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Agarwal G, Sattavan S, Vishvak Chanthar KMM, Kumar A, Sabaretnam M, Chand G, Mishra A, Agrawal V. Cost-Efficacy Analysis of Use of Frozen Section Histology for Margin Assessment During Breast Conservation Surgery in Breast Cancer Patients. World J Surg 2023; 47:2457-2463. [PMID: 37386245 DOI: 10.1007/s00268-023-07094-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Margin assessment is an essential component of breast conservation surgery (BCS). Re-excision of infiltrated margin(s) detected on paraffin section histology (PSH) needs reoperation, adding time, inconvenience and cost. Intra-operative assessment of margins using frozen section histology (IFSH) can potentially obviate need for re-operation, thus facilitating one-step oncologically complete BCS. METHODS IFSH and PSH reports of consecutive patients undergoing BCS (2010-2020) were reviewed. Accuracy and cost-efficacy of IFSH were assessed, considering PSH as gold standard. Cost of achieving oncologically complete BCS in whole cohort with IFSH (Scenario-A) was calculated and compared using appropriate statistical tests, with hospital costs for the cohort in a hypothetical Scenario-B, where IFSH was presumed not to have been used and all patients with infiltrated margin(s) on PSH would have been re-operated. RESULTS Of the 367 patients screened, 39 were excluded due to incomplete IFSH data. Of 328 patients analyzed, 59 (18%) had one or more margins were reported infiltrated on IFSH, managed by re-excision or mastectomy in the same sitting, thus avoiding a reoperation. Additional 8 (2.4%) had involved margins on PSH (False negative IFSH). Significantly higher number of reoperations (p < 0.001) would have been needed in scenario-B. Average cost of the first operation with use of IFSH was Indian Rupees (INR) 25791 which included INR660 as IFSH cost. The average cost of reoperation was INR23724 which could be avoided in 59 (18%) by use of IFSH. The average cost per patient to achieve oncologically complete surgery in scenario A utilizing IFSH was significantly lower (p = 0.001) by INR3101 (11.7%), c.w. that in scenario B. Significant cost-saving with IFSH was maintained in cost-efficacy analysis undertaken with various higher and lower costs assumptions. CONCLUSIONS Use of IFSH facilitates one-step oncologically complete BCS in majority of patients and results in considerable cost saving, resulting in avoidance of reoperations, besides preventing patient anxiety and delay in adjuvant treatment. TRIAL REGISTRATION Clinical Trials Registry-India (CTRI/2021/08/035896).
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Affiliation(s)
- Gaurav Agarwal
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India.
| | - Swati Sattavan
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - K M M Vishvak Chanthar
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Anup Kumar
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - M Sabaretnam
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Gyan Chand
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Anjali Mishra
- Department of Endocrine and Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Vinita Agrawal
- Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Mondal S, Sthanikam Y, Kumar A, Nandy A, Chattopadhyay S, Koner D, Rukmangadha N, Narendra H, Banerjee S. Mass Spectrometry Imaging of Lumpectomy Specimens Deciphers Diacylglycerols as Potent Biomarkers for the Diagnosis of Breast Cancer. Anal Chem 2023; 95:8054-8062. [PMID: 37167069 DOI: 10.1021/acs.analchem.3c01019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Detecting breast tumor markers with a fast turnaround time from frozen sections should foster intraoperative histopathology in breast-conserving surgery, reducing the need for a second operation. Hence, rapid label-free discrimination of the spatially resolved molecular makeup between cancer and adjacent normal breast tissue is of growing importance. We performed desorption electrospray ionization mass spectrometry imaging (DESI-MSI) of fresh-frozen excision specimens, including cancer and paired adjacent normal sections, obtained from the lumpectomy of 73 breast cancer patients. The results demonstrate that breast cancer tissue posits sharp metabolic upregulation of diacylglycerol, a lipid second messenger that activates protein kinase C for promoting tumor growth. We identified four specific sn-1,2-diacylglycerols that outperformed all other lipids simultaneously mapped by the positive ion mode DESI-MSI for distinguishing cancers from adjacent normal specimens. This result contrasts with several previous DESI-MSI studies that probed metabolic dysregulation of glycerophospholipids, sphingolipids, and free fatty acids for cancer diagnoses. A random forest-based supervised machine learning considering all detected ion signals also deciphered the highest diagnostic potential of these four diacylglycerols with the top four importance scores. This led us to construct a classifier with 100% overall prediction accuracy of breast cancer by using the parsimonious set of four diacylglycerol biomarkers only. The metabolic pathway analysis suggested that increased catabolism of phosphatidylcholine in breast cancer contributes to diacylglycerol overexpression. These results open up opportunities for mapping diacylglycerol signaling in breast cancer in the context of novel therapeutic and diagnostic developments, including the intraoperative assessment of breast cancer margin status.
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Affiliation(s)
- Supratim Mondal
- Department of Chemistry, Indian Institute of Science Education and Research Tirupati, Tirupati 517507, India
| | - Yeswanth Sthanikam
- Department of Chemistry, Indian Institute of Science Education and Research Tirupati, Tirupati 517507, India
| | - Anubhav Kumar
- Department of Chemistry, Indian Institute of Science Education and Research Tirupati, Tirupati 517507, India
| | - Abhijit Nandy
- Department of Chemistry, Indian Institute of Science Education and Research Tirupati, Tirupati 517507, India
| | - Sutirtha Chattopadhyay
- Department of Chemistry, Indian Institute of Science Education and Research Tirupati, Tirupati 517507, India
| | - Debasish Koner
- Department of Chemistry, Indian Institute of Science Education and Research Tirupati, Tirupati 517507, India
| | - Nandyala Rukmangadha
- Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati 517507, India
| | - Hulikal Narendra
- Department of Surgical Oncology, Sri Venkateswara Institute of Medical Sciences, Tirupati 517507, India
| | - Shibdas Banerjee
- Department of Chemistry, Indian Institute of Science Education and Research Tirupati, Tirupati 517507, India
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Gong P, Chin SL, Allen WM, Ballal H, Anstie JD, Chin L, Ismail HM, Zilkens R, Lakhiani DD, McCarthy M, Fang Q, Firth D, Newman K, Thomas C, Li J, Sanderson RW, Foo KY, Yeomans C, Dessauvagie BF, Latham B, Saunders CM, Kennedy BF. Quantitative Micro-Elastography Enables In Vivo Detection of Residual Cancer in the Surgical Cavity during Breast-Conserving Surgery. Cancer Res 2022; 82:4093-4104. [PMID: 36098983 PMCID: PMC9627129 DOI: 10.1158/0008-5472.can-22-0578] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/29/2022] [Accepted: 09/08/2022] [Indexed: 01/07/2023]
Abstract
Breast-conserving surgery (BCS) is commonly used for the treatment of early-stage breast cancer. Following BCS, approximately 20% to 30% of patients require reexcision because postoperative histopathology identifies cancer in the surgical margins of the excised specimen. Quantitative micro-elastography (QME) is an imaging technique that maps microscale tissue stiffness and has demonstrated a high diagnostic accuracy (96%) in detecting cancer in specimens excised during surgery. However, current QME methods, in common with most proposed intraoperative solutions, cannot image cancer directly in the patient, making their translation to clinical use challenging. In this proof-of-concept study, we aimed to determine whether a handheld QME probe, designed to interrogate the surgical cavity, can detect residual cancer directly in the breast cavity in vivo during BCS. In a first-in-human study, 21 BCS patients were scanned in vivo with the QME probe by five surgeons. For validation, protocols were developed to coregister in vivo QME with postoperative histopathology of the resected tissue to assess the capability of QME to identify residual cancer. In four cavity aspects presenting cancer and 21 cavity aspects presenting benign tissue, QME detected elevated stiffness in all four cancer cases, in contrast to low stiffness observed in 19 of the 21 benign cases. The results indicate that in vivo QME can identify residual cancer by directly imaging the surgical cavity, potentially providing a reliable intraoperative solution that can enable more complete cancer excision during BCS. SIGNIFICANCE Optical imaging of microscale tissue stiffness enables the detection of residual breast cancer directly in the surgical cavity during breast-conserving surgery, which could potentially contribute to more complete cancer excision.
