Factors Affecting Successful Breast Conservation for Ductal Carcinoma in Situ

Quantifying the extent of invasive carcinoma and margin status in partial mastectomy cases having a gross lesion: is a defined tissue processing protocol needed?

Accurate estimation of disease extent and margin status is critical when evaluating partial mastectomy cases because both are predictors of recurrence. No published standards exist for processing specimens involved by invasive carcinoma, presumably because such cases have a gross lesion. We retrospectively studied 100 partial mastectomy cases and concluded that a standardized tissue mapping protocol is needed to ensure adequate pathologic examination even when a gross lesion is present. When mapped and unmapped findings were compared, 17 cases (10 with ductal and 7 with lobular carcinoma) had an increase in carcinoma size, 12 cases (9 with ductal and 3 with lobular carcinoma) had an increase in pathologic T stage, and positive margins were found in 8 cases (7 with ductal and 1 with lobular carcinoma). We describe our tissue-mapping protocol, and advocate its use as a standardized protocol for processing all partial mastectomy specimens.

An immersed boundary method for simulating a single axisymmetric cell growth and division

For an animal cell, cytokinesis is the process by which a cell divides its cytoplasm to produce two daughter cells. We propose a new mathematical model for simulating cytokinesis. The proposed model is robust and realistic in deciding the position of the cleavage furrow and in defining the contractile force leading to cell division. We use an immersed boundary method to track the morphology of cell membrane during cytokinesis. For accurate calculation, we adaptively add and delete the immersed boundary points. We perform numerical simulations on the axisymmetric domain to have sufficient resolution and to incorporate three-dimensional effects such as anisotropic surface tension. Finally, we investigate the effects of each model parameter and compare a numerical result with the experimental data to demonstrate the efficiency and accuracy of our proposed method.

Ductal carcinoma in situ: size and resection volume predict margin status

OBJECTIVES

There is strong evidence that breast conservation surgery (BCS) with negative margins for ductal carcinoma in situ (DCIS) is associated with low rates of recurrence. Our goal was to identify factors associated with positive margins in BCS for DCIS.

METHODS

A retrospective database review identified 823 patients diagnosed with DCIS. The current analysis included 546 of those patients treated with BCS from 2000 to 2006 with complete data regarding tumor and lumpectomy dimensions. Variables analyzed included tumor size, lumpectomy volume, estrogen and progesterone receptor status, histologic subtype, grade, and age at diagnosis. χ analysis and t tests were used to identify factors that may predict positive margins. A multivariate regression model was developed to determine independent variables predictive of positive margin status.

RESULTS

A total of 33% of specimens had positive margins. Lumpectomy volume, tumor size, nuclear grade (low vs. high), and number of slides positive for DCIS were all significant for positive margin status by bivariate analysis. On multivariate analysis, tumor size (P < 0.001; odds ratio, 2.37; 95% confidence interval, 1.712, 3.296) and resection volume (P = 0.0006; odds ratio, 0.48; 95% confidence interval, 0.318, 0.729) remained significantly associated with positive margin status. Age at diagnosis, histologic subtype, tumor grade, and estrogen and progesterone status all were not associated with margin status.

CONCLUSIONS

Positive margins after BCS for DCIS are associated with larger lesions and a smaller volume of resection. With 33% of patients having positive margins, these data suggest that a more aggressive initial resection may avoid positive margins and thus lower the risk of recurrence or the need for additional surgery.

A low-cost, portable, and quantitative spectral imaging system for application to biological tissues

The ability of diffuse reflectance spectroscopy to extract quantitative biological composition of tissues has been used to discern tissue types in both pre-clinical and clinical cancer studies. Typically, diffuse reflectance spectroscopy systems are designed for single-point measurements. Clinically, an imaging system would provide valuable spatial information on tissue composition. While it is feasible to build a multiplexed fiber-optic probe based spectral imaging system, these systems suffer from drawbacks with respect to cost and size. To address these we developed a compact and low cost system using a broadband light source with an 8-slot filter wheel for illumination and silicon photodiodes for detection. The spectral imaging system was tested on a set of tissue mimicking liquid phantoms which yielded an optical property extraction accuracy of 6.40 +/- 7.78% for the absorption coefficient (micro(a)) and 11.37 +/- 19.62% for the wavelength-averaged reduced scattering coefficient (micro(s)').

