Margin re-excision and local recurrence in invasive breast cancer: A cost analysis using a decision tree model

Does Nipple-Ward Positive Margin Contribute to a Higher Rate of Re-Excision Procedures After a Lumpectomy with Pathology-Confirmed Positive Margins? A Retrospective Study

Background

Positive margins on lumpectomy specimens are associated with a twofold increased risk of local breast tumor recurrence. Prior literature has demonstrated various techniques and modalities for assessing margin status to reduce re-excision rates. However, there is paucity of literature analyzing which margin contributes to the highest re-excision rates. Therefore, the primary aim of the study was to investigate whether the nipple-ward margins resulted in a higher rate of re-excision in our patient population.

Methods

 A retrospective chart review was performed on patients who had re-excision surgery. Nipple-ward margin was identified by correlating radiological and pathological reports. A cut-off of more than 25% was used to demonstrate correlation between nipple-ward margin and re-excision rate.

Results

A total of 98 patients' data were analyzed, with 41 (41.8%), 14 (14.3%), 5 (5.1%), and 38 (38.8%) diagnosed with DCIS, IDC, ILC, and mixed pathology on their margins, respectively. Overall, 48% (n=47) of the positive margins were nipple-ward, with 44.7% (n=21) reporting DCIS. Upon stratification, 45 (45.9%) cases were single-margin positive, with 26 (57.8%) being nipple-ward. Furthermore, the remaining 53 (54.1%) patients had multiple positive margins, with 21 (39.6.7%) nipple-ward cases.

Conclusion

Positive nipple-ward margins significantly contribute to a higher re-excision rate p < 0.001; 48% of re-excision surgeries had positive nipple-ward margins, and 57.8% of positive single-margin cases were nipple-ward. Taking an additional shave during initial lumpectomy decreases re-excision rates. However, planning a lumpectomy procedure with a more elliptical rather than a spherical resection with additional cavity shave (ie, larger volume) in the nipple-ward direction and minimizing the remaining cavity shaves so the total volume resected remains unchanged. Nevertheless, future studies with larger sample sizes are required to bolster our findings.

Oncoplastic reduction mammoplasty: Systematic review and proportional meta-analysis of surgical outcomes

BACKGROUND

Breast-conserving surgery is the standard of care for early-stage breast cancer but can often result in unsatisfactory cosmetic outcomes. Oncoplastic surgery aims to address these issues by combining local excision with plastic surgery techniques to improve oncologic and esthetic outcomes. By incorporating breast reduction techniques into cancer surgery, wider margins of excision can be achieved, leading to enhanced oncological safety and reduced recurrence rates without causing significant asymmetry. This systematic review and meta-analysis aims to provide an updated understanding of the surgical outcomes associated with oncoplastic reduction mammoplasty.

METHODS

A systematic review of the literature was conducted according to PRISMA guidelines. Articles reporting post-operative outcomes following the oncoplastic reduction mammoplasty were included. A proportional meta-analysis of post-operative complications was performed to obtain their proportions and 95% Confidence Intervals (CIs).

RESULTS

Eighteen studies met the inclusion criteria, representing a total of 2711 oncoplastic reduction mammoplasty procedures in 2680 patients. The overall complication rate was 20% (95% CI: 15-25%). The positive margin rate following oncoplastic reduction mammoplasty was 11% (95% CI: 6-17%). The re-excision rate was 6% (95% CI: 3-12%). The completion mastectomy rate was 3% (95% CI: 2-6%).

CONCLUSIONS

Oncoplastic reduction mammoplasty is a safe and effective alternative to mastectomy and traditional breast-conserving surgery in the treatment of early-stage breast cancers.

Breast Cancer Disparities and Innovations: A Focus on Kosovo

Due to the current limited capacity to provide digital mammography-based screening to all women, and the lack of modern surgical oncology methods, mastectomy is still the predominant form of surgical treatment in many parts of the world. As such there is little incentive to detect breast cancer earlier and significant fear of treatment and outcomes continues to contribute to late presentations. Neoadjuvant chemotherapy, pre-operative breast MRI and surgical mapping techniques can combine forces to allow for more women to be treated with breast conservation, decrease fear of treatment and improve outcomes.

Diffuse reflectance spectroscopy for accurate margin assessment in breast-conserving surgeries: importance of an optimal number of fibers

During breast-conserving surgeries, it remains challenging to accomplish adequate surgical margins. We investigated different numbers of fibers for fiber-optic diffuse reflectance spectroscopy to differentiate tumorous breast tissue from healthy tissue ex vivo up to 2 mm from the margin. Using a machine-learning classification model, the optimal performance was obtained using at least three emitting fibers (Matthew's correlation coefficient (MCC) of 0.73), which was significantly higher compared to the performance of using a single-emitting fiber (MCC of 0.48). The percentage of correctly classified tumor locations varied from 75% to 100% depending on the tumor percentage, the tumor-margin distance and the number of fibers.

Breast-Conserving Surgery Margin Guidance Using Micro-Computed Tomography: Challenges When Imaging Radiodense Resection Specimens

BACKGROUND

Breast-conserving surgery (BCS) is an integral component of early-stage breast cancer treatment, but costly reexcision procedures are common due to the high prevalence of cancer-positive margins on primary resections. A need exists to develop and evaluate improved methods of margin assessment to detect positive margins intraoperatively.

METHODS

A prospective trial was conducted through which micro-computed tomography (micro-CT) with radiological interpretation by three independent readers was evaluated for BCS margin assessment. Results were compared to standard-of-care intraoperative margin assessment (i.e., specimen palpation and radiography [abbreviated SIA]) for detecting cancer-positive margins.