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Affiliation(s)
- Peijun Gong
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia.,Corresponding Author: Peijun Gong, BRITElab, Harry Perkins Institute of Medical Research, Perth 6009, Australia. Phone: 61-8-6488-6774; E-mail:
| | - Synn Lynn Chin
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Wes M. Allen
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Helen Ballal
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - James D. Anstie
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Lixin Chin
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Hina M. Ismail
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Renate Zilkens
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Division of Surgery, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Devina D. Lakhiani
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | | | - Qi Fang
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Daniel Firth
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Kyle Newman
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Caleb Thomas
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Jiayue Li
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Melbourne, Victoria, Australia
| | - Rowan W. Sanderson
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Ken Y. Foo
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia
| | - Chris Yeomans
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Benjamin F. Dessauvagie
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Division of Pathology and Laboratory Medicine, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Bruce Latham
- PathWest, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Christobel M. Saunders
- Breast Centre, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Division of Surgery, Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Breast Clinic, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Brendan F. Kennedy
- BRITElab, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Western Australia, Australia.,Department of Electrical, Electronic and Computer Engineering, School of Engineering, The University of Western Australia, Perth, Western Australia, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Melbourne, Victoria, Australia
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Nakhlis F, Portnow L, Gombos E, Daylan AEC, Leone JP, Kantor O, Richardson ET, Ho A, Dunn SA, Ohri N. Multidisciplinary Considerations in the Management of Breast Cancer Patients Receiving Neoadjuvant Chemotherapy. Curr Probl Surg 2022; 59:101191. [DOI: 10.1016/j.cpsurg.2022.101191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Zhao R, Xing J, Gao J. Development and Validation of a Prediction Model for Positive Margins in Breast-Conserving Surgery. Front Oncol 2022; 12:875665. [PMID: 35646633 PMCID: PMC9133412 DOI: 10.3389/fonc.2022.875665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/12/2022] [Indexed: 11/21/2022] Open
Abstract
Background The chances of second surgery due to positive margins in patients receiving breast-conversing surgery (BCS) were about 20-40%. This study aims to develop and validate a nomogram to predict the status of breast-conserving margins. Methods The database identified patients with core needle biopsy-proven ductal carcinoma in situ (DCIS) or invasive breast carcinoma who underwent BCS in Shanxi Bethune Hospital between January 1, 2015 and December 31, 2021 (n = 573). The patients were divided into two models: (1) The first model consists of 398 patients who underwent BCS between 2015 and 2019; (2) The validation model consists of 175 patients who underwent BCS between 2020 and 2021. The development of the nomogram was based on the findings of multivariate logistic regression analysis. Discrimination was assessed by computing the C-index. The Hosmer-Lemeshow goodness-of-fit test was used to validate the calibration performance. Results The final multivariate regression model was developed as a nomogram, including blood flow signals (OR = 2.88, p = 0.001), grade (OR = 2.46, p = 0.002), microcalcifications (OR = 2.39, p = 0.003), tumor size in ultrasound (OR = 2.12, p = 0.011) and cerbB-2 status (OR = 1.99, p = 0.042). C-indices were calculated of 0.71 (95% CI: 0.64-0.78) and 0.68 (95% CI: 0.59-0.78) for the modeling and the validation group, respectively. The calibration of the model was considered adequate in the validation group (p > 0.05). Conclusion We developed a nomogram that enables the estimation of the preoperative risk of positive BCS margins. Our nomogram provides a valuable tool for identifying high-risk patients who might have to undergo a wider excision.
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Affiliation(s)
- Rong Zhao
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Jun Xing
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Jinnan Gao
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
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6
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Thill M, Szwarcfiter I, Kelling K, van Haasteren V, Kolka E, Noelke J, Peles Z, Papa M, Aulmann S, Allweis T. Magnetic resonance imaging system for intraoperative margin assessment for DCIS and invasive breast cancer using the ClearSight™ system in breast-conserving surgery-Results from a postmarketing study. J Surg Oncol 2022; 125:361-368. [PMID: 34724205 PMCID: PMC9298117 DOI: 10.1002/jso.26721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 10/04/2021] [Accepted: 10/09/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Breast-conserving surgery (BCS) is followed by reoperations in approximately 25%. Reoperations lead to an increased risk of infection and wound healing problems as well as a worse cosmetic outcome. Several technical approaches for an intraoperative margin assessment to decrease the reoperation rate are under evaluation, some of them are still experimental. METHODS A prospective single-arm post-marketing study with 60 patients undergoing BCS for ductal carcinoma in situ (DCIS) and invasive breast cancer was conducted. The specimen was intraoperatively examined by the ClearSight™ system, a mobile magnetic resonance imaging system that is based on a diffusion-weighted imaging protocol. However, the results were blinded to the surgeon. RESULTS The ClearSight™ system was performed for both ductal and lobular breast cancer and DCIS, with a sensitivity of 0.80 (95% confidence interval [CI]: 0.44-0.96) and a specificity of 0.84 (95% CI 0.72-0.92), with an overall diagnostic accuracy of 80%. CONCLUSION Had the ClearSight™ been known to the surgeon intraoperatively, the reoperation rate would have been reduced by 83% for invasive carcinoma, from 10% to 2%, and 50% for DCIS, from 30% to 15% reoperations. A trial designed to examine the impact on reoperation rates is currently ongoing.
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Affiliation(s)
- Marc Thill
- Department of Gynecology and Gynecological OncologyAgaplesion Markus KrankenhausFrankfurtGermany
| | | | - Katharina Kelling
- Department of Gynecology and Gynecological OncologyAgaplesion Markus KrankenhausFrankfurtGermany
| | - Viviane van Haasteren
- Department of Gynecology and Gynecological OncologyAgaplesion Markus KrankenhausFrankfurtGermany
| | | | - Josefa Noelke
- Department of Gynecology and Gynecological OncologyAgaplesion Markus KrankenhausFrankfurtGermany
| | | | - Moshe Papa
- General Surgery UnitAssuta Medical CenterTel‐AvivIsrael,Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
| | | | - Tanir Allweis
- Medical Director, Breast Health CenterKaplan Medical CenteRehovotIsrael,Faculty of MedicineHebrew UniversityJerusalemIsrael
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G. K. AV, Gogoi G, Behera B, Rila S, Rangarajan A, Pandya HJ. RapidET: a MEMS-based platform for label-free and rapid demarcation of tumors from normal breast biopsy tissues. MICROSYSTEMS & NANOENGINEERING 2022; 8:1. [PMID: 35087680 PMCID: PMC8761751 DOI: 10.1038/s41378-021-00337-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 11/07/2021] [Accepted: 11/28/2021] [Indexed: 05/09/2023]
Abstract
The rapid and label-free diagnosis of malignancies in ex vivo breast biopsy tissues has significant utility in pathology laboratories and operating rooms. We report a MEMS-based platform integrated with microchips that performs phenotyping of breast biopsy tissues using electrothermal sensing. The microchip, fabricated on a silicon substrate, incorporates a platinum microheater, interdigitated electrodes (IDEs), and resistance temperature detectors (RTDs) as on-chip sensing elements. The microchips are integrated onto the platform using a slide-fit contact enabling quick replacement for biological measurements. The bulk resistivity (ρ B ), surface resistivity (ρ S ), and thermal conductivity (k) of deparaffinized and formalin-fixed paired tumor and adjacent normal breast biopsy samples from N = 8 patients were measured. For formalin-fixed samples, the mean ρ B for tumors showed a statistically significant fold change of 4.42 (P = 0.014) when the tissue was heated from 25 °C to 37 °C compared to the adjacent normal tissue, which showed a fold change of 3.47. The mean ρ S measurements also showed a similar trend. The mean k of the formalin-fixed tumor tissues was 0.309 ± 0.02 W m-1 K-1 compared to a significantly higher k of 0.563 ± 0.028 W m-1 K-1 for the adjacent normal tissues. A similar trend was observed in ρ B, ρ S, and k for the deparaffinized tissue samples. An analysis of a combination of ρ B , ρ S , and k using Fisher's combined probability test and linear regression suggests the advantage of using all three parameters simultaneously for distinguishing tumors from adjacent normal tissues with higher statistical significance.
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Affiliation(s)
- Anil Vishnu G. K.
- Center for BioSystems Science and Engineering, Indian Institute of Science, Bangalore, Karnataka India
| | - Gayatri Gogoi
- Department of Pathology, Assam Medical College, Dibrugarh, Assam India
| | - Bhagaban Behera
- Department of Electronic Systems Engineering, Indian Institute of Science, Bangalore, Karnataka India
| | - Saeed Rila
- Department of Electronic Systems Engineering, Indian Institute of Science, Bangalore, Karnataka India
| | - Annapoorni Rangarajan
- Department of Molecular Reproduction, Development, and Genetics, Indian Institute of Science, Bangalore, Karnataka India
| | - Hardik J. Pandya
- Department of Electronic Systems Engineering, Indian Institute of Science, Bangalore, Karnataka India
- Centre for Product Design and Manufacturing, Indian Institute of Science, Bangalore, Karnataka India
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Diagnostic Value of Intraoperative Frozen Section in Breast-Conserving Surgery: A Systematic Review and Meta-analysis. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2021. [DOI: 10.5812/ijcm.114082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Context: According to previous studies, using the frozen section procedure during breast surgery reduces the rate of error and the need for re-surgery. We aimed at performing a comprehensive systematic review and meta-analysis to provide reliable evidence on the diagnostic value of frozen section procedures in breast-conserving surgery (BCS). Data Sources: A thorough search was performed in PubMed, Embase, Cochrane Library, and Web of Science databases for human diagnostic studies that used the frozen section in BCS. Meta-analyses were done to find the sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR). Study Selection: Human diagnostic studies used the frozen section in breast-conserving surgery and studies that reported the sensitivity and specificity of the frozen section in BCS or contained data that could be calculated the desired parameters were selected for this meta-analysis. Data Extraction: Assessment of studies quality was done and data was extracted from included papers. Then, the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess the quality of included papers. Results: Thirty-five papers were entered into our study. The meta-analysis indicated the high sensitivity (83.47, 95%CI 79.61 - 87.32) and specificity (99.29, 95%CI 98.89 - 99.68) for the frozen section in BCS, which resulted in an accuracy of 93.77 (95%CI 92.45 - 95.10). We also found a significant PPV (93.26, 95%CI 91.25 - 95.27), NPV (92.17, 95%CI 90.22 - 94.11), PLR (7.99, 95%CI 6.01 - 9.96), and NLR (0.18, 95%CI 0.14 - 0.23). Conclusions: The findings showed that intraoperative frozen section analysis has high sensitivity and specificity for evaluating lumpectomy margins in patients with early-stage breast cancer and significantly reduces the need for re-operation. Accordingly, re-operation costs are not imposed on the patient and reduce the anxiety of the patients.
