Feasibility of Cone Beam Breast CT–Guided Wire Localization for Non-Palpable Breast Lesions

Feasibility of Cone Beam Breast CT–Guided Wire Localization for Non-Palpable Breast Lesions | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Feasibility of Cone Beam Breast CT–Guided Wire Localization for Non-Palpable Breast Lesions Zhao Xin, Zuo Yang, Yang Jun, Kang Wei, Zheng Zhongtao, Wei Wei, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8327692/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Objective: To evaluate the clinical value of cone-beam breast computed tomography (CBBCT) in wire localization for non-palpable breast lesions. Methods: A total of 39 patients with 45 non-palpable breast lesions underwent wire localization guided by CBBCT. Operation time, intraoperative complications, radiation dose, and postoperative pathological outcomes were recorded to assess the success rate and safety of CBBCT-guided wire localization. Results: CBBCT-guided wire localization was successfully performed in all 39 patients (40 breasts, 45 lesions), achieving a success rate of 100%. No intraoperative complications occurred. Postoperative pathology confirmed complete excision of all localized lesions. The average time spent with non-contrast CBBCT guided wire localization is 27.54±5.83 minutes. When contrast-enhancement CBBCT is used for wire localization, the average time spent is 30.73±5.62 minutes. The difference in operation time is statistically significant with p<0.05. Conclusion: CBBCT-guided wire localization offers a precise and reliable method for preoperative localization of non-palpable breast lesions. It effectively provides accurate guidance for breast lumpectomy without the limitations of conventional image-guided techniques. cone-beam computed tomography wire localization non-palpable breast lesions breast cancer Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Breast cancer is the most common malignant tumor in women worldwide. According to the latest global cancer burden data released by the International Agency for Research on Cancer (IARC) of the World Health Organization, there were approximately 2.29 million new cases of breast cancer in 2022, accounting for 11.5% of all cancer diagnoses, making it the most prevalent malignancy among women globally. With improvements in health awareness, widespread breast cancer screening programs, and advances in imaging technologies, an increasing number of non-palpable breast lesions (NPBLs) have been detected. Among these NPBLs, up to 47% are malignant [ 1 ]. Previous studies have reported that the 8-year survival rate of patients with early-stage, non-palpable breast cancer can reach 95–98%, which is significantly higher than that of palpable breast cancers [ 2 ]. Therefore, early detection and timely intervention for NPBLs are critical for improving patient outcomes. Lumpectomy has gained increasing acceptance in breast cancer management owing to its oncologic effectiveness, preservation of quality of life, and superior cosmetic outcomes compared with mastectomy. The success of lumpectomy relies heavily on accurate preoperative imaging and precise lesion localization to ensure complete tumor excision with clear surgical margins. Among available localization techniques, wire localization remains the most widely used approach due to its simplicity, cost-effectiveness, and ability to provide reliable intraoperative guidance. Wire localization is consistently performed under imaging guidance, particularly for NPBLs that cannot be detected by physical examination. The incorporation of imaging technology into wire localization provides several advantages, including procedural simplicity, high accuracy, and excellent safety. It allows for precise preoperative localization and delineation of lesion boundaries, thereby minimizing the removal of normal breast tissue and reducing the likelihood of positive surgical margins. As a result, imaging-guided wire localization facilitates the development of individualized surgical plans and contributes to optimal cosmetic outcomes following breast-conserving surgery. Consequently, this technique has become widely adopted and plays a crucial role in the management of NPBLs and the implementation of breast-conserving treatment [ 3 ]. Currently, the most commonly used imaging modalities for wire localization include ultrasonography, mammography, and magnetic resonance imaging (MRI), among which ultrasound-guided localization is the most widely adopted procedure [ 4 ]. Ultrasound offers several advantages, including the absence of ionizing radiation, high accuracy for masses, minimal invasiveness, and flexible real-time operation. However, its performance is limited in cases involving non-mass lesions or those characterized predominantly by microcalcifications, where lesion visualization may be suboptimal and highly dependent on operator experience. Although mammography-guided wire localization is more time-consuming than ultrasonography, it is technically straightforward and offers distinct advantages in localizing lesions characterized by microcalcifications or architectural distortions [ 5 ]. However, its effectiveness can be limited in patients with dense breast tissue, where small or obscured lesions may be missed due to tissue superimposition. Compared with ultrasound- and mammography-guided techniques, contrast-enhanced MRI-guided wire localization is less affected by dense breast tissue and allows for more precise targeting of small lesions and non-mass enhancements [ 6 ]. However, MRI demonstrates limited sensitivity for detecting microcalcifications and presents several practical disadvantages including longer procedure time, higher cost, technical complexity, and multiple contraindications to MRI examination. These limitations collectively hinder its widespread clinical application. Cone-beam breast computed tomography (CBBCT) is an emerging three-dimensional (3D) imaging technology characterized by non-compressive acquisition, isotropic high spatial resolution, rapid image acquisition, and fewer contraindications compared with conventional modalities. CBBCT provides clear visualization of the breast anatomical structure and suspicious lesions, including both masses and microcalcifications, and facilitates accurate localization of lesions from multiple viewing angles [ 7 – 8 ]. Furthermore, contrast-enhanced CBBCT can reveal both direct features of lesions (e.g., shape, margin, cystic or solid composition, and enhancement characteristics) and indirect features (e.g., architectural distortion of adjacent glandular tissue, surrounding tortuous vasculature, and increased vascularity) [ 9 ]. These capabilities make CBBCT particularly valuable for precise lesion localization and optimal surgical pathway planning. The CBBCT system is equipped with an image-guided biopsy subsystem comprising a biopsy bracket, grid and backplate, and needle blocks. In conjunction with CBBCT imaging, this subsystem enables localization of breast lesions and facilitates accurate guidance of the biopsy needle or localization wire [ 10 ]. Previous studies have reported favorable outcomes using CBBCT for percutaneous biopsy of breast lesions; however, its application in wire localization procedures remains limited. This study aims to evaluate the feasibility of using CBBCT imaging to guide wire localization in patients with NPBLs. Materials and Methods The prospective study protocol was reviewed and approved by the Ethics Committee (Approval No. CS2019-08) in accordance with the Declaration of Helsinki. Between July 2019 and October 2023, standard-of-care diagnostic CBBCT imaging was performed for patients who required further diagnostic evaluation. The CBBCT images were interpreted by two radiologists, each with more than 10 years of experience in breast imaging diagnosis. Patients presenting with NPBLs detected on CBBCT were eligible for inclusion. Patients were included if they met the following criteria: (1) received a Breast Imaging Reporting and Data System (BI-RADS) category of 3 or higher without other clinical findings sufficient to exclude malignancy; and (2) were