RESULTS

Six hundred margins from 100 patients were analyzed. Twenty-one margins in 14 patients were pathologically positive. On analysis at the specimen-level, SIA yielded a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 42.9%, 76.7%, 23.1%, and 89.2%, respectively. SIA correctly identified six of 14 margin-positive cases with a 23.5% false positive rate (FPR). Micro-CT readers achieved sensitivity, specificity, PPV, and NPV ranges of 35.7-50.0%, 55.8-68.6%, 15.6-15.8%, and 86.8-87.3%, respectively. Micro-CT readers correctly identified five to seven of 14 margin-positive cases with an FPR range of 31.4-44.2%. If micro-CT scanning had been combined with SIA, up to three additional margin-positive specimens would have been identified.

DISCUSSION

Micro-CT identified a similar proportion of margin-positive cases as standard specimen palpation and radiography, but due to difficulty distinguishing between radiodense fibroglandular tissue and cancer, resulted in a higher proportion of false positive margin assessments.

Positive surgical margins after breast-conserving surgery for ductal carcinoma in-situ: does histologic grade or estrogen receptor status matter?

PURPOSE

DCIS has been shown to have a higher rate of positive margins following breast-conserving surgery (BCS) than invasive breast cancer. We aim to analyze certain factors of DCIS, specifically histologic grade and estrogen receptor (ER) status, in patients with positive surgical margins following BCS to determine if there is an association.

METHODS

A retrospective review of our institutional patient registry was performed to identify women with DCIS and microinvasive DCIS who underwent BCS by a single surgeon from 1999 to 2021. Demographics and clinicopathologic characteristics between patients with and without positive surgical margins were compared using chi-square or Student's t-test. We assessed factors associated with positive margins using univariate and multivariable logistic regression.

RESULTS

Of the 615 patients evaluated, there was no significant difference in demographics between the patients with and without positive surgical margins. Increasing tumor size was an independent risk factor for margin positivity (P =  < 0.001). On univariate analysis both high histologic grade (P = 0.009) and negative ER status (P =  < 0.001) were significantly associated with positive surgical margins. However, when adjusted in multivariable analysis, only negative ER status remained significantly associated with margin positivity (OR = 0.39 [95% CI 0.20-0.77]; P = 0.006).

CONCLUSION

The study confirms increased tumor size as a risk factor for positive surgical margins. We also demonstrated that ER negative DCIS was independently associated with a higher rate of positive margins after BCS. Given this information, we can modify our surgical approach to reduce rate of positive margins in patients with large-sized ER negative DCIS.

Toward Intraoperative Margin Assessment Using a Deep Learning-Based Approach for Automatic Tumor Segmentation in Breast Lumpectomy Ultrasound Images

There is an unmet clinical need for an accurate, rapid and reliable tool for margin assessment during breast-conserving surgeries. Ultrasound offers the potential for a rapid, reproducible, and non-invasive method to assess margins. However, it is challenged by certain drawbacks, including a low signal-to-noise ratio, artifacts, and the need for experience with the acquirement and interpretation of images. A possible solution might be computer-aided ultrasound evaluation. In this study, we have developed new ensemble approaches for automated breast tumor segmentation. The ensemble approaches to predict positive and close margins (distance from tumor to margin ≤ 2.0 mm) in the ultrasound images were based on 8 pre-trained deep neural networks. The best optimum ensemble approach for segmentation attained a median Dice score of 0.88 on our data set. Furthermore, utilizing the segmentation results we were able to achieve a sensitivity of 96% and a specificity of 76% for predicting a close margin when compared to histology results. The promising results demonstrate the capability of AI-based ultrasound imaging as an intraoperative surgical margin assessment tool during breast-conserving surgery.

Effect of three-dimensional intraoperative imaging on surgical outcomes with breast conservation therapy

BACKGROUND

Breast conservation therapy (BCT) is frequently performed for breast cancer and associated with a significant risk for positive margins. Intraoperative three-dimensional (3-D) tomosynthesis potentially could limit the risk of positive margins.

METHODS

Retrospective review of an institutional breast cancer registry. Evaluated BCT cases for a two year time period prior to and after the introduction of intraoperative 3-D tomosynthesis. Primary outcome was the effect of 3-D tomosynthesis on margin positivity rates. Secondary measures were the impact of 3-D tomosynthesis on additional margin procurements at the index surgery and operative time.

RESULTS

A total of 228 cases were evaluated with 106 cases utilizing 3-D tomosynthesis and 122 cases with standard imaging. No significant difference in margin positivity rates between the cohorts at 23.9% versus 15.8% for 3-D tomosynthesis and standard imaging respectively (OR 1.53, CI 0.772-3.032, P = 0.221). 3-D tomosynthesis was associated with increased margin procurement rates (OR 2.34, 95%CI 1.303-4.190, P = 0.004) and longer operative times (P < 0.001).

CONCLUSION

Intraoperative 3-D tomosynthesis was not found to limit margin positivity rates or improve the performance of the procedure.

A Statewide Approach to Reducing Re-excision Rates for Women With Breast-conserving Surgery

OBJECTIVE

Test the effectiveness of benchmarked performance reports based on existing discharge data paired with a statewide intervention to implement evidence-based strategies on breast re-excision rates.

BACKGROUND

Breast-conserving surgery (BCS) is a common breast cancer surgery performed in a range of hospital settings. Studies have demonstrated variations in post-BCS re-excision rates, identifying it as a high-value improvement target.

METHODS

Wisconsin Hospital Association discharge data (2017-2019) were used to compare 60-day re-excision rates following BCS for breast cancer. The analysis estimated the difference in the average change preintervention to postintervention between Surgical Collaborative of Wisconsin (SCW) and nonparticipating hospitals using a logistic mixed-effects model with repeated measures, adjusting for age, payer, and hospital volume, including hospitals as random effects. The intervention included 5 collaborative meetings in 2018 to 2019 where surgeon champions shared guideline updates, best practices/challenges, and facilitated action planning. Confidential benchmarked performance reports were provided.