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9
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Intraoperative fluorescence imaging with aminolevulinic acid detects grossly occult breast cancer: a phase II randomized controlled trial. Breast Cancer Res 2021; 23:72. [PMID: 34253233 PMCID: PMC8276412 DOI: 10.1186/s13058-021-01442-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/25/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Re-excision due to positive margins following breast-conserving surgery (BCS) negatively affects patient outcomes and healthcare costs. The inability to visualize margin involvement is a significant challenge in BCS. 5-Aminolevulinic acid hydrochloride (5-ALA HCl), a non-fluorescent oral prodrug, causes intracellular accumulation of fluorescent porphyrins in cancer cells. This single-center Phase II randomized controlled trial evaluated the safety, feasibility, and diagnostic accuracy of a prototype handheld fluorescence imaging device plus 5-ALA for intraoperative visualization of invasive breast carcinomas during BCS. METHODS Fifty-four patients were enrolled and randomized to receive no 5-ALA or oral 5-ALA HCl (15 or 30 mg/kg). Forty-five patients (n = 15/group) were included in the analysis. Fluorescence imaging of the excised surgical specimen was performed, and biopsies were collected from within and outside the clinically demarcated tumor border of the gross specimen for blinded histopathology. RESULTS In the absence of 5-ALA, tissue autofluorescence imaging lacked tumor-specific fluorescent contrast. Both 5-ALA doses caused bright red tumor fluorescence, with improved visualization of tumor contrasted against normal tissue autofluorescence. In the 15 mg/kg 5-ALA group, the positive predictive value (PPV) for detecting breast cancer inside and outside the grossly demarcated tumor border was 100.0% and 55.6%, respectively. In the 30 mg/kg 5-ALA group, the PPV was 100.0% and 50.0% inside and outside the demarcated tumor border, respectively. No adverse events were observed, and clinical feasibility of this imaging device-5-ALA combination approach was confirmed. CONCLUSIONS This is the first known clinical report of visualization of 5-ALA-induced fluorescence in invasive breast carcinoma using a real-time handheld intraoperative fluorescence imaging device. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT01837225 . Registered 23 April 2013.
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10
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Mason EE, Mattingly E, Herb K, Śliwiak M, Franconi S, Cooley CZ, Slanetz PJ, Wald LL. Concept for using magnetic particle imaging for intraoperative margin analysis in breast-conserving surgery. Sci Rep 2021; 11:13456. [PMID: 34188077 PMCID: PMC8242088 DOI: 10.1038/s41598-021-92644-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/11/2021] [Indexed: 12/23/2022] Open
Abstract
Breast-conserving surgery (BCS) is a commonly utilized treatment for early stage breast cancers but has relatively high reexcision rates due to post-surgical identification of positive margins. A fast, specific, sensitive, easy-to-use tool for assessing margins intraoperatively could reduce the need for additional surgeries, and while many techniques have been explored, the clinical need is still unmet. We assess the potential of Magnetic Particle Imaging (MPI) for intraoperative margin assessment in BCS, using a passively or actively tumor-targeted iron oxide agent and two hardware devices: a hand-held Magnetic Particle detector for identifying residual tumor in the breast, and a small-bore MPI scanner for quickly imaging the tumor distribution in the excised specimen. Here, we present both hardware systems and demonstrate proof-of-concept detection and imaging of clinically relevant phantoms.
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Affiliation(s)
- Erica E Mason
- Department of Radiology, A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, 02129, USA.
- Harvard-MIT Division of Health Sciences and Technology, Cambridge, MA, 02139, USA.
| | - Eli Mattingly
- Harvard-MIT Division of Health Sciences and Technology, Cambridge, MA, 02139, USA
| | - Konstantin Herb
- Department of Radiology, A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, 02129, USA
- Department of Physics, ETH Zurich, Zurich, Switzerland
| | - Monika Śliwiak
- Department of Radiology, A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, 02129, USA
| | - Sofia Franconi
- Department of Radiology, A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, 02129, USA
| | - Clarissa Zimmerman Cooley
- Department of Radiology, A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, 02129, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Priscilla J Slanetz
- Department of Radiology, Boston University Medical Center, Boston, MA, 02118, USA
| | - Lawrence L Wald
- Department of Radiology, A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, 02129, USA
- Harvard Medical School, Boston, MA, 02115, USA
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11
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Koopmansch C, Noël JC, Maris C, Simon P, Sy M, Catteau X. Intraoperative Evaluation of Resection Margins in Breast-Conserving Surgery for In Situ and Invasive Breast Carcinoma. BREAST CANCER-BASIC AND CLINICAL RESEARCH 2021; 15:1178223421993459. [PMID: 33854326 PMCID: PMC8013925 DOI: 10.1177/1178223421993459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 01/15/2021] [Indexed: 11/16/2022]
Abstract
Background: The challenge of breast-conserving surgery (BCS) is to remove the entire tumour with free margins and avoid secondary excision that may adversely affect the cosmetic outcome. Consequently, intraoperative evaluation of surgical margins is critical. The aims of this study were multiple. First, to analyse our methodology of intraoperative examination of the resection margins and to evaluate radiological and pathological methods in the assessment of the surgical margins. Second, to evaluate the factors associated with positive margins in our patient population. M&m: The data on the resection margin status of 290 patients who underwent BCS for invasive carcinoma or ductal carcinoma in situ (DCIS) between 2009 and 2016 were reviewed. Results: In the cohort of BCS with invasive carcinoma, the negative predictive value was 97.4% for intraoperative assessment by radiography and 81.8% for intraoperative assessment by pathology. The re-operation rate among cases without intraoperative assessment was 23.6% compared to 7.3% among cases with intraoperative assessment (P = .003). Margin status was significantly associated with tumour size, histological subtype (invasive lobular carcinoma), and multifocality. In the population of BCS with DCIS, margin status was significantly associated with preoperative localisation and intraoperative margin assessment (P = .03). Conclusion: There is no statistical difference between pathological and radiological intraoperative assessment. Tumour size, lobular subtype, and multifocality were found to be significantly associated with positive margins in cases with invasive carcinoma, whereas absence of intraoperative margin assessment was significantly associated with positive margins in cases with DCIS. Therefore, intraoperative margin assessment improves the likelihood of complete excision of the lesion.
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Affiliation(s)
- Caroline Koopmansch
- Department of Pathology, Pathology and Genetic Institute, Gosselies, Belgium
| | - Jean-Christophe Noël
- Department of Pathology, Erasme University Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - Calliope Maris
- Department of Pathology, Erasme University Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - Philippe Simon
- Department of Gynaecology, Erasme University Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - Marième Sy
- Department of Radiology, Erasme University Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - Xavier Catteau
- Department of Pathology, CUREPATH laboratory (CHIREC, CHU Tivoli), Jumet, Belgium
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12
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Jurrius PAGT, Grootendorst MR, Krotewicz M, Cariati M, Kothari A, Patani N, Karcz P, Nagadowska M, Vyas KN, Purushotham A, Turska-d'Amico M. Intraoperative [ 18F]FDG flexible autoradiography for tumour margin assessment in breast-conserving surgery: a first-in-human multicentre feasibility study. EJNMMI Res 2021; 11:28. [PMID: 33738563 PMCID: PMC7973336 DOI: 10.1186/s13550-021-00759-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 02/05/2021] [Indexed: 12/13/2022] Open
Abstract
Introduction In women undergoing breast-conserving surgery (BCS), 20–25% require a re-operation as a result of incomplete tumour resection. An intra-operative technique to assess tumour margins accurately would be a major advantage. A novel method for intraoperative margin assessment was developed by applying a thin flexible scintillating film to specimens—flexible autoradiography (FAR) imaging. A single-arm, multi-centre study was conducted to evaluate the feasibility of intraoperative [18F]FDG FAR for the assessment of tumour margins in BCS.