Ductal carcinoma in situ (DCIS): pathological features, differential diagnosis, prognostic factors and specimen evaluation

Ductal carcinoma in situ (DCIS) is a heterogeneous, unicentric precursor of invasive breast cancer, which is frequently identified through mammographic breast screening programs. The lesion can cause particular difficulties for specimen handling in the laboratory and typically requires even more diligent macroscopic assessment and sampling than invasive disease. Pitfalls and tips for macroscopic handling, microscopic diagnosis and assessment, including determination of prognostic factors, such as cytonuclear grade, presence or absence of necrosis, size of the lesion and distance to margins are described. All should be routinely included in histopathology reports of this disease; in order not to omit these clinically relevant details, synoptic reports, such as that produced by the College of American Pathologists are recommended. No biomarkers have been convincingly shown, and validated, to predict the behavior of DCIS till date.

Performance metrics of an optical spectral imaging system for intra-operative assessment of breast tumor margins

As many as 20-70% of patients undergoing breast conserving surgery require repeat surgeries due to a close or positive surgical margin diagnosed post-operatively [1]. Currently there are no widely accepted tools for intra-operative margin assessment which is a significant unmet clinical need. Our group has developed a first-generation optical visible spectral imaging platform to image the molecular composition of breast tumor margins and has tested it clinically in 48 patients in a previously published study [2]. The goal of this paper is to report on the performance metrics of the system and compare it to clinical criteria for intra-operative tumor margin assessment. The system was found to have an average signal to noise ratio (SNR) >100 and <15% error in the extraction of optical properties indicating that there is sufficient SNR to leverage the differences in optical properties between negative and close/positive margins. The probe had a sensing depth of 0.5-2.2 mm over the wavelength range of 450-600 nm which is consistent with the pathologic criterion for clear margins of 0-2 mm. There was <1% cross-talk between adjacent channels of the multi-channel probe which shows that multiple sites can be measured simultaneously with negligible cross-talk between adjacent sites. Lastly, the system and measurement procedure were found to be reproducible when evaluated with repeated measures, with a low coefficient of variation (<0.11). The only aspect of the system not optimized for intra-operative use was the imaging time. The manuscript includes a discussion of how the speed of the system can be improved to work within the time constraints of an intra-operative setting.

Optical assessment of tumor resection margins in the breast

Breast conserving surgery, in which the breast tumor and surrounding normal tissue are removed, is the primary mode of treatment for invasive and in situ carcinomas of the breast, conditions that affect nearly 200,000 women annually. Of these nearly 200,000 patients who undergo this surgical procedure, between 20-70% of them may undergo additional surgeries to remove tumor that was left behind in the first surgery, due to the lack of intra-operative tools which can detect whether the boundaries of the excised specimens are free from residual cancer. Optical techniques have many attractive attributes which may make them useful tools for intra-operative assessment of breast tumor resection margins. In this manuscript, we discuss clinical design criteria for intra-operative breast tumor margin assessment, and review optical techniques appied to this problem. In addition, we report on the development and clinical testing of quantitative diffuse reflectance imaging (Q-DRI) as a potential solution to this clinical need. Q-DRI is a spectral imaging tool which has been applied to 56 resection margins in 48 patients at Duke University Medical Center. Clear sources of contrast between cancerous and cancer-free resection margins were identified with the device, and resulted in an overall accuracy of 75% in detecting positive margins.