RESULTS

In 2017, there were 3692 breast procedures in SCW and 1279 in nonparticipating hospitals; hospital-level re-excision rates ranged from 5% to >50%. There was no statistically significant baseline difference in re-excision rates between SCW and nonparticipating hospitals (16.1% vs. 17.1%, P =0.47). Re-excision significantly decreased for SCW but not for nonparticipating hospitals (odds ratio=0.69, 95% confidence interval=0.52-0.91).

CONCLUSIONS

Benchmarked performance reports and collaborative quality improvement can decrease post-BCS re-excisions, increase quality, and decrease costs. Our study demonstrates the effective use of administrative data as a platform for statewide quality collaboratives. Using existing data requires fewer resources and offers a new paradigm that promotes participation across practice settings.

Diagnostic accuracy of radiography, digital breast tomosynthesis, micro-CT and ultrasound for margin assessment during breast surgery: A systematic review and meta-analysis

RATIONALE AND OBJECTIVES

Achieving adequate resection margins in breast conserving surgery is challenging and often demands more than one surgical procedure. We evaluated pooled diagnostic sensitivity, and specificity of radiological methods for intraoperative margin assessment and their impact on repeat surgery rate.

MATERIALS AND METHODS

We included studies using radiography, digital breast tomosynthesis (DBT), micro-CT, and ultrasound for intraoperative margin assessment with the histological assessment as the reference method. A systematic search was performed in PubMed, Embase, Cochrane Library, Scopus, and Web of Science. Two investigators screened the studies for eligibility criteria and extracted data of the included studies independently. The quality assessment on diagnostic accuracy studies (QUADAS)-2 tool was used. A bivariate random effect model was used to obtained pooled sensitivity and specificity of the index tests in the meta-analysis.

RESULTS

The systematic search resulted in screening of 798 unique records. Twenty-two articles with 29 radiological imaging methods were selected for meta-analysis. Pooled sensitivity and specificity and area under the curve were calculated for each of the 4 subgroups in the meta-analysis respectively: Radiography; 52%, 77%, 60%, DBT; 67%, 76%, 76%, micro-CT; 68%, 69%, 72%, and ultrasound; 72%, 78%, 80%. The repeat surgery rate was poorly reported in the included studies.

CONCLUSION

Ultrasound showed the highest and radiography the lowest diagnostic performance for intraoperative margin assessment. However, the heterogeneity between studies was high and the subgroups small. The radiological methods for margin assessment need further improvement to provide reliable guidance in the clinical workflow and to prevent repeat surgeries.

Multi-class classification of breast tissue using optical coherence tomography and attenuation imaging combined via deep learning

We demonstrate a convolutional neural network (CNN) for multi-class breast tissue classification as adipose tissue, benign dense tissue, or malignant tissue, using multi-channel optical coherence tomography (OCT) and attenuation images, and a novel Matthews correlation coefficient (MCC)-based loss function that correlates more strongly with performance metrics than the commonly used cross-entropy loss. We hypothesized that using multi-channel images would increase tumor detection performance compared to using OCT alone. 5,804 images from 29 patients were used to fine-tune a pre-trained ResNet-18 network. Adding attenuation images to OCT images yields statistically significant improvements in several performance metrics, including benign dense tissue sensitivity (68.0% versus 59.6%), malignant tissue positive predictive value (PPV) (79.4% versus 75.5%), and total accuracy (85.4% versus 83.3%), indicating that the additional contrast from attenuation imaging is most beneficial for distinguishing between benign dense tissue and malignant tissue.

Nontoxic Tumor-Targeting Optical Agents for Intraoperative Breast Tumor Imaging

Precise identification of the tumor margins during breast-conserving surgery (BCS) remains a challenge given the lack of visual discrepancy between malignant and surrounding normal tissues. Therefore, we developed a fluorescent imaging agent, ICG-p28, for intraoperative imaging guidance to better aid surgeons in achieving negative margins in BCS. Here, we determined the pharmacokinetics (PK), biodistribution, and preclinical toxicity of ICG-p28. The PK and biodistribution of ICG-p28 indicated rapid tissue uptake and localization at tumor lesions. There were no dose-related effect and no significant toxicity in any of the breast cancer and normal cell lines tested. Furthermore, ICG-p28 was evaluated in clinically relevant settings with transgenic mice that spontaneously developed invasive mammary tumors. Intraoperative imaging with ICG-p28 showed a significant reduction in the tumor recurrence rate. This simple, nontoxic, and cost-effective method can offer a new approach that enables surgeons to intraoperatively identify tumor margins and potentially improves overall outcomes by reducing recurrence rates.

[Interest of systematic shavings to reduce reoperation in breast-conserving surgery of breast cancer]

OBJECTIVE

The INCa and HAS have developed quality and safety indicators for care specific to breast cancer. Among these, in the conservative surgery of this cancer includes the reoperation rate: target˂10%, alert>20%. The main objective of our study was to evaluate whether the practice of systematic recuts still called "shaving" would meet the objectives of the indicators.

METHODS

Observational, retrospective, single-center study over two years in a regional referral center. Two groups of patients were compared: one with "shaving" and one without (no shaving or oriented shaving).