Methods Eighty-eight patients with invasive breast cancer undergoing BCS received ≤ 300 MBq of [18F]FDG 60–180 min pre-operatively. Following surgical excision, intraoperative FAR imaging was performed using the LightPath® Imaging System. The first 16 patients were familiarisation patients; the remaining 72 patients were entered into the main study. FAR images were analysed post-operatively by three independent readers. Areas of increased signal intensity were marked, mean normalised radiances and tumour-to-tissue background (TBR) determined, agreement between histopathological margin status and FAR assessed and radiation dose to operating theatre staff measured. Subgroup analyses were performed for various covariates, with thresholds set based on ROC curves. Results Data analysis was performed on 66 patients. Intraoperative margin assessment using FAR was completed on 385 margins with 46.2% sensitivity, 81.7% specificity, 8.1% PPV, 97.7% NPV and an overall accuracy of 80.5%, detecting both invasive carcinoma and DCIS. A subgroup analysis based on [18F]FDG activity present at time of imaging revealed an increased sensitivity (71.4%), PPV (9.3%) and NPV (98.4%) in the high-activity cohort with mean tumour radiance and TBR of 126.7 ± 45.7 photons/s/cm2/sr/MBq and 2.1 ± 0.5, respectively. Staff radiation exposure was low (38.2 ± 38.1 µSv). Conclusion [18F]FDG FAR is a feasible and safe technique for intraoperative tumour margin assessment. Further improvements in diagnostic performance require optimising the method for scintillator positioning and/or the use of targeted radiopharmaceuticals. Trial registration: Identifier: NCT02666079. Date of registration: 28 January 2016. URL: https://clinicaltrials.gov/ct2/show/NCT02666079. ISRCTN registry: Reference: ISRCTN17778965. Date of registration: 11 February 2016. URL: http://www.isrctn.com/ISRCTN17778965.
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Affiliation(s)
- Patriek A G T Jurrius
- School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom. .,Department of Breast Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | | | - Marika Krotewicz
- Breast Cancer and Reconstructive Surgery Clinic, Maria Skłodowska-Curie Institute of Oncology, Warsaw, Poland
| | - Massimiliano Cariati
- Department of Breast Surgery, University College London Hospital, London, United Kingdom
| | - Ashutosh Kothari
- Department of Breast Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Neill Patani
- Department of Breast Surgery, University College London Hospital, London, United Kingdom
| | - Paulina Karcz
- Clinical Department of Endocrinology, Maria Skłodowska-Curie Institute of Oncology, Kraków, Poland
| | - Monika Nagadowska
- Breast Cancer and Reconstructive Surgery Clinic, Maria Skłodowska-Curie Institute of Oncology, Warsaw, Poland
| | | | - Arnie Purushotham
- School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom.,Department of Breast Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Maria Turska-d'Amico
- Oncological and Reconstructive Surgery Clinic, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice, Poland
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13
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Suurs FV, Qiu SQ, Yim JJ, Schröder CP, Timmer-Bosscha H, Bensen ES, Santini JT, de Vries EGE, Bogyo M, van Dam GM. Fluorescent image-guided surgery in breast cancer by intravenous application of a quenched fluorescence activity-based probe for cysteine cathepsins in a syngeneic mouse model. EJNMMI Res 2020; 10:111. [PMID: 32990883 PMCID: PMC7524956 DOI: 10.1186/s13550-020-00688-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/13/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose The reoperation rate for breast-conserving surgery is as high as 15–30% due to residual tumor in the surgical cavity after surgery. In vivo tumor-targeted optical molecular imaging may serve as a red-flag technique to improve intraoperative surgical margin assessment and to reduce reoperation rates. Cysteine cathepsins are overexpressed in most solid tumor types, including breast cancer. We developed a cathepsin-targeted, quenched fluorescent activity-based probe, VGT-309, and evaluated whether it could be used for tumor detection and image-guided surgery in syngeneic tumor-bearing mice. Methods Binding specificity of the developed probe was evaluated in vitro. Next, fluorescent imaging in BALB/c mice bearing a murine breast tumor was performed at different time points after VGT-309 administration. Biodistribution of VGT-309 after 24 h in tumor-bearing mice was compared to control mice. Image-guided surgery was performed at multiple time points tumors with different clinical fluorescent camera systems and followed by ex vivo analysis. Results The probe was specifically activated by cathepsins X, B/L, and S. Fluorescent imaging revealed an increased tumor-to-background contrast over time up to 15.1 24 h post probe injection. In addition, VGT-309 delineated tumor tissue during image-guided surgery with different optical fluorescent imaging camera systems. Conclusion These results indicate that optical fluorescent molecular imaging using the cathepsin-targeted probe, VGT-309, may improve intraoperative tumor detection, which could translate to more complete tumor resection when coupled with commercially available surgical tools and techniques.
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Affiliation(s)
- Frans V Suurs
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Si-Qi Qiu
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. .,Diagnosis and Treatment Center of Breast Diseases, Affiliated Shantou Hospital, Sun Yat-Sen University, Shantou, China.
| | - Joshua J Yim
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA, USA
| | - Carolien P Schröder
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hetty Timmer-Bosscha
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - Elisabeth G E de Vries
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Matthew Bogyo
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gooitzen M van Dam
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. .,Department of Nuclear Medicine and Molecular Imaging and Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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14
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DiCorpo D, Tiwari A, Tang R, Griffin M, Aftreth O, Bautista P, Hughes K, Gershenfeld N, Michaelson J. The role of Micro-CT in imaging breast cancer specimens. Breast Cancer Res Treat 2020; 180:343-357. [PMID: 32020431 DOI: 10.1007/s10549-020-05547-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 01/22/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE The goal of breast cancer surgery is to remove all of the cancer with a minimum of normal tissue, but absence of full 3-dimensional information on the specimen makes this difficult to achieve. METHOD Micro-CT is a high resolution, X-ray, 3D imaging method, widely used in industry but rarely in medicine. RESULTS We imaged and analyzed 173 partial mastectomies (129 ductal carcinomas, 14 lobular carcinomas, 28 DCIS). Imaging was simple and rapid. The size and shape of the cancers seen on Micro-CT closely matched the size and shape of the cancers seen at specimen dissection. Micro-CT images of multicentric/multifocal cancers revealed multiple non-contiguous masses. Micro-CT revealed cancer touching the specimen edge for 93% of the 114 cases judged margin positive by the pathologist, and 28 of the cases not seen as margin positive on pathological analysis; cancer occupied 1.55% of surface area when both the pathologist and Micro-CT suggested cancer at the edge, but only 0.45% of surface area for the "Micro-CT-Only-Positive Cases". Thus, Micro-CT detects cancers that touch a very small region of the specimen surface, which is likely to be missed on sectioning. CONCLUSIONS Micro-CT provides full 3D images of breast cancer specimens, allowing one to identify, in minutes rather than hours, while the patient is in OR, margin-positive cancers together with information on where the cancer touches the edge, in a fashion more accurate than possible from the histology slides alone.
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Affiliation(s)
- Daniel DiCorpo
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Ankur Tiwari
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA.,Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Rong Tang
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Molly Griffin
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Owen Aftreth
- Department of Urology, Los Angeles Medical Center, Kaiser Permanente, Los Angeles, CA, USA
| | - Pinky Bautista
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Kevin Hughes
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Neil Gershenfeld
- MIT Center for Bits and Atoms, Room E15-401, 20 Ames Street, Cambridge, MA, 02139, USA
| | - James Michaelson
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA. .,Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, 02115, USA. .,Department of Pathology, Massachusetts General Hospital, Boston, MA, 02115, USA. .,Department of Pathology, Harvard Medical School, Boston, MA, 02115, USA. .,, 12 Sheeps Crossing Lane, Woods Hole, USA.
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15
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Zhang B, Ye S, Shankara SB, Zhang H, Zheng Q. Neutral diagnosis: An innovative concept for medical device clinical trials. Contemp Clin Trials Commun 2019; 16:100436. [PMID: 31485547 PMCID: PMC6717093 DOI: 10.1016/j.conctc.2019.100436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 08/05/2019] [Accepted: 08/19/2019] [Indexed: 11/24/2022] Open
Abstract
Study design and statistical analysis are crucial in pivotal clinical trials to evaluate the effectiveness and safety of new medical devices under investigation. In recent years, innovative intraoperative in vivo breast tumor diagnostic devices have been proposed to improve the accuracy and surgical outcomes of breast tumor patients undergoing resection. Although such technologies are promising, investigators need to obtain statistical evidence for the effectiveness and safety of these devices by conducting valid clinical trials. However, the study design and statistical analysis for these clinical trials are complicated. While these trials are designed to provide real-time intraoperative diagnosis of cancerous tissue, they also have clear therapeutic objectives to lower the reoperation rate of breast cancer surgery. This research article introduces the new concept of neutral diagnosis (ND), and the ND clinical trial design as an innovative study design to evaluate the effectiveness and safety of diagnostic devices with direct therapeutic purposes. A joint modeling approach is adopted to make inferences on the effectiveness and safety of these devices for non-neutral diagnosis (non-ND) clinical trials. Simulation studies were conducted to show the efficiency of the ND trials and strength of the joint modeling approach in the non-ND clinical trials. An example on a diagnostic medical device that provides real-time, intraoperative diagnosis of breast cancer tumor tissues during breast cancer surgeries is comprehensively discussed and analyzed.