able to provide informed consent. Patients were excluded if they met any of the following conditions: (1) the NPBL was located in the axillary region or too close to the chest wall, beyond the operative field of view; (2) had severe systemic disease, bleeding disorders, or coagulopathy; or (3) had spinal deformity or were unable to maintain the prone position for an extended period during the procedure. All enrolled patients provided written informed consent before undergoing the CBBCT-guided wire localization procedure. Procedure Procedure Preparation The CBBCT imaging system used in this study (KBCT-1000; Koning (Tianjin) Medical Equipment Co., Ltd., Tianjin, China) is shown in Fig. 1 . The system was equipped with a dedicated CBBCT biopsy bracket (Fig. 2 ). A grid with a needle guide block and a backplate were used to stabilize the breast and guide the localization needle. Prior to the procedure, diagnostic CBBCT images were carefully reviewed to determine whether the medial or lateral side of the breast would be used for needle insertion. Patient Positioning During the procedure, the patient was positioned prone on the examination table, with both arms placed alongside the head and the affected breast naturally hanging through the table opening into the imaging field. The grid and backplate, mounted on the biopsy bracket, were adjusted to an appropriate position to stabilize the breast with suitable pressure. The side of the breast where the lesion was closest to the skin and most accessible for operation was selected as the needle entry site, which was subsequently disinfected. Pre-insertion Scan A pre-insertion scan was performed on the stabilized breast. For fatty or scattered-dense breasts, a non-contrast CBBCT scan was typically sufficient to locate the lesion. When dense breast tissue was present, or when the non-contrast CBBCT scan could not clearly visualize the lesion, a contrast-enhanced CBBCT scan was performed to identify the target lesion. Table 1 summarizes the scanning parameters used for CBBCT imaging. Table 1 Scanning parameters used in the cone-beam breast computed tomography imaging Parameter Value Tube voltage (kVp) 49 Tube current (mA) 50–160 Tube pulse time (ms) 8 Data acquisition rate (frames/s) 30 Number of projections 300 Acquisition time (s) 10 Focal spot size (mm) 0.3 Reconstructed isotropic voxel size (mm 3 ) (0.155) 3 or (0.273) 3 For contrast-enhanced imaging, an iodinated contrast agent (320 mg I/mL) was administered intravenously using a dual-syringe power injector at a flow rate of 2 mL/s, with a total volume of 1.5–2.0 mL/kg. A single-phase contrast-enhanced scan of the affected breast was acquired 60 seconds after the start of contrast injection. Target Localization After the pre-insertion scan, the lesion position was identified using multiplanar views, and the center of the lesion—or the most densely calcified or prominently enhanced area—was selected as the optimal wire localization target. Based on the selected target area, the coordinates, entry path, and insertion depth for the guidewire were determined using the CBBCT software. Wire Insertion Local anesthesia was administered with a small amount of 2% lidocaine at the target area. The wire guide block was placed in the grid corresponding to the coordinates of the target, and the guidewire was inserted into the target area according to the planned trajectory and depth. Wire Confirmation Scan A non-contrast CBBCT scan was then performed to confirm the guidewire tip position. After verification, the guidewire was released from the sheath and the hooked end was deployed. Post-Insertion Scan The grid and backplate were then removed to release the breast from the stabilized state. A follow-up non-contrast CBBCT scan was performed to confirm the final position of the guidewire hook with the breast in an uncompressed state. The external portion of the guidewire was then secured and wrapped with sterile gauze. Post-Surgery Specimen Scan After surgical excision, a non-contrast CBBCT scan was performed on the resected specimens to assess the guidewire integrity and confirm whether the microcalcification lesions had been completely removed. When multiple lesions in the ipsilateral breast were localized using guidewires, CBBCT was performed to verify the position of each guidewire tip after placement. Results A total of 39 patients were enrolled in this study, including 45 lesions across 40 breasts. The demographic information of the patients is summarized in Table 2 . Among the 39 patients, one patient had four ipsilateral lesions, one patient had four bilateral lesions-two in each breast, and two patients had two ipsilateral lesions. Table 2 Clinical data of the patients Clinical data n = 39 Mean age (years) 43.18 ± 7.42 Menstrual state No menopause 35 Has been menopausal 4 Type of glandular tissue Dense type 33 Non-dense type 6 Time-consuming (points) Single lesion 29.54 ± 5.82 Multi-onset foci 37.25 ± 7.41 Unilateral breast radiation dose (mGy) 20.10 ± 7.58 CBBCT-guided wire localization was successfully performed for all lesions. The success rate of CBBCT-guided wire localization was 100% (Figs. 3 and 4 ), with no complications observed in any procedure. Pathological examination further confirmed that all targeted lesions were completely excised following surgical resection. The pathology and sizes of the lesions are summarized in Table 3 .Table 4 compares the diagnostic results of CBBCT and ultrasound before guidewire positioning with the postoperative pathological results. Table 3 Lesion imaging and pathological data of the patients Lesion imaging and pathological data n = 45 The longest diameter of the lesion ≤ 5 mm 10 5–10 mm 22 > 10 mm 13 Imaging type of the lesion Non-calcified lesion 20 Mass or non-mass enhancement with calcification 15 Pure microcalcification 10 Histopathological results Cyclomastopathy 11 Adenopathy 7 Fibroadenoma 4 Catheter epithelial dysplasia 1 Breast ductal dilation 2 Intraductal papillomas coexist with hyperplasia 1 Ductal carcinoma in situ 9 Infiltrating cancer 10 Table 4 Comparison of the CBBCT and ultrasound diagnoses with the pathological results Pathological results (n = 45) CBBCT diagnosis Ultrasound diagnosis BI-RADS 1 BI-RADS 2–3 BI-RADS 4–5 BI-RADS 1 BI-RADS 2–3 BI-RADS 4–5 Optimum 0 8 18 16 3 7 Malignant 0 0 19 11 2 6 BI-RADS, breast imaging-reporting and data system; CBBCT, cone-beam breast computed tomography The time spent in the procedure varies with the patient conditions, whether contrast imaging was performed to identify the lesion, and the number of lesions in one procedure. The time spent under different patient conditions is summarized in Table 5 . Table 5 Time by Patient Condition Condition Average Time (min) Single ipsilateral lesions without contrast enhancement (n = 13) 27.54 ± 5.83 Single ipsilateral lesions with contrast enhancement (n = 22) 30.73 ± 5.62 Four ipsilateral lesions (n = 1) 44 Two ipsilateral lesions (n = 2) 31 Four bilateral lesions, two in each breast (n = 1) 43 Discussion Clinical Context and Rationale Wire localization remains the most widely used approach for guiding surgical excision of NPBLs. Conventional guidance modalities—ultrasound and mammography—are effective for certain lesion types but have well-recognized limitations. In particular, these methods often fail to detect or accurately localize small or subtle lesions, especially microcalcifications and non-mass-like enhancements embedded within dense breast tissue [ 11 ]. This diagnostic gap complicates preoperative planning and increases the risk of incomplete excision or repeated interventions. To address these challenges, CBBCT has emerged as a three-dimensional breast imaging modality capable of visualizing both microcalcifications and soft-tissue contrast within a single exam, with or without contrast enhancement. Its tomographic reconstruction eliminates tissue overlap and provides high-resolution isotropic images, offering a potential solution to the limitations of conventional 2D methods. Imaging Strengths and Diagnostic Rationale of CBBCT CBBCT displays the breast in a true 3D model, enabling observation of lesions