RESULTS

In total, 381 patients were operated on, including 48 (12.6%) with shaving and 333 (87.4%) without. Revision rates for damaged margins were 18.75% (9/48) in the shaving group which met the quality criterias vs. 23.7% (79/333) which did not satisfy them; P=0.4. Furthermore, the rate of discovery of occult sites on recuts was higher in the shaving group: 22.9% (11/48) vs. 9.9% (33/333); P=0.02. In the shaving group, 10.4% (5/48) of the patients were resected again for damaged margins for the initial cancer vs. 18.6% (62/333) in the group without shaving; P=0.23.

CONCLUSION

Our study confirms the interest of performing "shaving" to meet the requirements of the INCa and HAS quality criteria. The absence of systematic cross-sectioning leads to the risk of not recognizing the existence of occult sites. However, the discovery of occult cancers does not significantly reduce the rate of repeat surgery.

Developing diagnostic assessment of breast lumpectomy tissues using radiomic and optical signatures

High positive margin rates in oncologic breast-conserving surgery are a pressing clinical problem. Volumetric X-ray scanning is emerging as a powerful ex vivo specimen imaging technique for analyzing resection margins, but X-rays lack contrast between non-malignant and malignant fibrous tissues. In this study, combined micro-CT and wide-field optical image radiomics were developed to classify malignancy of breast cancer tissues, demonstrating that X-ray/optical radiomics improve malignancy classification. Ninety-two standardized features were extracted from co-registered micro-CT and optical spatial frequency domain imaging samples extracted from 54 breast tumors exhibiting seven tissue subtypes confirmed by microscopic histological analysis. Multimodal feature sets improved classification performance versus micro-CT alone when adipose samples were included (AUC = 0.88 vs. 0.90; p-value = 3.65e-11) and excluded, focusing the classification task on exclusively non-malignant fibrous versus malignant tissues (AUC = 0.78 vs. 0.85; p-value = 9.33e-14). Extending the radiomics approach to high-dimensional optical data-termed "optomics" in this study-offers a promising optical image analysis technique for cancer detection. Radiomic feature data and classification source code are publicly available.

Evaluating the Quality of Cost-Effectiveness Literature in Breast Surgery: What Do We Do Well and How Can We Do Better? A Systematic Review

BACKGROUND

Surgical options for breast cancer are numerous and span multiple surgical disciplines. Decision analyses aid surgeons in making the most cost-effective choice, thus reducing health care expenditure while maximizing patient outcome. In this study, we aimed to evaluate existing breast surgery cost-effectiveness literature against the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) validated scoring system.

METHODS

A PRISMA search was performed for cost-effectiveness within breast surgery. Articles were scored with CHEERS criteria on a 0-24 scale and qualitative data were collected. Subgroup analysis was performed comparing pre-CHEERS (published in 2013 or earlier) and post-CHEERS (published in 2014 or later) cohorts. Chi-squared analysis was performed to compare where studies lost points between cohorts.

RESULTS

Of 2279 articles screened, 46 articles were included. The average CHEERS score was 18.18. Points were most often lost for characterizing heterogeneity, followed by discount rate, incremental costs and outcomes, and abstract. Quality-adjusted life year was the most commonly used health outcome, with visual model or analog scales as the most commonly used measure of effectiveness obtained primarily from surgeons or physicians. Most articles characterized uncertainty by deterministic sensitivity analysis, followed by both deterministic and probabilistic, then probabilistic. Average CHEERS scores were similar between pre- and post-CHEERS cohorts (17.67 vs. 18.40, P > .05) There were several significant differences in where articles lost points between pre- and post-CHEERS cohorts.

DISCUSSION

In order to standardize the reporting of results, cost-effectiveness studies in breast surgery should adhere to the current CHEERS criteria and aim to better characterize heterogeneity in their analyses.

Applications of 3D printing in breast cancer management

Three-dimensional (3D) printing is a method by which two-dimensional (2D) virtual data is converted to 3D objects by depositing various raw materials into successive layers. Even though the technology was invented almost 40 years ago, a rapid expansion in medical applications of 3D printing has only been observed in the last few years. 3D printing has been applied in almost every subspecialty of medicine for pre-surgical planning, production of patient-specific surgical devices, simulation, and training. While there are multiple review articles describing utilization of 3D printing in various disciplines, there is paucity of literature addressing applications of 3D printing in breast cancer management. Herein, we review the current applications of 3D printing in breast cancer management and discuss the potential impact on future practices.

Similar rates of residual disease in patients with DCIS within 2 mm of lumpectomy margin regardless of the presence of invasive carcinoma

PURPOSE

The 2014 Society of Surgical Oncology/American Society for Radiation Oncology (SSO/ASTRO) breast-conserving surgery (BCS) margin guidelines for invasive cancer recommended "no ink on tumor" as an adequate margin width. However, 2016 SSO/ASTRO margin guidelines for pure DCIS recommended a 2 mm margin. Thus, management of a margin with DCIS > 0 mm but < 2 mm differs based on presence or absence of invasive carcinoma. We compared rates of residual disease in patients with pure DCIS to patients with invasive cancer with DCIS.

METHODS

BCS with complete shaved cavity margins (SCM) for invasive carcinoma or pure DCIS from 2004 to 2006 at our institution was reviewed. Margin width was measured on the main specimen and the presence of carcinoma in the SCM was used as a surrogate for residual disease in the cavity. Rates of residual disease were determined for varying margin widths of invasive carcinoma and DCIS.

RESULTS

Of 329 BCS patients, 123 (37%) patients had pure DCIS and 206 (63%) had invasive cancer with DCIS. In the pure DCIS cohort, 61 patients had DCIS between 0 and 2 mm from the inked margin; 32 (52%) of which had residual disease in the SCM. In the invasive cancer plus DCIS cohort, 92 had DCIS between 0 and 2 mm from the inked margin; 39 (42%) of which had residual disease in the SCM (p = 0.221).