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Affiliation(s)
- Bo Zhang
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, 01605, USA
| | - Shangyuan Ye
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, 01605, USA
| | - Sravya B Shankara
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, 01605, USA
| | - Hui Zhang
- Division of Biostatistics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60611, USA
| | - Qingfeng Zheng
- Department of Thoracic Surgery, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
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16
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Metcalfe LN, Zysk AM, Yemul KS, Jacobs LK, Oker EE, Underwood HR, Thompson AM. Beyond the Margins-Economic Costs and Complications Associated With Repeated Breast-Conserving Surgeries. JAMA Surg 2019; 152:1084-1086. [PMID: 28768303 DOI: 10.1001/jamasurg.2017.2661] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
| | - Adam M Zysk
- Diagnostic Photonics, Inc., Chicago, Illinois
| | | | - Lisa K Jacobs
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Elif E Oker
- Health Care Services Corporation, Chicago, Illinois
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17
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Janssen NNY, van Seijen M, Loo CE, Vrancken Peeters MJTFD, Hankel T, Sonke JJ, Nijkamp J. Feasibility of Micro-Computed Tomography Imaging for Direct Assessment of Surgical Resection Margins During Breast-Conserving Surgery. J Surg Res 2019; 241:160-169. [PMID: 31026794 DOI: 10.1016/j.jss.2019.03.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/31/2019] [Accepted: 03/22/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND To analyze the feasibility and accuracy of micro-computed tomography (micro-CT) for surgical margin assessment in breast excision specimen. MATERIALS AND METHODS Two data sets of 30 micro-CT scans were retrospectively evaluated for positive resection margins by four observers in two phases, using pathology as a gold standard. Results of phase 1 were evaluated to define micro-CT evaluation guidelines for phase 2. Interobserver agreement was also assessed (kappa). In addition, a prospective study was conducted in which 40 micro-CT scans were directly acquired, reconstructed, and evaluated for positive resection margins by one observer. A suspect positive resection margin on micro-CT was annotated onto the specimen with ink, enabling local validation by pathology. Main outcome measures were accuracy, sensitivity, specificity, and positive predictive value (PPV). RESULTS Average accuracy, sensitivity, specificity, and PPV for the four observers were 63%, 38%, 70%, and 22%, respectively, in phase 1 and 72%, 40%, 78%, and 26%, respectively, in phase 2. The interobserver agreement was fair [kappa (range), 0.31 (0.12-0.80) in phase 1 and 0.23 (0-0.43) in phase 2]. In the prospective study 70% of the surgical resection margins were correctly evaluated. Ten specimens were annotated for positive resection margins, which correlated with three positive and three close (<1 mm) margins on pathology. Sensitivity, specificity, and PPV were 38%, 78%, and 30%, respectively. CONCLUSIONS Micro-CT imaging of breast excision specimen has moderate accuracy and considerable interobserver variation for analysis of surgical resection margins. Especially sensitivity and PPV need to be improved before micro-CT-based margin assessment can be introduced in clinical practice.
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Affiliation(s)
- Natasja N Y Janssen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Maartje van Seijen
- Department of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Claudette E Loo
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Tara Hankel
- Department of Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Jasper Nijkamp
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
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18
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Chen Y, Xie W, Glaser AK, Reder NP, Mao C, Dintzis SM, Vaughan JC, Liu JTC. Rapid pathology of lumpectomy margins with open-top light-sheet (OTLS) microscopy. BIOMEDICAL OPTICS EXPRESS 2019; 10:1257-1272. [PMID: 30891344 PMCID: PMC6420271 DOI: 10.1364/boe.10.001257] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/11/2019] [Accepted: 01/25/2019] [Indexed: 05/18/2023]
Abstract
Open-top light-sheet microscopy is a technique that can potentially enable rapid ex vivo inspection of large tissue surfaces and volumes. Here, we have optimized an open-top light-sheet (OTLS) microscope and image-processing workflow for the comprehensive examination of surgical margin surfaces, and have also developed a novel fluorescent analog of H&E staining that is robust for staining fresh unfixed tissues. Our tissue-staining method can be achieved within 2.5 minutes followed by OTLS microscopy of lumpectomy surfaces at a rate of up to 1.5 cm2/minute. An image atlas is presented to show that OTLS image quality surpasses that of intraoperative frozen sectioning and can approximate that of gold-standard H&E histology of formalin-fixed paraffin-embedded (FFPE) tissues. Qualitative evidence indicates that these intraoperative methods do not interfere with downstream post-operative H&E histology and immunohistochemistry. These results should facilitate the translation of OTLS microscopy for intraoperative guidance of lumpectomy and other surgical oncology procedures.
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Affiliation(s)
- Ye Chen
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195, USA
- These authors contributed equally
| | - Weisi Xie
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195, USA
- These authors contributed equally
| | - Adam K. Glaser
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195, USA
| | - Nicholas P. Reder
- Department of Pathology, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Chenyi Mao
- Department of Chemistry, University of Washington Seattle, WA 98195, USA
| | - Suzanne M. Dintzis
- Department of Pathology, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Joshua C. Vaughan
- Department of Chemistry, University of Washington Seattle, WA 98195, USA
- Department of Physiology and Biophysics, University of Washington, Seattle, WA 98195, USA
| | - Jonathan T. C. Liu
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195, USA
- Department of Pathology, University of Washington School of Medicine, Seattle, WA 98195, USA
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19
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Qiu SQ, Dorrius MD, de Jongh SJ, Jansen L, de Vries J, Schröder CP, Zhang GJ, de Vries EGE, van der Vegt B, van Dam GM. Micro-computed tomography (micro-CT) for intraoperative surgical margin assessment of breast cancer: A feasibility study in breast conserving surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018; 44:1708-1713. [PMID: 30005963 DOI: 10.1016/j.ejso.2018.06.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/01/2018] [Accepted: 06/20/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE Around 15%-30% of patients receiving breast-conserving surgery (BCS) for invasive breast carcinoma or ductal carcinoma in situ (DCIS) need a reoperation due to tumor-positive margins at final histopathology. Currently available intraoperative surgical margin assessment modalities all have specific limitations. Therefore, we aimed to assess the feasibility and accuracy of micro-computed tomography (micro-CT) as a novel method for intraoperative margin assessment in BCS. METHODS Lumpectomy specimens from 30 consecutive patients diagnosed with invasive breast cancer or DCIS were imaged using a micro-CT. Margin status was assessed on micro-CT images by two investigators who were blinded to the final histopathological margin status. The micro-CT margin status was compared with the histopathological margin status. RESULTS The margin status could be assessed by micro-CT in 29 out of 30 patients. Of these, nine patients had a positive tumor margin and 20 a negative tumor margin at final histopathology. Margin status evaluation by micro-CT took always less than 15 min. The margin status in 25 patients was correctly predicted by micro-CT. There were four false-negative predictions. The accuracy, sensitivity, specificity, positive predictive value and negative predictive value of micro-CT in margin status prediction were 86%, 56%, 100%, 100% and 83%, respectively. With micro-CT, the positive margin rate could potentially have been reduced from 31% to 14%. CONCLUSIONS Whole lumpectomy specimen micro-CT scanning is a promising technique for intraoperative margin assessment in BCS. Intraoperative quick feedback on the margin status could potentially lead to a reduction in the number of reoperations.
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Affiliation(s)
- Si-Qi Qiu
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; The Breast Center, Cancer Hospital of Shantou University Medical College, Guangdong, China
| | - Monique D Dorrius
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Steven J de Jongh
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Liesbeth Jansen
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jakob de Vries
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carolien P Schröder
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Guo-Jun Zhang
- Changjiang Scholar's Laboratory of Shantou University Medical College, Guangdong, China; The Cancer Center, Xiang'an Hospital of Xiamen University, Fujian, China
| | - Elisabeth G E de Vries
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bert van der Vegt
- Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gooitzen M van Dam
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nuclear Medicine and Molecular Imaging and Intensive Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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20
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Adank MW, Fleischer JC, Dankelman J, Hendriks BHW. Real-time oncological guidance using diffuse reflectance spectroscopy in electrosurgery: the effect of coagulation on tissue discrimination. JOURNAL OF BIOMEDICAL OPTICS 2018; 23:1-10. [PMID: 30447060 DOI: 10.1117/1.jbo.23.11.115004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 10/15/2018] [Indexed: 05/15/2023]
Abstract
In breast surgery, a lack of knowledge about what is below the tissue surface may lead to positive tumor margins and iatrogenic damage. Diffuse reflectance spectroscopy (DRS) is a spectroscopic technique that can distinguish between healthy and tumor tissue making it a suitable technology for intraoperative guidance. However, because tumor surgeries are often performed with an electrosurgical knife, the effect of a coagulated tissue layer on DRS measurements must be taken into account. It is evaluated whether real-time DRS measurements obtained with a photonic electrosurgical knife could provide useful information of tissue properties also when tissue is coagulated and cut. The size of the coagulated area is determined and the effect of its presence on DR spectra is studied using ex vivo porcine adipose and muscle tissue. A coagulated tissue layer with a depth of 0.1 to 0.4 mm is observed after coagulating muscle with an electrosurgical knife. The results show that the effect of coagulating adipose tissue is negligible. Using the fat/water ratio's calculated from the measured spectra of the photonic electrosurgical knife, it was possible to determine the distance from the instrument tip to a tissue transition during cutting. In conclusion, the photonic electrosurgical knife can determine tissue properties of coagulated and cut tissue and has, therefore, the potential to provide real-time feedback about the presence of breast tumor margins during cutting, helping surgeons to establish negative margins and improve patient outcome.