from multiple perspectives. When combined with contrast enhancement, it allows clear visualization of lesion intensity, morphology, and vascular features, as well as surrounding parenchymal structures. This capability is particularly advantageous for calcifications, small or multifocal lesions, and non-mass lesions that are frequently occult on ultrasound or mammography. Moreover, CBBCT’s volumetric data enables accurate measurement of needle trajectory and insertion depth, allowing operators to plan the optimal wire localization path with precision. Its high spatial resolution and optional use of contrast agents substantially increase the detection rate of occult, small, and non-mass-enhancing lesions, surpassing traditional 2D modalities in both sensitivity and localization accuracy [ 12 , 13 ]. Technical and Procedural Advantages The CBBCT-guided wire localization system incorporates a specialized localization device and 3D reconstruction image guidance technology. This integration allows precise targeting of small lesions while maintaining a fixed breast position throughout the procedure. Compared with mammography, ultrasound, and MRI, the CBBCT-guided wire localization is less dependent on operator experience, involves fewer manual adjustments, and is not limited by magnetic field constraints [ 14 ]. Wire-localization generally takes 30 min with mammography guidance and 13 min with ultrasound guidance, given the conditions that these lesions are visible on the modalities used for guidance [ 15 ]. The average time spent with CBBCT-guided wire localization is 27.54 min without contrast and 30.53 with contrast enhancement. Using CBBCT guidance does not significantly increase the procedure time compared with mammography guidance even with the use of contrast enhanced imaging, yet the detectability of lesions, especially within dense tissue is greatly increased with CBBCT, which was proved by the diagnostic performance of CE-CBBCT vs. diagnostic mammography reported in earlier studies. Although ultrasound is a much faster procedure, ultrasound may fail to detect NMPLs and making the ultrasound-guided procedure unapplicable. Our study compares the diagnostic results of CBBCT and ultrasound in the diagnostic workup phase of the cases. Only 40% of the lesions were detectable by ulatrasound, compared with 100% detected by CBBCT. The CBBCT system enables simultaneous localization of multiple lesions. In this study, three patients with multiple ipsilateral breast lesions successfully underwent multi-wire placement, with all lesions subsequently excised. The positioning information for all ipsilateral lesions can be acquired within a single scan without repositioning the patient, thereby simplifying workflow and the complexity of the procedure. Procedure Efficiency and Workflow The CBBCT wire-localization protocol was streamlined into three essential scans: Pre-insertion Scan: Lesion localization with or without contrast enhancement Wire Confirmation Scan: Wire localization confirmation before hook deployment, and Hook Confirmation Scan: Confirmation after the hook deployment The CBBCT-guided wire localization workflow demonstrated a high technical success rate, with 42 of 45 lesions (93.3%) localized without the need for re-scanning. Wire confirmation scan was repeated in 3 cases (6.7%) due to slight misalignment between the wire tip and the target lesion. This minor misalignment could potentially be minimized by using a needle block with smaller guide holes more closely matched to the wire diameter, thereby further improving targeting accuracy. Notably, in cases with multiple ipsilateral lesions, all positioning information was acquired in one scan, and the placement of multiple guidewires did not increase the number of scans needed. The major factors determining the total procedure time were operator experience and the ability to quickly recognize the lesion-wire relationship. Thus, repeated model-based training is recommended to improve procedural efficiency. Radiation Dose While CBBCT involves X-ray exposure, its radiation dose can be optimized and individualized based on the patient’s breast density type and scanning parameters (e.g., tube voltage, current, and scan phase). A large study involving 1590 Chinese patients reported that the mean glandular dose (MGD) of CBBCT varies from 3.9 to 5.1 mGy [ 16 ]. In this study, the MGD was 20.10 ± 7.58 mGy because of the multi-phase scans used in the workflow, which is lower than previously reported CBBCT-guided puncture biopsy and conventional radiography-guided localization biopsy [ 13 ] (31.7 ± 16.0 mGy and 37.7 ± 24.2 mGy, respectively). Limitations and Challenges CBBCT-guided wire localization is inherently more time-consuming than ultrasound-guided procedure because of the need for three scans. The requirement for patients to lie prone during imaging may present difficulty for individuals with limited spinal mobility, shoulder periarthritis, or other conditions restricting positioning. Furthermore, because the CBBCT field of view does not fully cover the axillary tail, lesions located in this region may be difficult to be targeted [ 17 ]. Ongoing efforts should focus on improving ergonomic design, expanding field coverage, and improving operator training to enhance patient comfort and workflow efficiency. Conclusion CBBCT-guided wire localization is a precise and innovative technology that enables clear visualization of microcalcifications and soft-tissue lesions, thereby facilitating the detection and preoperative localization of NPBLs occult to other modalities. This method offers significant advantages over conventional imaging-guided localization techniques, including improved lesion detection, reduced operator dependence, and the ability to guide multi-lesion localization in a single scan. With continued refinement and standardization of the procedural workflow, CBBCT-guided localization is poised to become an important tool in the era of precision breast-conserving surgery. Abbreviations BI-RADS, breast imaging-reporting and data system; CBBCT, cone-beam breast computed tomography; MRI, magnetic resonance imaging; NPBL, nonpalpable breast lesions Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of the Affiliated Cancer Hospital of Guangxi Medical University [CS2019 (08)]. Written informed consent was obtained from all individual participants included in the study. Consent for publication Written informed consent was obtained from all enrolled patients for publication of their personal/clinical details and any potentially identifying images in this manuscript. Availability of data and materials The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by the Guangxi Clinical Research Center for Medical Imaging Construction (Grant No. Guike AD20238096), and the Regional High-Incidence Diseases Research of Guangxi Natural Science Foundation (Grant Nos. 2023GXNSFBA026035 and 2023GXNSFBA026247). Authors' contributions X. Zhao and D. Su wrote the main manuscript text. Y. Zuo and J. Yang prepared figures and tables. W. Kang and Z. Zheng performed data analysis. W. Wei and Y. Liu collected data. All authors reviewed the manuscript. Acknowledgements Not applicable. References Skinner K A , Silberman H , Sposto R ,et al.Palpable Breast Cancers Are Inherently Different From Nonpalpable Breast Cancers[J].Annals of Surgical Oncology, 2001, 8(9):705-710. Ball C G , Butchart M , Macfarlane J K .Effect on biopsy technique of the breast imaging reporting and data system (BI-RADS) for nonpalpable mammographic abnormalities[J].Canadian Journal of Surgery, 2002, 45(4):259-263. Masroor I, Afzal S, Shafqat G,et al. Usefulness of hook wire localization biopsy under imaging guidance for nonpalpable breast lesions detected radiologically[J]. Int J Womens Health. 2012;4:445-449. Demiral G , Senol M , Bayraktar B ,et al.Diagnostic Value of Hook Wire Localization Technique for Non-Palpable Breast Lesions[J].Journal of Clinical Medicine Research, 2016, 8(5):389-395 Markopoulos C , Kouskos E , Revenas K ,et al.Open surgical biopsy for nonpalpable breast lesions detected on screening mammography[J].European Journal of Gynaecological Oncology, 2005, 26(3):311. Gao Y, Bagadiya NR, Jardon ML, et al. Outcomes of Preoperative MRI-Guided Needle Localization of Nonpalpable Mammographically Occult Breast Lesions[J]. AJR Am J Roentgenol. 