The traditional methods for selecting women for breast conservation therapy (BCT), coupled with adjuvant radiation therapy, have reduced recurrence rates of BCT to acceptable levels. These recurrence rates are still significant, however. They may be further affected by the application of more anatomically targeted radiation therapy. Preoperative MR imaging should theoretically reduce the local failure rate of BCT by at least 5%, with only a modest increase in the mastectomy rate. The evolution of BCT to include more targeted radiation therapy and ablation should place an even larger emphasis on accurate tumor localization and has the potential to allow BCT to become more prevalent and effective.