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Affiliation(s)
- Maartje W Adank
- Delft University of Technology, Biomechanical Engineering Department, Delft, The Netherlands
| | - Julie C Fleischer
- Delft University of Technology, Biomechanical Engineering Department, Delft, The Netherlands
| | - Jenny Dankelman
- Delft University of Technology, Biomechanical Engineering Department, Delft, The Netherlands
| | - Benno H W Hendriks
- Delft University of Technology, Biomechanical Engineering Department, Delft, The Netherlands
- Philips Research, In-Body Systems Department, Eindhoven, The Netherlands
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Chagpar AB, Wilke LG. Should Reexcision Rates in Breast Cancer Care be a Quality Measure? Ann Surg Oncol 2018; 25:2818-2822. [PMID: 29947002 DOI: 10.1245/s10434-018-6576-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Anees B Chagpar
- Department of Surgery, Yale University School of Medicine, 20 York Street, First Floor, Suite A, New Haven, CT, USA.
| | - Lee G Wilke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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22
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Präger M, Kiechle M, Stollenwerk B, Hinzen C, Glatz J, Vogl M, Leidl R. Costs and effects of intra-operative fluorescence molecular imaging - A model-based, early assessment. PLoS One 2018; 13:e0198137. [PMID: 29856875 PMCID: PMC5983425 DOI: 10.1371/journal.pone.0198137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/14/2018] [Indexed: 11/25/2022] Open
Abstract
Introduction Successful breast conserving cancer surgeries come along with tumor free resection margins and account for cosmetic outcome. Positive margins increase the likelihood of tumor recurrence. Intra-operative fluorescence molecular imaging (IFMI) aims to focus surgery on malignant tissue thus substantially lowering the presence of positive margins as compared with standard techniques of breast conservation (ST). A goal of this paper is to assess the incremental number of surgeries and costs of IFMI vs. ST. Methods We developed a decision analytical model and applied it for an early evaluation approach. Given uncertainty we considered that IFMI might reduce the proportion of positive margins found by ST from all to none and this proportion is assumed to be reduced to 10% for the base case. Inputs included data from the literature and a range of effect estimates. For the costs of IFMI, respective cost components were added to those of ST. Results The base case reduction lowered number of surgeries (mean [95% confidence interval]) by 0.22 [0.15; 0.30] and changed costs (mean [95% confidence interval]) by €-663 [€-1,584; €50]. A tornado diagram identified the Diagnosis Related Group (DRG) costs, the proportion of positive margins of ST, the staff time saving factor and the duration of frozen section analysis (FSA) as important determinants of this cost. Conclusions These early results indicate that IFMI may be more effective than ST and through the reduction of positive margins it is possible to save follow-up surgeries–indicating further health risk–and to save costs through this margin reduction and the avoidance of FSA.
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Affiliation(s)
- Maximilian Präger
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH)—German Research Center for Environmental Health, Neuherberg, Germany
- * E-mail:
| | - Marion Kiechle
- Center for Hereditary Breast and Ovarian Cancer, Department of Gynecology, Klinikum Rechts der Isar, Technical University Munich (TUM), Munich, Germany
- Comprehensive Cancer Center Munich (CCCM), Munich, Germany
| | - Björn Stollenwerk
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH)—German Research Center for Environmental Health, Neuherberg, Germany
| | - Christoph Hinzen
- Institute of Biological and Medical Imaging, Helmholtz Zentrum München (GmbH)—German Research Center for Environmental Health, Neuherberg, Germany
- Chair for Biological Imaging, Technical University Munich, Munich, Germany
| | - Jürgen Glatz
- Institute of Biological and Medical Imaging, Helmholtz Zentrum München (GmbH)—German Research Center for Environmental Health, Neuherberg, Germany
- Chair for Biological Imaging, Technical University Munich, Munich, Germany
| | - Matthias Vogl
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH)—German Research Center for Environmental Health, Neuherberg, Germany
| | - Reiner Leidl
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH)—German Research Center for Environmental Health, Neuherberg, Germany
- Munich Center of Health Sciences, Ludwig-Maximilians-Universität München, Munich, Germany
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23
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Murphy BL, Gonzalez AB, Keeney MG, Chen B, Conners AL, Henrichsen TL, Degnim AC, Harmsen WS, Boughey JC, Hieken TJ, Habermann EB, Jakub JW. Ability of Intraoperative Pathologic Analysis of Ductal Carcinoma In Situ to Guide Selective Use of Sentinel Lymph Node Surgery. Am Surg 2018. [DOI: 10.1177/000313481808400427] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
For patients with ductal carcinoma in situ (DCIS), sentinel lymph node (SLN) surgery is generally reserved for patients at high risk of being upstaged to invasive disease. The use of frozen section (FS) pathologic analysis of the primary tumor may allow for selective surgical nodal staging within one procedure. We sought to define the reliability of FS for detection of upstaging. Eight hundred and twenty-seven patients were identified with DCIS on core needle biopsy that underwent 834 operations at our institution between January 2004 and October 2014. We calculated the rate of upstage from DCIS to invasive cancer on both intraoperative FS and final pathology to determine the performance of FS. Upstage rate on final pathology was 118/834 (14.1%) 95 per cent confidence interval 11.8 to 16.7 per cent. FS identified 88/118 (74.6%) of the upstages. Specificity was 99.3 per cent (711/716). Overall accuracy was 95.8 per cent (799/834) and the positive predictive value was 96.0 per cent (711/741 patients). Mean size of invasive cancers identifiedon FS was 5.6 mm, versus 3.5 mm for those identified only on permanent section, P = 0.11. Intraoperative FS analysis of DCIS is useful for identification of upstage to invasive disease. This may facilitate a selective approach to SLN surgery that both decreases unnecessary SLN surgery and the need for a second operation.
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Affiliation(s)
- Brittany L. Murphy
- Departments of Surgery, Rochester, Minnesota
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | | | | | - Beiyun Chen
- Departments of Anatomic Pathology, Rochester, Minnesota
| | - Amy L. Conners
- Departments of Diagnostic Radiology, Rochester, Minnesota
| | | | | | | | | | | | - Elizabeth B. Habermann
- Departments of Surgery, Rochester, Minnesota
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
- Departments of Diagnostic Radiology, Rochester, Minnesota
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Murphy BL, Boughey JC, Keeney MG, Glasgow AE, Racz JM, Keeney GL, Habermann EB. Factors Associated With Positive Margins in Women Undergoing Breast Conservation Surgery. Mayo Clin Proc 2018; 93:429-435. [PMID: 29439832 DOI: 10.1016/j.mayocp.2017.11.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 11/03/2017] [Accepted: 11/27/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To identify factors predicting positive margins at lumpectomy prompting intraoperative reexcision in patients with breast cancer treated at a large referral center. PATIENTS AND METHODS We reviewed all breast cancer lumpectomy cases managed at our institution from January 1, 2012, through December 31, 2013. Associations between rates of positive margin and patient and tumor factors were assessed using χ2 tests and univariate and adjusted multivariate logistic regression, stratified by ductal carcinoma in situ (DCIS) or invasive cancer. RESULTS We identified 382 patients who underwent lumpectomy for definitive surgical resection of breast cancer, 102 for DCIS and 280 for invasive cancer. Overall, 234 patients (61.3%) required intraoperative reexcision for positive margins. The reexcision rate was higher in patients with DCIS than in those with invasive disease (78.4% [80 of 102] vs 56.4% [158 of 280]; univariate odds ratio, 2.80; 95% CI, 1.66-4.76; P<.001). Positive margin rates did not vary by patient age, surgeon, estrogen receptor, progesterone receptor, or ERBB2 status of the tumor. Among the 280 cases of invasive breast cancer, the only factor independently associated with lower odds of margin positivity was seed localization vs no localization (P=.03). CONCLUSION Ductal carcinoma in situ was associated with a higher rate of positive margins at lumpectomy than invasive breast cancer on univariate analysis. Within invasive disease, seed localization was associated with lower rates of margin positivity.