2016;207(3):676-684. Uhlig J , Fischer U , Biggemann L ,et al.Pre- and post-contrast versus post-contrast cone-beam breast CT: can we reduce radiation exposure while maintaining diagnostic accuracy?[J].European radiology, 2019, 29(6):3141-3148. Zhongtao Z , Wei K , Danke SU ,et al.Progresses in biopsy of breast cancer guided by different imaging techniques[J].Chinese Journal of Medical Imaging Technology, 2019. He N, Wu YP, Kong Y, et al. The utility of breast cone-beam computed tomography, ultrasound, and digital mammography for detecting malignant breast tumors: A prospective study with 212 patients[J]. Eur J Radiol. 2016;85(2):392-403. Chinese Association of Breast Surgery. Zhonghua Wai Ke Za Zhi. 2019;57(6):404-407. doi:10.3760/cma.j.issn.0529-5815.2019.06.002 Kuhl C K , Schrading S , Leutner C C ,et al.Mammography, Breast Ultrasound, and Magnetic Resonance Imaging for Surveillance of Women at High Familial Risk for Breast Cancer[J].Journal of Clinical Oncology Official Journal of the American Society of Clinical Oncology, 2005, 23(33):8469-76. Wienbeck S , Uhlig J , Luftner-Nagel S ,et al.The role of cone-beam breast-CT for breast cancer detection relative to breast density[J].European Radiology, 2017. O'Connell,Avice,M,et al.Newer Technologies in Breast Cancer Imaging: Dedicated Cone-Beam Breast Computed Tomography[J].Seminars in Ultrasound Ct & Mri, 2018. Wienbeck,Susanne,Fischer,et al.Contrast-enhanced cone-beam breast-CT (CBBCT): clinical performance compared to mammography and MRI[J].EUROPEAN RADIOLOGY, 2018. Cheung B H H , Co M , Lui T T N ,et al.Evolution of localization methods for non-palpable breast lesions: a literature review from a translational medicine perspective[J].Translational Breast Cancer Research, 2024, 5(Apr):16. Ke X , Hui X , Bao-Rong Y ,et al.An assessment of the average glandular dose of breast cone-beam CT in China based on clinical patients[J].The British Journal of Radiology, 2025, 000(000). Li H, Yin L, Ye Z et al .Comparative study of breast tissue coverage in cone-beam breast CT versus digital mammography[J]. Chinese J Radiol 2025,49:488-490. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 13 Jan, 2026 Editor assigned by journal 12 Jan, 2026 Editor invited by journal 23 Dec, 2025 Submission checks completed at journal 20 Dec, 2025 First submitted to journal 20 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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13:13:27","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":68048,"visible":true,"origin":"","legend":"","description":"","filename":"c6cc3f6e2a1b4e7083ffe7215786b55e1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8327692/v1/1aca7d90addf863d3833495f.xml"},{"id":100411935,"identity":"aa9e8c77-86ae-4e54-9e70-e0deb2bec1e3","added_by":"auto","created_at":"2026-01-16 13:13:36","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":79406,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8327692/v1/17832dc2457f02585d6e744d.html"},{"id":100422161,"identity":"cfacb23f-12cd-4606-9f2e-520b20a28050","added_by":"auto","created_at":"2026-01-16 14:06:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":322658,"visible":true,"origin":"","legend":"\u003cp\u003eThe dedicated cone-beam breast computed tomography system (Koning Breast CT, CBCT 1,000, Koning Corporation).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8327692/v1/e9b3674b83744c404da98369.png"},{"id":100411890,"identity":"55fd4ddd-23b1-4c9f-b303-dacb038c65d8","added_by":"auto","created_at":"2026-01-16 13:13:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":319546,"visible":true,"origin":"","legend":"\u003cp\u003eThe cone-beam breast computed tomography special positioning biopsy bracket equipped with a grid and fixed backplate without a grid. The grid is filled with positioning guide blocks.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8327692/v1/ffb01a85ba5c11506816f2da.png"},{"id":100411880,"identity":"7192db60-35db-4f2f-afba-c6a9f9a2ebcb","added_by":"auto","created_at":"2026-01-16 13:13:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":137751,"visible":true,"origin":"","legend":"\u003cp\u003eA 34-year-old woman, without a clinical mass.(A) On the preoperative coronal CBBCT image of the right breast, focal calcification in the upper quadrant of the right breast (the area indicated by the red arrow) and non-mass-like enhancement in the surrounding glands (the area indicated by the blue arrow) can be observed; (B) Before guidewire implantation, the right-breast CBBCT plain coronal images were used to locate the calcified lesions; (C) The right-breast CBBCT plain scan coronal image after inserting the guidewire showed that the head end of the guidewire was located in the target area; (D) On the CBBCT plain scan image of the isolated specimen after operation, it can be observed that the calcification focus (the area indicated by the yellow arrow) is located in the isolated specimen and the guidewire structure is complete.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8327692/v1/49f795f05bd237ce55543123.png"},{"id":100411990,"identity":"5d1f4f9d-ed17-4e08-97dd-bde9e2465538","added_by":"auto","created_at":"2026-01-16 13:13:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":100496,"visible":true,"origin":"","legend":"\u003cp\u003eA 46-year-old woman with no clinical mass or lesions found using preoperative ultrasound. (A) On the preoperative CBBCT enhanced cross-sectional image of the left breast, the focal non-mass-like enhancement in the upper quadrant of the left breast can be observed (the area indicated by the red arrow); (B) CBBCT enhanced cross-sectional images before guidewire implantation were used to locate the non-mass-enhanced lesion area (the area indicated by the blue arrow); (C) After the guidewire was inserted, the CBBCT plain scan cross-sectional image showed that the head end of the guidewire was located in the target area.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8327692/v1/43ee057e650fde974c087892.png"},{"id":100423824,"identity":"06fc9919-a33b-44fe-8cd6-8e0620288113","added_by":"auto","created_at":"2026-01-16 14:15:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1930349,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8327692/v1/92fe9fd1-c1d8-421a-be22-5333e0b04e4e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Feasibility of Cone Beam Breast CT–Guided Wire Localization for Non-Palpable Breast Lesions","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreast cancer is the most common malignant tumor in women worldwide. According to the latest global cancer burden data released by the International Agency for Research on Cancer (IARC) of the World Health Organization, there were approximately 2.29\u0026nbsp;million new cases of breast cancer in 2022, accounting for 11.5% of all cancer diagnoses, making it the most prevalent malignancy among women globally. With improvements in health awareness, widespread breast cancer screening programs, and advances in imaging technologies, an increasing number of non-palpable breast lesions (NPBLs) have been detected. Among these NPBLs, up to 47% are malignant [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Previous studies have reported that the 8-year survival rate of patients with early-stage, non-palpable breast cancer can reach 95\u0026ndash;98%, which is significantly higher than that of palpable breast cancers [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Therefore, early detection and timely intervention for NPBLs are critical for improving patient outcomes.\u003c/p\u003e \u003cp\u003eLumpectomy has gained increasing acceptance in breast cancer management owing to its oncologic effectiveness, preservation of quality of life, and superior cosmetic outcomes compared with mastectomy. The success of lumpectomy relies heavily on accurate preoperative imaging and precise lesion localization to ensure complete tumor excision with clear surgical margins. Among available localization techniques, wire localization remains the most widely used approach due to its simplicity, cost-effectiveness, and ability to provide reliable intraoperative guidance.