Preferential accumulation of 5-aminolevulinic acid-induced protoporphyrin IX in breast cancer: a comprehensive study on six breast cell lines with varying phenotypes

We describe the potential of 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) fluorescence as a source of contrast for margin detection in commonly diagnosed breast cancer subtypes. Fluorescence intensity of PpIX in untreated and ALA-treated normal mammary epithelial and breast cancer cell lines of varying estrogen receptor expression were quantitatively imaged with confocal microscopy. Percentage change in fluorescence intensity integrated over 610-700 nm (attributed to PpIX) of posttreated compared to pretreated cells showed statistically significant differences between four breast cancer and two normal mammary epithelial cell lines. However, a direct comparison of post-treatment PpIX fluorescence intensities showed no differences between breast cancer and normal mammary epithelial cell lines due to confounding effects by endogenous fluorescence from flavin adenine dinucleotide (FAD). Clinically, it is impractical to obtain pre- and post-treatment images. Thus, spectral imaging was demonstrated as a means to remove the effects of endogenous FAD fluorescence allowing for discrimination between post-treatment PpIX fluorescence of four breast cancer and two normal mammary epithelial cell lines. Fluorescence spectral imaging of ALA-treated breast cancer cells showed preferential PpIX accumulation regardless of malignant phenotype and suggests a useful contrast mechanism for discrimination of residual cancer at the surface of breast tumor margins.

Intraoperative evaluation of breast tumor margins with optical coherence tomography

As breast cancer screening rates increase, smaller and more numerous lesions are being identified earlier, leading to more breast-conserving surgical procedures. Achieving a clean surgical margin represents a technical challenge with important clinical implications. Optical coherence tomography (OCT) is introduced as an intraoperative high-resolution imaging technique that assesses surgical breast tumor margins by providing real-time microscopic images up to 2 mm beneath the tissue surface. In a study of 37 patients split between training and study groups, OCT images covering 1 cm(2) regions were acquired from surgical margins of lumpectomy specimens, registered with ink, and correlated with corresponding histologic sections. A 17-patient training set used to establish standard imaging protocols and OCT evaluation criteria showed that areas of higher scattering tissue with a heterogeneous pattern were indicative of tumor cells and tumor tissue in contrast to lower scattering adipocytes found in normal breast tissue. The remaining 20 patients were enrolled into the feasibility study. Of these lumpectomy specimens, 11 were identified with a positive or close surgical margin and 9 were identified with a negative margin under OCT. Based on histologic findings, 9 true positives, 9 true negatives, 2 false positives, and 0 false negatives were found, yielding a sensitivity of 100% and specificity of 82%. These results show the potential of OCT as a real-time method for intraoperative margin assessment in breast-conserving surgeries.

High and intermediate grade ductal carcinoma in-situ of the breast: a comparison of pathologic features in core biopsies and excisions and an evaluation of core biopsy features that may predict a close or positive margin in the excision