CONCLUSION

Rates of residual disease are similar in patients treated with lumpectomy for pure DCIS and those with invasive carcinoma with DCIS when DCIS is found between 0 and 2 mm from the inked margin.

Impact of SSO-ASTRO "No Ink on Tumor" Guidelines on Reexcision Rates among Older Breast Cancer Patients

BACKGROUND

The SSO-ASTRO consensus guideline on invasive breast cancer defined negative margin as no ink on tumor, obviating the need for reexcision in some patients. We evaluated the impact of these recommendations on the rates of reexcision in older breast cancer patients undergoing breast-conserving surgery (BCS).

PATIENTS AND METHODS

Women age ≥ 66 years with stage I-II breast cancer who underwent BCS and radiation were identified in the SEER-Medicare linked database (2012-2015). We divided patients into three cohorts: pre-guideline (January 2012 to September 2013), peri-guideline (October 2013 to March 2014), and post-guideline (April 2014 to September 2016). Descriptive statistics were used, and the relative change in reexcision rate between the pre- and post-guideline periods was calculated. Multivariable logistic regression was used to evaluate factors associated with risk of reexcision.

RESULTS

A total of 11,639 patients were included (pre-guideline, N = 5211; peri-guideline, N = 1366; post-guideline, N = 5062); overall, 21.7% of patients underwent reexcision. The reexcision rates decreased after the guideline was published (23.5% vs. 19.3%, p < 0.001). In the multivariable model, BCS during the post-guideline period was associated with a statistically significant decreased risk of reexcision (RR = 0.84; 95% CI 0.78-0.90). Lobular histology was associated with a higher risk of reexcision (RR = 1.32; 95% CI 1.19-1.46), and greater surgeon volume was associated with lower risk of reexcision (RR = 0.92; 95% CI 0.85-1.0).

CONCLUSIONS

Among older breast cancer patients undergoing BCS for invasive cancer, reexcision rates decreased with the dissemination of the SSO-ASTRO consensus guideline. Identifying factors associated with higher rates of reexcision could improve guideline compliance and reduce the frequency of unnecessary interventions in older patients.

Accuracy of gross intraoperative margin assessment for breast cancer: experience since the SSO-ASTRO margin consensus guidelines

Gross intraoperative assessment can be used to ensure negative margins at the time of surgery. Previous studies of this technique were conducted before the introduction of consensus guidelines defining a “positive” margin. We performed a retrospective study examining the accuracy of this technique since these guidelines were published. We identified all specimens that were grossly examined at the time of breast conserving surgery from January 2014 to July 2020. Gross and final microscopic diagnoses were compared and the performance of intraoperative examination was assessed in terms of false positive and false negative rates. Logistic regression models were used to examine the effect of clinicopathologic covariates on discordance. 327 cases were reviewed. Gross exam prompted re-excision in 166 cases (61%). The rate of false negative discordance was 8.6%. In multivariate analysis, multifocality on final pathology was associated with discordance. We consider the false negative rate acceptable for routine clinical use; however, there is an ongoing need for more accurate methods for the intraoperative assessment of margins.

The shape of breast cancer

PURPOSE

Little is known about the three-dimensional shape of breast cancer. Implicit to approaches that localize the center of the tumor for breast-conserving surgery (BCS) of non-palpable cancers is the assumption that breast cancers are spherical about a central point, which may not be accurate.

METHODS

Pre-operative supine breast MRI images were obtained of 83 breast cancer patients undergoing partial mastectomy using supine MRI-guided resection techniques. Three-dimensional (3D) tumor models were derived after radiologists outlined tumor edges on successive MRI slices. Ideal resection volumes were determined by adding 1 cm in every dimension to the actual tumor volume. Geometrically defined parameters were used to define tumor shapes and associations between clinical variables and shapes were examined.

RESULTS

Seventy-five patients had invasive cancer. Breast cancers were categorized into four tumor shapes: 34% of tumors were discoidal, 29% segmental, 19% spherical, and 18% irregular. If hypothetical spherical excisions were performed, non-spherical cases would excise 143% more tissue than the ideal resection volume. When the 3D shape of each tumor was provided to the surgeon during MR-guided BCS, the percentage of tissue overexcised in non-spherical cases was significantly less (143% vs. 66%, p < 0.001).

CONCLUSIONS

Information obtained from a supine MRI can be used to generate 3D tumor models and rapidly classify breast tumor shapes. The vast majority of invasive cancers and DCIS are not spherical. Knowledge of tumor shape may allow surgeons to excise breast cancer more precisely.

Factors related to re-excision procedures following primary breast-conserving surgery for women with breast cancer in the U.S. Military Health System

BACKGROUND AND OBJECTIVES

Re-excision surgery is undertaken to obtain clear margins after breast-conserving surgery (BCS) for localized breast cancer. This study examines patient and tumor characteristics related to re-excision surgery in the universal-access Military Health System (MHS).

METHODS

Retrospective analysis of patients with pathologically confirmed stage I-III breast cancer between 1998 and 2014 in the Department of Defense Central Cancer Registry and MHS Data Repository-linked databases who received primary BCS. Multivariable stepwise logistic regression methods identified characteristics associated with re-excision surgery (lumpectomy and mastectomy) and conversion to mastectomy, given as adjusted odds ratios (AOR) and 95% confidence intervals (CIs).

RESULTS

Of 7637 women receiving BCS, 26.3% had a re-excision and 9.9% converted to mastectomy. Tumor location, larger tumor size (≥4 cm), and regional lymph node involvement were associated with a greater likelihood of re-excision and mastectomy conversion. Pathology before BCS (AOR, 0.39; 95% CI, 0.35, 0.44 for re-excision) and neoadjuvant treatment (AOR, 0.50; 95% CI, 0.36, 0.69 for re-excision) were associated with a decreased likelihood of these outcomes. Additionally, age, tumor histology, and military-specific variables were associated with mastectomy conversion.