\u003c/p\u003e \u003cp\u003eWire localization is consistently performed under imaging guidance, particularly for NPBLs that cannot be detected by physical examination. The incorporation of imaging technology into wire localization provides several advantages, including procedural simplicity, high accuracy, and excellent safety. It allows for precise preoperative localization and delineation of lesion boundaries, thereby minimizing the removal of normal breast tissue and reducing the likelihood of positive surgical margins. As a result, imaging-guided wire localization facilitates the development of individualized surgical plans and contributes to optimal cosmetic outcomes following breast-conserving surgery. Consequently, this technique has become widely adopted and plays a crucial role in the management of NPBLs and the implementation of breast-conserving treatment [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, the most commonly used imaging modalities for wire localization include ultrasonography, mammography, and magnetic resonance imaging (MRI), among which ultrasound-guided localization is the most widely adopted procedure [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Ultrasound offers several advantages, including the absence of ionizing radiation, high accuracy for masses, minimal invasiveness, and flexible real-time operation. However, its performance is limited in cases involving non-mass lesions or those characterized predominantly by microcalcifications, where lesion visualization may be suboptimal and highly dependent on operator experience.\u003c/p\u003e \u003cp\u003eAlthough mammography-guided wire localization is more time-consuming than ultrasonography, it is technically straightforward and offers distinct advantages in localizing lesions characterized by microcalcifications or architectural distortions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, its effectiveness can be limited in patients with dense breast tissue, where small or obscured lesions may be missed due to tissue superimposition.\u003c/p\u003e \u003cp\u003eCompared with ultrasound- and mammography-guided techniques, contrast-enhanced MRI-guided wire localization is less affected by dense breast tissue and allows for more precise targeting of small lesions and non-mass enhancements [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, MRI demonstrates limited sensitivity for detecting microcalcifications and presents several practical disadvantages including longer procedure time, higher cost, technical complexity, and multiple contraindications to MRI examination. These limitations collectively hinder its widespread clinical application.\u003c/p\u003e \u003cp\u003eCone-beam breast computed tomography (CBBCT) is an emerging three-dimensional (3D) imaging technology characterized by non-compressive acquisition, isotropic high spatial resolution, rapid image acquisition, and fewer contraindications compared with conventional modalities. CBBCT provides clear visualization of the breast anatomical structure and suspicious lesions, including both masses and microcalcifications, and facilitates accurate localization of lesions from multiple viewing angles [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, contrast-enhanced CBBCT can reveal both direct features of lesions (e.g., shape, margin, cystic or solid composition, and enhancement characteristics) and indirect features (e.g., architectural distortion of adjacent glandular tissue, surrounding tortuous vasculature, and increased vascularity) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These capabilities make CBBCT particularly valuable for precise lesion localization and optimal surgical pathway planning.\u003c/p\u003e \u003cp\u003eThe CBBCT system is equipped with an image-guided biopsy subsystem comprising a biopsy bracket, grid and backplate, and needle blocks. In conjunction with CBBCT imaging, this subsystem enables localization of breast lesions and facilitates accurate guidance of the biopsy needle or localization wire [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Previous studies have reported favorable outcomes using CBBCT for percutaneous biopsy of breast lesions; however, its application in wire localization procedures remains limited. This study aims to evaluate the feasibility of using CBBCT imaging to guide wire localization in patients with NPBLs.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThe prospective study protocol was reviewed and approved by the Ethics Committee (Approval No. CS2019-08) in accordance with the Declaration of Helsinki. Between July 2019 and October 2023, standard-of-care diagnostic CBBCT imaging was performed for patients who required further diagnostic evaluation. The CBBCT images were interpreted by two radiologists, each with more than 10 years of experience in breast imaging diagnosis. Patients presenting with NPBLs detected on CBBCT were eligible for inclusion.\u003c/p\u003e \u003cp\u003ePatients were included if they met the following criteria: (1) received a Breast Imaging Reporting and Data System (BI-RADS) category of 3 or higher without other clinical findings sufficient to exclude malignancy; and (2) were able to provide informed consent.\u003c/p\u003e \u003cp\u003ePatients were excluded if they met any of the following conditions: (1) the NPBL was located in the axillary region or too close to the chest wall, beyond the operative field of view; (2) had severe systemic disease, bleeding disorders, or coagulopathy; or (3) had spinal deformity or were unable to maintain the prone position for an extended period during the procedure.\u003c/p\u003e \u003cp\u003e All enrolled patients provided written informed consent before undergoing the CBBCT-guided wire localization procedure.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eProcedure Preparation\u003c/h2\u003e \u003cp\u003eThe CBBCT imaging system used in this study (KBCT-1000; Koning (Tianjin) Medical Equipment Co., Ltd., Tianjin, China) is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The system was equipped with a dedicated CBBCT biopsy bracket (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A grid with a needle guide block and a backplate were used to stabilize the breast and guide the localization needle. Prior to the procedure, diagnostic CBBCT images were carefully reviewed to determine whether the medial or lateral side of the breast would be used for needle insertion.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003ePatient Positioning\u003c/h3\u003e\n\u003cp\u003eDuring the procedure, the patient was positioned prone on the examination table, with both arms placed alongside the head and the affected breast naturally hanging through the table opening into the imaging field. The grid and backplate, mounted on the biopsy bracket, were adjusted to an appropriate position to stabilize the breast with suitable pressure. The side of the breast where the lesion was closest to the skin and most accessible for operation was selected as the needle entry site, which was subsequently disinfected.\u003c/p\u003e\n\u003ch3\u003ePre-insertion Scan\u003c/h3\u003e\n\u003cp\u003eA pre-insertion scan was performed on the stabilized breast. For fatty or scattered-dense breasts, a non-contrast CBBCT scan was typically sufficient to locate the lesion. When dense breast tissue was present, or when the non-contrast CBBCT scan could not clearly visualize the lesion, a contrast-enhanced CBBCT scan was performed to identify the target lesion. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the scanning parameters used for CBBCT imaging.