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MESH Headings
- Adult
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Female
- Humans
- Margins of Excision
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Staging
- Neoplasm, Residual/prevention & control
- Retrospective Studies
- Risk Factors
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Affiliation(s)
- Brittany L Murphy
- Department of Surgery, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Michael G Keeney
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Amy E Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Gary L Keeney
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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Ha R, Friedlander LC, Hibshoosh H, Hendon C, Feldman S, Ahn S, Schmidt H, Akens MK, Fitzmaurice M, Wilson BC, Mango VL. Optical Coherence Tomography: A Novel Imaging Method for Post-lumpectomy Breast Margin Assessment-A Multi-reader Study. Acad Radiol 2018; 25:279-287. [PMID: 29174226 DOI: 10.1016/j.acra.2017.09.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/12/2017] [Accepted: 09/18/2017] [Indexed: 01/08/2023]
Abstract
RATIONALE AND OBJECTIVES This study aimed to assess whether different breast cancer subspecialty physicians can be trained to distinguish non-suspicious from suspicious areas of post-lumpectomy specimen margin in patients with breast cancer using optical coherence tomography (OCT) images (a near-infrared based imaging technique) with final histology as the reference standard. MATERIALS AND METHODS This institutional review board-exempt, Health Insurance Portability and Accountability Act-compliant study was performed on 63 surgically excised breast specimens from 35 female patients, creating a 90-case atlas containing both non-suspicious and suspicious areas for cancer. OCT images of the specimens were performed, providing 6.5-15 µm resolution with tissue visualization 1-2 mm subsurface. From the 90-case atlas, 40 cases were chosen for training and 40 were randomly selected for reader assessment. Three breast imaging radiologists, two pathologists, two breast surgeons, and one non-clinical reader were trained and assessed for ability to distinguish non-suspicious from suspicious findings blinded to clinical data and corresponding histology slides. Duration of training and assessment, sensitivity, specificity, positive predictive value, negative predictive value, and the area under the curve for each reader were calculated as well as averages by subspecialty. RESULTS The average training time was 3.4 hours (standard deviation, 1.2). The average assessment time was 1.9 hours (standard deviation, 0.7). The overall average reader sensitivity, specificity, and accuracy for detecting suspicious findings with histologic confirmation of cancer at the surgical margin for all eight readers were 80%, 87%, and 87%, respectively. Radiologists demonstrated the highest average among the disciplines, 85%, 93%, and 94%, followed by pathologists, 79%, 90%, and 84%, and surgeons, 76%, 84%, and 82% respectively. CONCLUSIONS With relatively short training (3.4 hours), readers from different medical specialties were able to distinguish suspicious from non-suspicious OCT imaging findings in ex vivo breast tissue as confirmed by histology. These results support the potential of OCT as a real-time intraoperative tool for post-lumpectomy specimen margin assessment.
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Affiliation(s)
- Richard Ha
- Columbia University Medical Center, New York, New York.
| | | | | | | | | | - Soojin Ahn
- Mount Sinai, New Icahn School of Medicine, New York, New York
| | - Hank Schmidt
- Mount Sinai, New Icahn School of Medicine, New York, New York
| | - Margaret K Akens
- Princess Margaret Cancer Centre/University Health Network, Toronto, ON, Canada
| | | | - Brian C Wilson
- Princess Margaret Cancer Centre/University Health Network, Toronto, ON, Canada
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Ko S, Chun YK, Kang SS, Hur MH. The Usefulness of Intraoperative Circumferential Frozen-Section Analysis of Lumpectomy Margins in Breast-Conserving Surgery. J Breast Cancer 2017; 20:176-182. [PMID: 28690654 PMCID: PMC5500401 DOI: 10.4048/jbc.2017.20.2.176] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 06/16/2017] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Intraoperative frozen-section analysis of the lumpect-omy margin during breast-conserving surgery (BCS) is an excellent method in obtaining a clear resection margin. This study aimed to investigate the usefulness of intraoperative circumferential frozen-section analysis (IOCFS) of lumpectomy margin during BCS for breast cancer, and to find factors that increase the conversion into mastectomy. METHODS From 2007 to 2011, 509 patients with breast cancer underwent IOCFS during BCS. The outer surfaces of the shaved lumpectomy margins were evaluated. A negative margin was defined as no ink on the tumor. All margins were evaluated using the permanent section analysis. RESULTS Among the 509 patients, 437 (85.9%) underwent BCS and 72 (14.1%) finally underwent mastectomy. Of the 483 pathologically confirmed patients, 338 (70.0%) were true-negative, 24 (5.0%) false-negative, 120 (24.8%) true-positive, and 1 (0.2%) false-positive. Twenty-four patients (4.7%) among total 509 patients had undetermined margins as either atypical ductal hyperplasia or ductal carcinoma in situ in the first IOCFS. The IOCFS has an accuracy of 94.8% with 83% sensitivity, 99.7% specificity, 93.4% negative predictive value, and 99.2% positive predictive value. Sixty-three cases (12.4%) were converted to mastectomy, the first intraoperatively. Of the 446 (87.6%) patients who successfully underwent BCS, 64 patients received additional excisions and 32 were reoperated to achieve clear margin (reoperation rate, 6.3%). Twenty-three of the reoperated patients underwent re-excisions using the second intraoperative frozen section analysis, and achieved BCS. Nine cases were additionally converted to mastectomy. No significant differences in age, stage, and biological factors were found between the BCS and mastectomy cases. Factors such as invasive lobular carcinoma, multiple tumors, large tumor, and multiple excisions increased the conversion to mastectomy. CONCLUSION The IOCFS analysis during BCS is useful in evaluating lumpectomy margins and preventing reoperation.
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Affiliation(s)
- SeungSang Ko
- Department of Surgery, Cheil General Hospital & Women's Healthcare Center, Dankook University College of Medicine, Seoul, Korea
| | - Yi Kyeong Chun
- Department of Pathology, Cheil General Hospital & Women's Healthcare Center, Dankook University College of Medicine, Seoul, Korea
| | - Sung Soo Kang
- Department of Surgery, Cheil General Hospital & Women's Healthcare Center, Dankook University College of Medicine, Seoul, Korea
| | - Min Hee Hur
- Department of Surgery, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
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St John ER, Balog J, McKenzie JS, Rossi M, Covington A, Muirhead L, Bodai Z, Rosini F, Speller AVM, Shousha S, Ramakrishnan R, Darzi A, Takats Z, Leff DR. Rapid evaporative ionisation mass spectrometry of electrosurgical vapours for the identification of breast pathology: towards an intelligent knife for breast cancer surgery. Breast Cancer Res 2017; 19:59. [PMID: 28535818 PMCID: PMC5442854 DOI: 10.1186/s13058-017-0845-2] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/25/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Re-operation for positive resection margins following breast-conserving surgery occurs frequently (average = 20-25%), is cost-inefficient, and leads to physical and psychological morbidity. Current margin assessment techniques are slow and labour intensive. Rapid evaporative ionisation mass spectrometry (REIMS) rapidly identifies dissected tissues by determination of tissue structural lipid profiles through on-line chemical analysis of electrosurgical aerosol toward real-time margin assessment. METHODS Electrosurgical aerosol produced from ex-vivo and in-vivo breast samples was aspirated into a mass spectrometer (MS) using a monopolar hand-piece. Tissue identification results obtained by multivariate statistical analysis of MS data were validated by histopathology. Ex-vivo classification models were constructed from a mass spectral database of normal and tumour breast samples. Univariate and tandem MS analysis of significant peaks was conducted to identify biochemical differences between normal and cancerous tissues. An ex-vivo classification model was used in combination with bespoke recognition software, as an intelligent knife (iKnife), to predict the diagnosis for an ex-vivo validation set. Intraoperative REIMS data were acquired during breast surgery and time-synchronized to operative videos. RESULTS A classification model using histologically validated spectral data acquired from 932 sampling points in normal tissue and 226 in tumour tissue provided 93.4% sensitivity and 94.9% specificity. Tandem MS identified 63 phospholipids and 6 triglyceride species responsible for 24 spectral differences between tissue types. iKnife recognition accuracy with 260 newly acquired fresh and frozen breast tissue specimens (normal n = 161, tumour n = 99) provided sensitivity of 90.9% and specificity of 98.8%. The ex-vivo and intra-operative method produced visually comparable high intensity spectra. iKnife interpretation of intra-operative electrosurgical vapours, including data acquisition and analysis was possible within a mean of 1.80 seconds (SD ±0.40). CONCLUSIONS The REIMS method has been optimised for real-time iKnife analysis of heterogeneous breast tissues based on subtle changes in lipid metabolism, and the results suggest spectral analysis is both accurate and rapid. Proof-of-concept data demonstrate the iKnife method is capable of online intraoperative data collection and analysis. Further validation studies are required to determine the accuracy of intra-operative REIMS for oncological margin assessment.
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Affiliation(s)
- Edward R. St John
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - Julia Balog
- Division of Computational and Systems Medicine, Imperial College, London, UK
- Waters Research Centre, Budapest, Hungary
| | - James S. McKenzie
- Division of Computational and Systems Medicine, Imperial College, London, UK
| | - Merja Rossi
- Division of Computational and Systems Medicine, Imperial College, London, UK
| | - April Covington
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - Laura Muirhead
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - Zsolt Bodai
- Division of Computational and Systems Medicine, Imperial College, London, UK
| | - Francesca Rosini
- Division of Computational and Systems Medicine, Imperial College, London, UK
- Department of Pathology, Imperial College NHS Trust, London, UK
| | - Abigail V. M. Speller
- Division of Computational and Systems Medicine, Imperial College, London, UK
- Department of Pathology, Imperial College NHS Trust, London, UK
| | - Sami Shousha
- Department of Pathology, Imperial College NHS Trust, London, UK
| | | | - Ara Darzi
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
| | - Zoltan Takats
- Division of Computational and Systems Medicine, Imperial College, London, UK
- Sir Alexander Fleming Building, South Kensington Campus, Imperial College, London, SW7 2AZ UK
| | - Daniel R. Leff
- Department of BioSurgery and Surgical Technology, Imperial College London, London, UK
- Department of BioSurgery and Surgical Technology, Clinical Senior Lecturer and Consultant Breast Surgeon, St Mary’s Hospital, 10th Floor, QEQM Wing, London, W2 1NY UK
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28
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Kim MJ, Kim CS, Park YS, Choi EH, Han KD. The Efficacy of Intraoperative Frozen Section Analysis During Breast-Conserving Surgery for Patients with Ductal Carcinoma In Situ. BREAST CANCER-BASIC AND CLINICAL RESEARCH 2016; 10:205-210. [PMID: 27980416 PMCID: PMC5147452 DOI: 10.4137/bcbcr.s40868] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/25/2016] [Accepted: 10/27/2016] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Recently, the incidence of ductal carcinoma in situ (DCIS), a noninvasive breast malignancy, has increased. This has resulted in an increase in the incidence of breast-conserving surgery (BCS). Numerous studies have suggested that intraoperative frozen section analysis (IFSA) could reduce the rate of additional excisions required to obtain adequate resection margins. However, DCIS is a known risk factor for positive margin status during BCS. Furthermore, some authors have concluded that IFSA may not be reliable for the detection of DCIS. AIM The aim of this study was to evaluate the safety and efficacy of IFSA in patients with DCIS. METHODS The operative and pathological reports of patients with DCIS, who underwent BCS at our institute between 2006 and 2015, were retrospectively reviewed. The results of IFSA and the pathological findings of final reanalyzed frozen tissue specimens were analyzed. RESULTS In total, 25 patients were included in our analysis. None of the patients required additional operations. The correct diagnosis rate for IFSA was 89.6%, with a sensitivity and specificity of 60.0% and 95.8%, respectively. CONCLUSION IFSA could be beneficial for determining safety resection margins in patients with DCIS.