Low and high-grade ductal carcinoma in-situ (DCIS) are known to be highly disparate by a multitude of parameters, including progression potential, immunophenotype, gene expression profile and DNA ploidy. In this study, we analyzed a group of intermediate and high-grade DCIS cases to determine how well the core biopsy predicts the maximal pathology in the associated excisions, and to determine if there are any core biopsy morphologic features that may predict a close (≤ 0.2 cm) or positive margin in the subsequent excision. Forty-nine consecutive paired specimens [core biopsies with a maximal diagnosis of DCIS, and their corresponding excisions, which included 20 and 29 specimens from mastectomies and breast conserving surgeries respectively] were evaluated in detail. In 5 (10%) of 49 cases, no residual carcinoma was found in the excision. In another 4 cases, the changes were diagnostic only of atypical ductal hyperplasia. There were 4 and 3 respective cases of invasive and microinvasive carcinoma out of the 49 excision specimens, for an overall invasion frequency of 14%. In 28 cases where a sentinel lymph node evaluation was performed, only 1 was found to be positive. Among the 40 cases with at least residual DCIS in the excision, there were 5 cases in which comedo-pattern DCIS was present in the excision but not in the core biopsy, attributed to the lower maximal nuclear grade in the biopsy proliferation in 4 cases and the absence of central necrosis in the 5^th. For the other main histologic patterns, in 8 (20%) of 40 cases, there were more patterns identified in the core biopsy than in the corresponding excision. For the other 32 cases, 100%, 66%, 50%, 33% and 25% of the number of histologic patterns in the excisions were captured in 35%, 5%, 17.5%, 15% and 7.5% of the preceding core biopsies respectively. Therefore, the core biopsy reflected at least half of the non-comedo histologic patterns in 77.5% of cases. In 6(15%) of the 40 cases, the maximum nuclear grade of the excision (grade 3) was higher than that seen in the core biopsy (grade 2). Overall, however, the maximum nuclear grade in the excision was significantly predicted by maximum nuclear grade in the core biopsy (p = 0.028), with a Phi of 0.347, indicating a moderately strong association. At a size threshold of 2.7 cm, there was no significant association between lesional size and core biopsy features. Furthermore, the clear margin width of the cases with lesional size ≤ 2.7 cm (mean 0.69 cm) was not significantly different (p = 0.4) from the cases with lesional size > 2.7 cm (mean 0.56 cm). Finally, among a variety of core biopsy features that were evaluated, including maximum nuclear grade, necrosis, cancerization of lobules, number of tissue cores with DCIS, number of DCIS ducts per tissue core, total DCIS ducts, or comedo-pattern, only necrosis was significantly associated with a positive or close (≤ 0.2 cm) margin on multivariate analysis (Phi of 0.350). It is concluded that a significant change [to invasive disease (14%) or to no residual disease (10%)] is seen in approximately 24% of excisions that follow a core biopsy diagnosis of intermediate or high-grade DCIS. Core biopsy features are of limited value in predicting a close or positive margin in these lesions.

Intraoperative ultrasound versus mammographic needle localization for ductal carcinoma in situ

BACKGROUND

Ductal carcinoma in situ (DCIS) often requires some method of localization to achieve breast-conserving therapy. The purpose of this study was to compare the efficacy of intraoperative ultrasound versus mammographic needle localization (MNL) for partial mastectomy in DCIS.

MATERIALS AND METHODS

Data were collected from a Breast Cancer Surgery Database. All DCIS cases undergoing partial mastectomy (PM) were identified. Margin status, re-excision rates, and cost were determined for both groups.

RESULTS

A total of 155 patients undergoing PM for DCIS were identified from the database. In the 96 patients undergoing ultrasound-guided PM (Group 1), the positive margin rate was 10.4%, and close margins (<1 mm) were observed in 22.9% after initial surgery. There were 59 patients who underwent MNL (Group 2); the positive margin rate was 11.9%, and close margins were observed in 27.1%. The difference between positive and close margins in Group 1 versus Group 2 was not statistically significant. The rate of re-excision was 20.8% for Group 1 and 30.5% for Group 2, resulting in 1.23 and 1.37 operations per patient, respectively. The average cost of an intraoperative ultrasound at our institution was $933 and $1858 for MNL (excluding cost of radiologic interpretation), a difference of $925 per case.

CONCLUSION

Our study showed equivalent rates of positive margins and re-excision between intraoperative ultrasound and MNL when performing PM for nonpalpable DCIS. Considering the more invasive nature and increased cost of MNL, we consider surgeon-performed intraoperative ultrasound, when possible, the more cost-effective and practical procedure for patients with DCIS.

Measuring extent of ductal carcinoma in situ in breast excision specimens: a comparison of 4 methods

CONTEXT

Measuring the extent of nonpalpable ductal carcinoma in situ (DCIS) in a breast specimen is challenging but important because it influences patient management. There is no standardized method for estimating the extent of DCIS, although serial sequential sampling with mammographic correlation is considered an accurate method.