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eScanning parameters used in the cone-beam breast computed tomography imaging\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTube voltage (kVp)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTube current (mA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTube pulse time (ms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eData acquisition rate (frames/s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of projections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcquisition time (s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFocal spot size (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReconstructed isotropic voxel size (mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(0.155)\u003csup\u003e3\u003c/sup\u003e or (0.273)\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFor contrast-enhanced imaging, an iodinated contrast agent (320 mg I/mL) was administered intravenously using a dual-syringe power injector at a flow rate of 2 mL/s, with a total volume of 1.5\u0026ndash;2.0 mL/kg. A single-phase contrast-enhanced scan of the affected breast was acquired 60 seconds after the start of contrast injection.\u003c/p\u003e\n\u003ch3\u003eTarget Localization\u003c/h3\u003e\n\u003cp\u003eAfter the pre-insertion scan, the lesion position was identified using multiplanar views, and the center of the lesion\u0026mdash;or the most densely calcified or prominently enhanced area\u0026mdash;was selected as the optimal wire localization target. Based on the selected target area, the coordinates, entry path, and insertion depth for the guidewire were determined using the CBBCT software.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eWire Insertion\u003c/h2\u003e \u003cp\u003e Local anesthesia was administered with a small amount of 2% lidocaine at the target area. The wire guide block was placed in the grid corresponding to the coordinates of the target, and the guidewire was inserted into the target area according to the planned trajectory and depth.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eWire Confirmation Scan\u003c/h3\u003e\n\u003cp\u003eA non-contrast CBBCT scan was then performed to confirm the guidewire tip position. After verification, the guidewire was released from the sheath and the hooked end was deployed.\u003c/p\u003e\n\u003ch3\u003ePost-Insertion Scan\u003c/h3\u003e\n\u003cp\u003eThe grid and backplate were then removed to release the breast from the stabilized state. A follow-up non-contrast CBBCT scan was performed to confirm the final position of the guidewire hook with the breast in an uncompressed state. The external portion of the guidewire was then secured and wrapped with sterile gauze.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePost-Surgery Specimen Scan\u003c/h2\u003e \u003cp\u003eAfter surgical excision, a non-contrast CBBCT scan was performed on the resected specimens to assess the guidewire integrity and confirm whether the microcalcification lesions had been completely removed. When multiple lesions in the ipsilateral breast were localized using guidewires, CBBCT was performed to verify the position of each guidewire tip after placement.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 39 patients were enrolled in this study, including 45 lesions across 40 breasts. The demographic information of the patients is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Among the 39 patients, one patient had four ipsilateral lesions, one patient had four bilateral lesions-two in each breast, and two patients had two ipsilateral lesions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical data of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;39\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.18\u0026thinsp;\u0026plusmn;\u0026thinsp;7.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenstrual state\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo menopause\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas been menopausal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of glandular tissue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDense type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-dense type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime-consuming (points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.54\u0026thinsp;\u0026plusmn;\u0026thinsp;5.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMulti-onset foci\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.25\u0026thinsp;\u0026plusmn;\u0026thinsp;7.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilateral breast radiation dose (mGy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.10\u0026thinsp;\u0026plusmn;\u0026thinsp;7.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCBBCT-guided wire localization was successfully performed for all lesions. The success rate of CBBCT-guided wire localization was 100% (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), with no complications observed in any procedure. Pathological examination further confirmed that all targeted lesions were completely excised following surgical resection. The pathology and sizes of the lesions are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e compares the diagnostic results of CBBCT and ultrasound before guidewire positioning with the postoperative pathological results.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLesion imaging and pathological data of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLesion imaging and pathological data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;45\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe longest diameter of the lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;10 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImaging type of the lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-calcified lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMass or non-mass enhancement with calcification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePure microcalcification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistopathological results\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCyclomastopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFibroadenoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCatheter epithelial dysplasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreast ductal dilation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraductal papillomas coexist with hyperplasia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuctal carcinoma in situ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfiltrating cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the CBBCT and ultrasound diagnoses with the pathological results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePathological results (n\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eCBBCT diagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eUltrasound diagnosis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBI-RADS 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBI-RADS\u003c/p\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBI-RADS 4\u0026ndash;5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBI-RADS 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBI-RADS\u003c/p\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBI-RADS\u003c/p\u003e \u003cp\u003e4\u0026ndash;5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOptimum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalignant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eBI-RADS, breast imaging-reporting and data system; CBBCT, cone-beam breast computed tomography\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe time spent in the procedure varies with the patient conditions, whether contrast imaging was performed to identify the lesion, and the number of lesions in one procedure. The time spent under different patient conditions is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTime by Patient Condition\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCondition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage Time (min)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle ipsilateral lesions without contrast enhancement (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.54\u0026thinsp;\u0026plusmn;\u0026thinsp;5.