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Affiliation(s)
- Mi Jin Kim
- Department of General Surgery, Presbyterian Medical Center, Jeonju, Korea
| | - Cheol Seung Kim
- Department of General Surgery, Presbyterian Medical Center, Jeonju, Korea
| | - Young Sam Park
- Department of General Surgery, Presbyterian Medical Center, Jeonju, Korea
| | - Eun Hye Choi
- Department of General Surgery, Presbyterian Medical Center, Jeonju, Korea
| | - Kyu Dam Han
- Department of General Surgery, Presbyterian Medical Center, Jeonju, Korea
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Alves-Ribeiro L, Osório F, Amendoeira I, Fougo JL. Positive margins prediction in breast cancer conservative surgery: Assessment of a preoperative web-based nomogram. Breast 2016; 28:167-73. [DOI: 10.1016/j.breast.2016.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 05/21/2016] [Indexed: 11/16/2022] Open
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Abstract
Each year, millions of individuals undergo cancer surgery that is intended to be curative or at least a necessary component of a curative regimen. Particularly for those patients whose cancer harbors cells that are resistant to chemotherapy or radiation, the extent of surgery often defines whether they will be a survivor or casualty of the disease. For many solid tumor types, the difference in survival between patients who undergo gross total resection and those who have residual bulky disease is often profound. With surgery being central to cancer survivorship, it is stunning how few resources have been invested in improving surgical outcomes, particularly in comparison to chemotherapeutic research and discovery. This article reviews recent advances related to developing targeted fluorescent agents to guide surgeons during cancer removal. The goal of these drugs and devices is to clearly distinguish cancer from normal tissue to improve surgical outcome for cancer patients.
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31
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Fu HL, Mueller JL, Whitley MJ, Cardona DM, Willett RM, Kirsch DG, Brown JQ, Ramanujam N. Structured Illumination Microscopy and a Quantitative Image Analysis for the Detection of Positive Margins in a Pre-Clinical Genetically Engineered Mouse Model of Sarcoma. PLoS One 2016; 11:e0147006. [PMID: 26799613 PMCID: PMC4723137 DOI: 10.1371/journal.pone.0147006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 12/28/2015] [Indexed: 11/18/2022] Open
Abstract
Intraoperative assessment of surgical margins is critical to ensuring residual tumor does not remain in a patient. Previously, we developed a fluorescence structured illumination microscope (SIM) system with a single-shot field of view (FOV) of 2.1 × 1.6 mm (3.4 mm2) and sub-cellular resolution (4.4 μm). The goal of this study was to test the utility of this technology for the detection of residual disease in a genetically engineered mouse model of sarcoma. Primary soft tissue sarcomas were generated in the hindlimb and after the tumor was surgically removed, the relevant margin was stained with acridine orange (AO), a vital stain that brightly stains cell nuclei and fibrous tissues. The tissues were imaged with the SIM system with the primary goal of visualizing fluorescent features from tumor nuclei. Given the heterogeneity of the background tissue (presence of adipose tissue and muscle), an algorithm known as maximally stable extremal regions (MSER) was optimized and applied to the images to specifically segment nuclear features. A logistic regression model was used to classify a tissue site as positive or negative by calculating area fraction and shape of the segmented features that were present and the resulting receiver operator curve (ROC) was generated by varying the probability threshold. Based on the ROC curves, the model was able to classify tumor and normal tissue with 77% sensitivity and 81% specificity (Youden's index). For an unbiased measure of the model performance, it was applied to a separate validation dataset that resulted in 73% sensitivity and 80% specificity. When this approach was applied to representative whole margins, for a tumor probability threshold of 50%, only 1.2% of all regions from the negative margin exceeded this threshold, while over 14.8% of all regions from the positive margin exceeded this threshold.
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Affiliation(s)
- Henry L. Fu
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
| | - Jenna L. Mueller
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
| | - Melodi J. Whitley
- Department of Pharmacology & Cancer Biology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Diana M. Cardona
- Department of Pathology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Rebecca M. Willett
- Department of Electrical and Computer Engineering, University of Wisconsin—Madison, Madison, Wisconsin, United States of America
| | - David G. Kirsch
- Department of Pharmacology & Cancer Biology, Duke University School of Medicine, Durham, North Carolina, United States of America
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - J. Quincy Brown
- Department of Biomedical Engineering, Tulane University, New Orleans, Louisiana, United States of America
| | - Nimmi Ramanujam
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
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Zysk AM, Chen K, Gabrielson E, Tafra L, May Gonzalez EA, Canner JK, Schneider EB, Cittadine AJ, Carney PS, Boppart SA, Tsuchiya K, Sawyer K, Jacobs LK. Intraoperative Assessment of Final Margins with a Handheld Optical Imaging Probe During Breast-Conserving Surgery May Reduce the Reoperation Rate: Results of a Multicenter Study. Ann Surg Oncol 2015; 22. [PMID: 26202553 PMCID: PMC4839389 DOI: 10.1245/s10434-015-4665-2] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND A multicenter, prospective, blinded study was performed to test the feasibility of using a handheld optical imaging probe for the intraoperative assessment of final surgical margins during breast-conserving surgery (BCS) and to determine the potential impact on patient outcomes. METHODS Forty-six patients with early-stage breast cancer (one with bilateral disease) undergoing BCS at two study sites, the Johns Hopkins Hospital and Anne Arundel Medical Center, were enrolled in this study. During BCS, cavity-shaved margins were obtained and the final margins were examined ex vivo in the operating room with a probe incorporating optical coherence tomography (OCT) hardware and interferometric synthetic aperture microscopy (ISAM) image processing. Images were interpreted after BCS by three physicians blinded to final pathology-reported margin status. Individual and combined interpretations were assessed. Results were compared to conventional postoperative histopathology. RESULTS A total of 2,191 images were collected and interpreted from 229 shave margin specimens. Of the eight patients (17 %) with positive margins (0 mm), which included invasive and in situ diseases, the device identified all positive margins in five (63%) of them; reoperation could potentially have been avoided in these patients. Among patients with pathologically negative margins (>0 mm), an estimated mean additional tissue volume of 10.7 ml (approximately 1% of overall breast volume) would have been unnecessarily removed due to false positives. CONCLUSIONS Intraoperative optical imaging of specimen margins with a handheld probe potentially eliminates the majority of reoperations.
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Affiliation(s)
| | - Kai Chen
- The Johns Hopkins Hospital, Baltimore, MD
- Sun Yat-sen Memorial Hospital, Guangzhou, Guangdong, People’s Republic of China
| | | | | | | | | | | | | | | | - Stephen A. Boppart
- Diagnostic Photonics, Inc., Chicago, IL
- University of Illinois at Urbana-Champaign, Urbana, IL
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O'Kelly Priddy CM, Forte VA, Lang JE. The importance of surgical margins in breast cancer. J Surg Oncol 2015; 113:256-63. [PMID: 26394558 DOI: 10.1002/jso.24047] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 09/08/2015] [Indexed: 12/22/2022]
Abstract
Achieving negative margins with "no tumor on ink" is an appropriate goal in breast conserving therapy (BCT). Wider margins do not decrease recurrence rates, and re-excision in patients with microscopic positive margins is warranted. Several strategies exist to increase rates of negative margins, including techniques to improve tumor localization, intraoperative assessment of margins and oncoplastic techniques. Negative margins should be the goal of BCT, as this will improve both local control and long-term survival.
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Affiliation(s)
- Colleen M O'Kelly Priddy
- Department of Surgery, Section of Breast Soft Tissue Surgery, USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Victoria A Forte
- Department of Medicine, Division of Medical Oncology, USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Julie E Lang
- Department of Surgery, Section of Breast Soft Tissue Surgery, USC Norris Comprehensive Cancer Center, Los Angeles, California
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