CONCLUSION

Comprehensive preoperative workup, including tumor pathology, may better inform surgical decision-making and reduce re-excision rates.

Re-Excision Rates in Breast-Conserving Surgery for Invasive Breast Cancer after Neoadjuvant Chemotherapy with and without the Use of a Radiopaque Tissue Transfer and X-ray System

Background

Significant re-excision rates in breast-conserving surgery (BCS) after neoadjuvant systemic chemotherapy may result from difficulties in defining the surgical target particularly in cases with excellent treatment response. Devices allowing an exact topographic localisation of the lesion in the resected tissue could reduce re-excision rates by optimising the intraoperative detection of involved margins.

Methods

80 patients with invasive breast cancer receiving BCS after neoadjuvant chemotherapy were included in this non-randomized case-control study. 40 patients with specimen radiography performed in a standard approach (control group) were compared to 40 patients with use of a radiopaque tissue transfer system (study group).

Results

19/80 (23.75%) patients required re-excision because of involved margins; among those, 14/40 (35%) were in the control group and 5/40 (12.5%) in the study group. The association between the use of the radiopaque tissue transfer system and the lower re-excision rate was statistically significant (p = 0.023).

Conclusion

Our analysis provides a rationale for the routine use of a radiopaque tissue transfer system for specimen radiography in BCS after neoadjuvant chemotherapy for invasive breast cancer in order to reduce re-excision rates.

A Randomized Prospective Trial of Supine MRI-Guided Versus Wire-Localized Lumpectomy for Breast Cancer

BACKGROUND

Wire-localized excision of non-palpable breast cancer is imprecise, resulting in positive margins 15-35% of the time.

METHODS

Women with a confirmed diagnosis of non-palpable invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS) were randomized to a new technique using preoperative supine magnetic resonance imaging (MRI) with intraoperative optical scanning and tracking (MRI group) or wire-localized (WL group) partial mastectomy. The main outcome measure was the positive margin rate.

RESULTS

In this study, 138 patients were randomly assigned. Sixty-six percent had IBC and DCIS, 22% had IBC, and 12% had DCIS. There were no differences in patient or tumor characteristics between the groups. The proportion of patients with positive margins in the MRI-guided surgery group was half that observed in the WL group (12 vs. 23%; p = 0.08). The specimen volumes in the MRI and WL groups did not differ significantly (74 ± 33.9 mL vs. 69.8 ± 25.1 mL; p = 0.45). The pathologic tumor diameters were underestimated by 2 cm or more in 4% of the cases by MRI and in 9% of the cases by mammography. Positive margins were observed in 68% and 58% of the cases underestimated by 2 cm or more using MRI and mammography, respectively, and in 15% and 14% of the cases not underestimated using MRI and mammography, respectively.

CONCLUSIONS

A novel system using supine MRI images co-registered with intraoperative optical scanning and tracking enabled tumors to be resected with a trend toward a lower positive margin rate compared with wire-localized partial mastectomy. Margin positivity was more likely when imaging underestimated pathologic tumor size.

Awareness of residents' technical ability can affect margin status in breast conserving operations

PURPOSE

The current study was performed to determine if awareness of the potential affect of residents could affect margin status.

METHODS

Retrospective review of all patients who underwent lumpectomy from July 2006 to May 2017 was evaluated. The effect of surgical residents' participation and their technical ability was evaluated to determine the effect on margin status. Logistic regression analysis was performed to determined factors which affect margin status.

RESULTS

Of 444 patients, 14% of patients had positive margins. The positive margin rate was lower during the second time period after the effect of technical ability of the residents was known 12% versus 19% (p = 0.10). Greater participation by the attending surgeon (32% vs. 21%) occurred in the second time period. In multivariate logistic regression analysis, operations done by residents with satisfactory technical skills or attending surgeon were less likely to have positive margins than those done by residents with unsatisfactory technical skills (OR 0.19, 95% CI 0.10-0.38; p = 0.0001). With mean follow-up of 48 months, 1.4% had local recurrences as a first event.

CONCLUSIONS

Technically ability of residents appears to affect margin status after lumpectomy. Increased intervention by the attending surgeon can improve this outcome.

Patient-level costs in margin re-excision for breast-conserving surgery

BACKGROUND

High rates of reoperation following breast-conserving surgery (BCS) for positive margins are associated with costs to healthcare providers. The aim was to assess the quality of evidence on reported re-excision costs and compare the direct patient-level costs between patients undergoing successful BCS versus reoperations after BCS.

METHODS

The study used data from women who had BCS with or without reoperation at a single institution between April 2015 and March 2016. A systematic review of health economic analysis in BCS was conducted and scored using the Quality of Health Economic Studies (QHES) instrument. Financial data were retrieved using the Patient-Level Information and Costing Systems (PLICS) for patients. Exchange rates used were: US $1 = £0·75, £1 = €1·14 and US $1 = €0·85.

RESULTS

The median QHES score was 47 (i.q.r. 32·5-79). Only two of nine studies scored in the upper QHES quartile (score at least 75). Costs of initial lumpectomy and reoperation were in the range US $1234-11786 and $655-9136 respectively. Over a 12-month interval, 153 patients had definitive BCS and 59 patients underwent reoperation. The median cost of reoperations after BCS (59 patients) was £4511 (range 1752-18 019), representing an additional £2136 per patient compared with BCS without reoperation (P < 0·001).