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle ipsilateral lesions with contrast enhancement (n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.73\u0026thinsp;\u0026plusmn;\u0026thinsp;5.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFour ipsilateral lesions (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTwo ipsilateral lesions (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFour bilateral lesions, two in each breast (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eClinical Context and Rationale\u003c/h2\u003e \u003cp\u003eWire localization remains the most widely used approach for guiding surgical excision of NPBLs. Conventional guidance modalities\u0026mdash;ultrasound and mammography\u0026mdash;are effective for certain lesion types but have well-recognized limitations. In particular, these methods often fail to detect or accurately localize small or subtle lesions, especially microcalcifications and non-mass-like enhancements embedded within dense breast tissue [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This diagnostic gap complicates preoperative planning and increases the risk of incomplete excision or repeated interventions.\u003c/p\u003e \u003cp\u003eTo address these challenges, CBBCT has emerged as a three-dimensional breast imaging modality capable of visualizing both microcalcifications and soft-tissue contrast within a single exam, with or without contrast enhancement. Its tomographic reconstruction eliminates tissue overlap and provides high-resolution isotropic images, offering a potential solution to the limitations of conventional 2D methods.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eImaging Strengths and Diagnostic Rationale of CBBCT\u003c/h2\u003e \u003cp\u003eCBBCT displays the breast in a true 3D model, enabling observation of lesions from multiple perspectives. When combined with contrast enhancement, it allows clear visualization of lesion intensity, morphology, and vascular features, as well as surrounding parenchymal structures. This capability is particularly advantageous for calcifications, small or multifocal lesions, and non-mass lesions that are frequently occult on ultrasound or mammography.\u003c/p\u003e \u003cp\u003eMoreover, CBBCT\u0026rsquo;s volumetric data enables accurate measurement of needle trajectory and insertion depth, allowing operators to plan the optimal wire localization path with precision. Its high spatial resolution and optional use of contrast agents substantially increase the detection rate of occult, small, and non-mass-enhancing lesions, surpassing traditional 2D modalities in both sensitivity and localization accuracy [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTechnical and Procedural Advantages\u003c/h2\u003e \u003cp\u003eThe CBBCT-guided wire localization system incorporates a specialized localization device and 3D reconstruction image guidance technology. This integration allows precise targeting of small lesions while maintaining a fixed breast position throughout the procedure. Compared with mammography, ultrasound, and MRI, the CBBCT-guided wire localization is less dependent on operator experience, involves fewer manual adjustments, and is not limited by magnetic field constraints [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWire-localization generally takes 30 min with mammography guidance and 13 min with ultrasound guidance, given the conditions that these lesions are visible on the modalities used for guidance [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The average time spent with CBBCT-guided wire localization is 27.54 min without contrast and 30.53 with contrast enhancement. Using CBBCT guidance does not significantly increase the procedure time compared with mammography guidance even with the use of contrast enhanced imaging, yet the detectability of lesions, especially within dense tissue is greatly increased with CBBCT, which was proved by the diagnostic performance of CE-CBBCT vs. diagnostic mammography reported in earlier studies. Although ultrasound is a much faster procedure, ultrasound may fail to detect NMPLs and making the ultrasound-guided procedure unapplicable. Our study compares the diagnostic results of CBBCT and ultrasound in the diagnostic workup phase of the cases. Only 40% of the lesions were detectable by ulatrasound, compared with 100% detected by CBBCT.\u003c/p\u003e \u003cp\u003eThe CBBCT system enables simultaneous localization of multiple lesions. In this study, three patients with multiple ipsilateral breast lesions successfully underwent multi-wire placement, with all lesions subsequently excised. The positioning information for all ipsilateral lesions can be acquired within a single scan without repositioning the patient, thereby simplifying workflow and the complexity of the procedure.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eProcedure Efficiency and Workflow\u003c/h2\u003e \u003cp\u003eThe CBBCT wire-localization protocol was streamlined into three essential scans:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePre-insertion Scan: Lesion localization with or without contrast enhancement\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWire Confirmation Scan: Wire localization confirmation before hook deployment, and\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHook Confirmation Scan: Confirmation after the hook deployment\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe CBBCT-guided wire localization workflow demonstrated a high technical success rate, with 42 of 45 lesions (93.3%) localized without the need for re-scanning. Wire confirmation scan was repeated in 3 cases (6.7%) due to slight misalignment between the wire tip and the target lesion. This minor misalignment could potentially be minimized by using a needle block with smaller guide holes more closely matched to the wire diameter, thereby further improving targeting accuracy.\u003c/p\u003e \u003cp\u003eNotably, in cases with multiple ipsilateral lesions, all positioning information was acquired in one scan, and the placement of multiple guidewires did not increase the number of scans needed.\u003c/p\u003e \u003cp\u003eThe major factors determining the total procedure time were operator experience and the ability to quickly recognize the lesion-wire relationship. Thus, repeated model-based training is recommended to improve procedural efficiency.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eRadiation Dose\u003c/h2\u003e \u003cp\u003eWhile CBBCT involves X-ray exposure, its radiation dose can be optimized and individualized based on the patient\u0026rsquo;s breast density type and scanning parameters (e.g., tube voltage, current, and scan phase).\u003c/p\u003e \u003cp\u003eA large study involving 1590 Chinese patients reported that the mean glandular dose (MGD) of CBBCT varies from 3.9 to 5.1 mGy [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In this study, the MGD was 20.10\u0026thinsp;\u0026plusmn;\u0026thinsp;7.58 mGy because of the multi-phase scans used in the workflow, which is lower than previously reported CBBCT-guided puncture biopsy and conventional radiography-guided localization biopsy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] (31.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.0 mGy and 37.7\u0026thinsp;\u0026plusmn;\u0026thinsp;24.2 mGy, respectively).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Challenges\u003c/h2\u003e \u003cp\u003eCBBCT-guided wire localization is inherently more time-consuming than ultrasound-guided procedure because of the need for three scans. The requirement for patients to lie prone during imaging may present difficulty for individuals with limited spinal mobility, shoulder periarthritis, or other conditions restricting positioning. Furthermore, because the CBBCT field of view does not fully cover the axillary tail, lesions located in this region may be difficult to be targeted [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOngoing efforts should focus on improving ergonomic design, expanding field coverage, and improving operator training to enhance patient comfort and workflow efficiency.