OBJECTIVE

To estimate the extent of DCIS using various methods and to compare these estimations with the extent as determined by the serial sequential sampling method.

DESIGN

A total of 78 primary breast excisions with DCIS were retrospectively reviewed. All specimens had been sampled using the serial sequential sampling method, which involved mapping the location of each block on the sliced specimen radiograph and calculating the extent through 3-dimensional reconstruction. The other measures for estimating extent included (1) calculating size based on areas of calcification, (2) recording the number of blocks involved by DCIS and multiplying that number by 0.3 cm, and (3) measuring the largest extent of DCIS on a single slide.

RESULTS

All 3 alternative methods tended to underestimate the DCIS. Discrepancies became more pronounced as size increased. The percentage of cases estimated to within 1 cm of the serial sequential sampling method were 81%, 72%, and 50%, respectively, for the calcification, blocks, and single-slide methods; differences of more than 2 cm were seen in 9%, 8%, and 30% of cases, respectively.

CONCLUSIONS

The single-slide method performed poorly and should be used only when DCIS is limited to a single slide. Although the calcification and the blocks methods gave better estimates, both produced substantial underestimates and/or overestimates that could affect clinical decision making.

Management of cancerisation of the lobules with pre-invasive or invasive breast carcinoma: a case series

Cancerisation of the lobules (CL), the intra-luminal extension of carcinoma from ducts and ductules into the breast lobules, is not often encountered in clinical practice. A retrospective study of eight individuals diagnosed with CL and ductal carcinoma in situ (DCIS) or cancer of the breast between 1999 and 2006 was undertaken to determine the management of the disease and patient outcomes. In most cases, breast conservation surgery with postoperative radiotherapy or mastectomy and systemic therapy were the chosen methods of treatment. None of the patients experienced tumour relapse or progression during a mean follow-up period of 40.6 (range 8–90) months. The management philosophy for this particular neoplastic condition should be based on the understanding that CL, when detected with DCIS or invasive breast cancer, may represent more extensive disease. Moreover, the finding of such histopathology underlines the need for meticulous attention to the resection margins and additional treatment as indicated.

Needle core biopsy characteristics identify patients at risk of compromised margins in breast conservation surgery

Selection of patients for breast-conserving surgery relies on inexact parameters such as the preoperative estimation of lesion size. This study investigates the value of needle core biopsy findings, in particular, the relative quantity of DCIS, in improving patient selection for breast conservation. Patients undergoing breast-conserving surgery for invasive ductal carcinoma from 1999 to 2004 were identified. Only patients who had a preoperative diagnosis of carcinoma (DCIS and invasive) on core biopsy were included. All core biopsies were reviewed by a breast histopathologist to document the quantity and characteristics of the DCIS component. Of a total of 281 patients, 46% (n=129) had invasive disease on core biopsy (group 1) and 54% (n=152) had either invasive disease with an accompanying DCIS component or DCIS only on core biopsy (group 2). The compromised margin rate for group 1 was 23% compared to 39% for group 2 (P=0.004). The rate of compromised margins increased progressively as the core biopsy DCIS component increased until a rate of 75% (n=18/24) was reached in patients with DCIS only on core biopsy. In patients with a DCIS component on core biopsy, the presence of necrosis (P=0.002), solid type architecture (P=0.008), high grade DCIS (P=0.007), calcification (P=0.003), and the relative proportion of DCIS present (P<0.001) were associated with compromised margins on univariate analysis. On multivariate analysis of this subgroup, the proportion of DCIS in this subgroup (P=0.048) was an independent predictor of compromised margins. The presence and relative proportion of DCIS on core biopsy provides important information as to whether patients are at risk of compromised margins. Documentation of these parameters may assist patient selection for breast-conserving surgery or identify patients who may benefit from wider margins at the time of initial operation.