CONCLUSION

The systematic review demonstrated variation in methodological approach to cost estimates and a paucity of high-quality cost estimate studies for reoperations. Extrapolating local PLICS data to a national level suggests that getting BCS right first time could result in substantial savings.

In Vivo and Ex Vivo Microscopy: A Business Plan to Justify the Introduction of Similar Emerging Technologies Into Pathology Practice

CONTEXT.—

Our patients are now demanding value for their medical diagnoses and treatment in terms of optimal costs, quality, and outcomes. The financial justification for the introduction of new emerging technologies that may better meet these needs will depend on many factors, even if there is an established reimbursement code. In vivo and ex vivo microscopic technologies (IVM and EVM, respectively) will be used as examples of potentially transforming technologies.

OBJECTIVE.—

To describe the components of a business plan that ensures all of the ramifications of introducing a new technology into pathology practice have been considered. As well as the financial justification, such a plan should include strategic vision and congruence, the advantages and drawbacks of introducing such technology, and how plans for marketing, implementation, and verification can be operationalized.

DATA SOURCES.—

Unlike many pathologists, administrative directors in clinical laboratories already know the components of a financially sound business plan. In addition to the financial justifications, other considerations of such a plan include expense reductions, multiyear buildups in revenue generation, the replacement of other technologies, improved productivity and workflows, additional space, new capital, retrained personnel, and the impact on other departments.

CONCLUSIONS.—

Pathologists will learn a business plan format to improve their confidence in making the sound financial justifications needed to consider the introduction of an emerging technology into pathology practice, even when there is initially no obvious revenue stream because formal reimbursement codes have not been established.

Update of the American Society of Breast Surgeons Toolbox to address the lumpectomy reoperation epidemic

In 2015, the American Society of Breast Surgeons (ASBrS) convened a multidisciplinary consensus conference, the Collaborative Attempt to Lower Lumpectomy Reoperation Rates (CALLER). The CALLER conference endorsed a "toolbox" of multiple processes of care for which there was evidence that they were associated with fewer reoperations. We present an update of the toolbox taking into consideration the latest advances in decreasing re excision rates. In this review, we performed a comprehensive review of the literature from 2015-2018 using search terms for each tool. The original ten tools were updated with the latest evidence from the literature and our strength of recommendation. We added an additional section looking at new tools and techniques that may provide more accurate intraoperative assessment of margins. The updates on the CALLER Toolbox for lumpectomy will help guide surgeons to various resources to aid in the removal of breast cancer, while being aware of cosmesis and decreasing re excision rates.

Factors influencing reoperation following breast-conserving surgery

BACKGROUND

Reoperation rates after breast-conserving surgery are highly variable and the best techniques for optimizing margin clearance are being evaluated. The aim was to identify the reoperation rate at our centre and identify influential factors, including a change in guidelines on margin recommendations and the introduction of in-theatre specimen X-ray.

METHODS

A retrospective review of medical records was undertaken to identify 562 patients who underwent breast conservation at The Royal Melbourne Hospital and Royal Women's Hospital between 2013 and 2015. All cases that underwent subsequent re-excision or total mastectomy were captured and factors influencing margin excision recorded.

RESULTS

Reoperation was undertaken in 19.5% of patients (110; 86 re-excisions and 24 total mastectomies). There was a reduction in reoperation rate from 25% to 17% (P = 0.01) with adoption of the margin guidelines in 2014, but no significant reduction with the introduction of in-theatre specimen X-ray in 2015 (21% versus 16%, P = 0.14). On multivariate analysis, factors that significantly influenced reoperation rates were the presence of multifocality on mammogram (odds ratio (OR): 5.3, 95% confidence interval (CI): 1.6-16.7, P < 0.01); lesion size on mammogram (OR: 2.2 per 10 mm, 95% CI: 1.4-3.6, P < 0.01); smaller excision specimen weight (OR: 0.5 per 25 g of resection, 95% CI: 0.3-0.8, P < 0.01); and pure ductal carcinoma in situ on final pathology (OR: 5.9, 95% CI: 1.9-16.7, P < 0.01).

CONCLUSION

Optimizing reoperation rates following breast-conserving surgery remains a surgical challenge, particularly in patients with in situ or multifocal disease. Adoption of international margin guidelines reduced reoperation rates at our centre; however, introduction of intraoperative specimen X-ray had no influence.

Margins in breast cancer: How much is enough?

The appropriate negative margin width for women undergoing breast-conserving surgery for both ductal carcinoma in situ (DCIS) and invasive carcinoma is controversial. This review examines the available data on the margin status for invasive breast cancer and DCIS, and highlights the similarities and differences in tumor biology and standard treatments that affect the local recurrence (LR) risk and, therefore, the optimal surgical margin. Consensus guidelines support a negative margin, defined as no ink on tumor, for invasive carcinoma treated with breast-conserving therapy. Because of differences in the growth pattern and utilization of systemic therapy, a margin of 2 mm has been found to minimize the LR risk for women with DCIS undergoing lumpectomy and radiation therapy (RT). Wider negative margins do not improve local control for DCIS or invasive carcinoma when they are treated with lumpectomy and RT. Re-excision for negative margins should be individualized, and the routine practice of performing additional surgery to obtain a wider negative margin is not supported by the literature. Cancer 2018;124:1335-41. © 2018 American Cancer Society.

Evaluating the Effect of Margin Consensus Guideline Publication on Operative Patterns and Financial Impact of Breast Cancer Operation

BACKGROUND

This study sought to evaluate re-excision rates, patient satisfaction with their breasts, and healthcare costs before and after publication of 2014 Society of Surgical Oncology/American Society of Radiation Oncology consensus guideline on margins for breast conserving operation with whole-breast irradiation for stage I and II breast cancer at an academic institution.