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCBBCT-guided wire localization is a precise and innovative technology that enables clear visualization of microcalcifications and soft-tissue lesions, thereby facilitating the detection and preoperative localization of NPBLs occult to other modalities. This method offers significant advantages over conventional imaging-guided localization techniques, including improved lesion detection, reduced operator dependence, and the ability to guide multi-lesion localization in a single scan.\u003c/p\u003e \u003cp\u003eWith continued refinement and standardization of the procedural workflow, CBBCT-guided localization is poised to become an important tool in the era of precision breast-conserving surgery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBI-RADS, breast imaging-reporting and data system; CBBCT, cone-beam breast computed tomography; MRI, magnetic resonance imaging; NPBL, nonpalpable breast lesions\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of the Affiliated Cancer Hospital of Guangxi Medical University [CS2019 (08)]. Written informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all enrolled patients for publication of their personal/clinical details and any potentially identifying images in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Guangxi Clinical Research Center for Medical Imaging Construction (Grant No. Guike AD20238096), and the Regional High-Incidence Diseases Research of Guangxi Natural Science Foundation (Grant Nos. 2023GXNSFBA026035 and 2023GXNSFBA026247).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eX. Zhao and D. Su wrote the main manuscript text. Y. Zuo and J. Yang prepared figures and tables. W. Kang and Z. Zheng performed data analysis. W. Wei and Y. Liu collected data. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSkinner K A , Silberman H , Sposto R ,et al.Palpable Breast Cancers Are Inherently Different From Nonpalpable Breast Cancers[J].Annals of Surgical Oncology, 2001, 8(9):705-710.\u003c/li\u003e\n\u003cli\u003eBall C G , Butchart M , Macfarlane J K .Effect on biopsy technique of the breast imaging reporting and data system (BI-RADS) for nonpalpable mammographic abnormalities[J].Canadian Journal of Surgery, 2002, 45(4):259-263.\u003c/li\u003e\n\u003cli\u003eMasroor I, Afzal S, Shafqat G,et al. Usefulness of hook wire localization biopsy under imaging guidance for nonpalpable breast lesions detected radiologically[J]. Int J Womens Health. 2012;4:445-449.\u003c/li\u003e\n\u003cli\u003eDemiral G , Senol M , Bayraktar B ,et al.Diagnostic Value of Hook Wire Localization Technique for Non-Palpable Breast Lesions[J].Journal of Clinical Medicine Research, 2016, 8(5):389-395\u003c/li\u003e\n\u003cli\u003eMarkopoulos C , Kouskos E , Revenas K ,et al.Open surgical biopsy for nonpalpable breast lesions detected on screening mammography[J].European Journal of Gynaecological Oncology, 2005, 26(3):311.\u003c/li\u003e\n\u003cli\u003eGao Y, Bagadiya NR, Jardon ML, et al. Outcomes of Preoperative MRI-Guided Needle Localization of Nonpalpable Mammographically Occult Breast Lesions[J]. AJR Am J Roentgenol. 2016;207(3):676-684.\u003c/li\u003e\n\u003cli\u003eUhlig J , Fischer U , Biggemann L ,et al.Pre- and post-contrast versus post-contrast cone-beam breast CT: can we reduce radiation exposure while maintaining diagnostic accuracy?[J].European radiology, 2019, 29(6):3141-3148.\u003c/li\u003e\n\u003cli\u003eZhongtao Z , Wei K , Danke SU ,et al.Progresses in biopsy of breast cancer guided by different imaging techniques[J].Chinese Journal of Medical Imaging Technology, 2019.\u003c/li\u003e\n\u003cli\u003eHe N, Wu YP, Kong Y, et al. The utility of breast cone-beam computed tomography, ultrasound, and digital mammography for detecting malignant breast tumors: A prospective study with 212 patients[J]. Eur J Radiol. 2016;85(2):392-403.\u003c/li\u003e\n\u003cli\u003eChinese Association of Breast Surgery. Zhonghua Wai Ke Za Zhi. 2019;57(6):404-407. doi:10.3760/cma.j.issn.0529-5815.2019.06.002\u003c/li\u003e\n\u003cli\u003eKuhl C K , Schrading S , Leutner C C ,et al.Mammography, Breast Ultrasound, and Magnetic Resonance Imaging for Surveillance of Women at High Familial Risk for Breast Cancer[J].Journal of Clinical Oncology Official Journal of the American Society of Clinical Oncology, 2005, 23(33):8469-76. \u003c/li\u003e\n\u003cli\u003eWienbeck S , Uhlig J , Luftner-Nagel S ,et al.The role of cone-beam breast-CT for breast cancer detection relative to breast density[J].European Radiology, 2017.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Connell,Avice,M,et al.Newer Technologies in Breast Cancer Imaging: Dedicated Cone-Beam Breast Computed Tomography[J].Seminars in Ultrasound Ct \u0026amp; Mri, 2018.\u003c/li\u003e\n\u003cli\u003eWienbeck,Susanne,Fischer,et al.Contrast-enhanced cone-beam breast-CT (CBBCT): clinical performance compared to mammography and MRI[J].EUROPEAN RADIOLOGY, 2018.\u003c/li\u003e\n\u003cli\u003eCheung B H H , Co M , Lui T T N ,et al.Evolution of localization methods for non-palpable breast lesions: a literature review from a translational medicine perspective[J].Translational Breast Cancer Research, 2024, 5(Apr):16.\u003c/li\u003e\n\u003cli\u003eKe X , Hui X , Bao-Rong Y ,et al.An assessment of the average glandular dose of breast cone-beam CT in China based on clinical patients[J].The British Journal of Radiology, 2025, 000(000).\u003c/li\u003e\n\u003cli\u003eLi H, Yin L, Ye Z et al .Comparative study of breast tissue coverage in cone-beam breast CT versus digital mammography[J]. Chinese J Radiol 2025,49:488-490. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cone-beam computed tomography, wire localization, non-palpable breast lesions, breast cancer","lastPublishedDoi":"10.21203/rs.3.rs-8327692/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8327692/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo evaluate the clinical value of cone-beam breast computed tomography (CBBCT) in wire localization for non-palpable breast lesions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 39 patients with 45 non-palpable breast lesions underwent wire localization guided by CBBCT. Operation time, intraoperative complications, radiation dose, and postoperative pathological outcomes were recorded to assess the success rate and safety of CBBCT-guided wire localization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCBBCT-guided wire localization was successfully performed in all 39 patients (40 breasts, 45 lesions), achieving a success rate of 100%. No intraoperative complications occurred. Postoperative pathology confirmed complete excision of all localized lesions. The average time spent with non-contrast CBBCT guided wire localization is 27.54±5.83 minutes. When contrast-enhancement CBBCT is used for wire localization, the average time spent is 30.73±5.62 minutes. The difference in operation time is statistically significant with p\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCBBCT-guided wire localization offers a precise and reliable method for preoperative localization of non-palpable breast lesions. It effectively provides accurate guidance for breast lumpectomy without the limitations of conventional image-guided techniques.\u003c/p\u003e","manuscriptTitle":"Feasibility of Cone Beam Breast CT–Guided Wire Localization for Non-Palpable Breast Lesions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 11:18:11","doi":"10.21203/rs.3.rs-8327692/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-01-13T12:08:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-13T03:19:18+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-23T16:11:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-21T03:47:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2025-12-21T03:43:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"47c67262-34ce-4ccb-a482-b9d5b837a3f2","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-16T11:18:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 11:18:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8327692","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8327692","identity":"rs-8327692","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}