatment with iodine to saturate and safeguard the thyroid gland in case of 125I
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| Radio-guided Occult Lesion Localization (ROLL) |
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Scheduling issues: procedure needs to be performed on the day of surgery or the day before Radiation safety procedures required Potential radiation exposure to patient and staff Invasive preoperative procedure necessary Reposition after placement not possible Control mammogram not possible unless contrast also given
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Magnetic and paramagnetic localization
Commercially available systems:
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No radioactivity involved Marker placement under radiographic or ultrasound guidance possible → suitable for localization of lesions visible only upon mammography (e.g., microcalcifications) Scheduling flexibility: localization can be performed several days/weeks before surgery or—in case of neoadjuvant therapy—before start of treatment No decrease of signal over time → reliable detectability in case of longer than planned neoadjuvant therapy Control mammogram after marker placement possible Can be combined with magnetic tracer for sentinel node biopsy
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Concerns regarding use in patients with pacemakers and implantable defibrillators Standard metal surgical tools may lead to interference during measurement Large MRI artifacts Not suitable for lesions visible only upon MRI Higher device cost Adequate localization may be limited in case of a large distance between marker and detection probe Reposition after placement not possible
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Radar reflector-based localization
Commercially available systems:
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No radioactivity involved Minimal MRI artifact Marker placement under radiographic or ultrasound guidance possible → suitable for localization of lesions visible only upon mammography (e.g., microcalcifications) Scheduling flexibility: localization can be performed several days/weeks before surgery or—in case of neoadjuvant therapy—before start of treatment No decrease of signal over time → reliable detectability in case of longer than planned neoadjuvant therapy Control mammogram after marker placement possible
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Potential signal interference with lights in the operating theatre Small MRI artifacts Not suitable for lesions visible only upon MRI Higher device cost Adequate localization may be limited in case of a large distance between marker and detection probe Reposition after placement not possible
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Radiofrequency identification tags (RFID)
Commercially available systems:
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No radioactivity involved Scheduling flexibility: localization can be performed several days/weeks before surgery or—in case of neoadjuvant therapy—before start of treatment Marker placement under radiographic or ultrasound guidance possible → suitable for localization of lesions visible only upon mammography (e.g., microcalcifications) No decrease of signal over time → reliable detectability in case of longer than planned neoadjuvant therapy Unique tag number → differentiation between tags possible Control mammogram after marker placement possible
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Concerns regarding use in patients with pacemakers and implantable defibrillators MRI artifacts Not suitable for lesions visible only upon MRI Higher device cost Adequate localization may be limited in case of a large distance between marker and detection probe Reposition after placement not possible
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| Intraoperative ultrasound (IOUS) |
Direct visualization during surgery No radioactivity involved Patient friendly (non-invasive) No preoperative invasive procedure necessary → scheduling flexibility Specimen sonography is performed immediately after tissue removal → no time loss due to specimen transport Specimen sonography performed in the operating room → exact and reliable topographic localization of close margins for immediate re-excision Relatively low cost
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Surgeon needs to be experienced in breast ultrasound, otherwise radiologist’s presence in the operating theatre necessary Learning curve Useful only for lesions with good sonographic visibility Not suitable for lesions visible only upon mammography (e.g., microcalcifications) or MRI Use in the neoadjuvant setting limited in case of complete remission due to low sonographic visibility of some tissue markers Ultrasound machine must be available in the operating theatre during surgery Some ultrasound machines available in operating theatres are unsuitable for breast ultrasound (frequency, transducer type) or of a much lower quality than machines in the diagnostics department Radiogram showing lesion and marker not possible
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| Carbon |
No radioactivity involved Low cost Scheduling flexibility: localization can be performed several days/weeks before surgery or—in case of neoadjuvant therapy—before start of treatment Marker placement under radiographic or ultrasound guidance possible No MRI artifacts
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Marker cannot be localized without surgical exploration Possible ink migration Intentional or unintentional tattooing of skin Reposition after placement not possible Control mammogram not possible
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