STUDY DESIGN

Patients with stage I and II invasive carcinomas who underwent partial mastectomy were divided into 2 groups based on whether they were treated before (PRE) or after (POST) guideline publication in March 2014. Groups were compared with respect to re-excision rates, conversion to mastectomy, specimen volumes, mean cost per patient of surgical care, and prospectively collected patient post-procedure quality of life.

RESULTS

A total of 237 patients who underwent partial mastectomy were examined (n = 126 in the PRE group and n = 111 in the POST group). Patients in the POST group were less likely to require re-excision (9% POST vs 37% PRE; p < 0.001) and were less likely to undergo conversion to mastectomy (5% POST vs 14% PRE; p = 0.02). After consensus guideline publication, mean operative cost per patient decreased ($4,874 POST vs $5,772 PRE; p < 0.001), and patients had improved breast quality of life scores (77 out of 100 POST vs 61 out of 100 PRE; p = 0.03). On multivariable analysis, publication of the consensus statement was an independent predictor of decreased re-excision rates (odds ratio 0.17; 95% CI 0.08 to 0.38; p < 0.001) and operative cost per patient (odds ratio 0.14; 95% CI 0.78 to 0.30; p < 0.001).

CONCLUSIONS

Widespread implementation of the consensus guideline on margins for breast conserving operation will likely lead to the intended improvements in operative and financial outcomes, as well as patient satisfaction with breast conserving operation.

A Patient-Specific 3D-Printed Form Accurately Transfers Supine MRI-Derived Tumor Localization Information to Guide Breast-Conserving Surgery

BACKGROUND

Wire-localized excision of nonpalpable breast cancer is imprecise, resulting in positive margins 25-30% of the time.

METHODS

Patients underwent preoperative supine magnetic resonance imaging (MRI). A radiologist outlined the tumor edges on consecutive images, creating a three-dimensional (3D) view of its location. Using 3D printing, a bra-like plastic form (the Breast Cancer Locator [BCL]) was fabricated, with features that allowed a surgeon to (1) mark the edges of the tumor on the breast surface; (2) inject blue dye into the breast 1 cm from the tumor edges; and (3) place a wire in the tumor at the time of surgery.

RESULTS

Nineteen patients with palpable cancers underwent partial mastectomy after placement of surgical cues using patient-specific BCLs. The cues were in place in <5 min and no adverse events occurred. The BCL accurately localized 18/19 cancers. In the 18 accurately localized cases, all 68 blue-dye injections were outside of the tumor edges. Median distance from the blue-dye center to the pathologic tumor edge was 1.4 cm, while distance from the blue dye to the tumor edge was <5 mm in 4% of injections, 0.5-2.0 cm in 72% of injections, and >2 cm in 24% of injections. Median distance from the tumor center to the BCL-localized wire and to the clip placed at the time of diagnosis was similar (0.49 vs. 0.73 cm) on specimen mammograms.

CONCLUSIONS

Information on breast cancer location and shape derived from a supine MRI can be transferred safely and accurately to patients in the operating room using a 3D-printed form.

Re-excision rates after breast conserving surgery following the 2014 SSO-ASTRO guidelines

BACKGROUND

In 2014, SSO-ASTRO published guidelines which recommended "no ink on tumor" as adequate margins for patients undergoing breast conservation for invasive breast cancer. In 2016, new SSO-ASTRO-ASCO guidelines recommended 2 mm margins for DCIS. We evaluated whether these guidelines affected re-excision rates at our institution.

METHODS

Patients treated with breast conservation surgery from January 1, 2010-March 1, 2016 were identified. Re-excision rates, tumor characteristics, and presence of residual disease were recorded. The 2016 guidelines were retrospectively applied to the same cohort and expected re-excision rates calculated.

RESULTS

Re-excision rates did not significantly decline before and after 2014 guideline adoption (11.9% before, 10.9% after; p = 0.65) or when the 2016 guidelines were retrospectively applied (8.4%; p = 0.10).

CONCLUSIONS

The 2014 and 2016 guidelines had minimal impact on our re-excision rates, as most re-excisions were done for DCIS and 2016 guidelines supported our prior institutional practices of 2 mm margins for these patients.

Changes in margin re-excision rates: Experience incorporating the "no ink on tumor" guideline into practice

INTRODUCTION

Prior to the "no ink on tumor" SSO/ASTRO consensus guideline, approximately 20% of women with stage I/II breast cancers undergoing breast conservation surgery at our institution underwent margin re-excision. On May 20, 2013, our institution changed the definition of negative margins from 2 mm to "no ink on tumor."

METHODS

A retrospective review was conducted of patients who had surgery at our institution with clinical stage I/II breast cancers between June 1, 2011 and May 1, 2015. In the pre-guideline cohort (pre) and post-guideline cohort (post), negative margins were 2 mm and "no ink on tumor," respectively.

RESULTS

Implementation of the guideline resulted in a significant decrease in the positive/close margin rate (29.6% pre vs 10.1% post; P < 0.001) and numerical decrease in re-excision rate (20.4% pre vs 16.3% post; P = 0.104). No significant difference was found in local recurrence between the cohorts with limited follow-up (1.2% pre vs 1.5% post; P = 0.787).

CONCLUSION

The implementation of the "no ink on tumor" guideline at our institution has resulted in a significant decrease in positive margin rates and a numerical decrease in margin re-excisions. In addition to margin status, surgeons continue to use individual patient and histologic factors to decide for or against margin re-excision.

Intraoperative Assessment of Tumor Resection Margins in Breast-Conserving Surgery Using 18F-FDG Cerenkov Luminescence Imaging: A First-in-Human Feasibility Study

In early-stage breast cancer, the primary treatment option for most women is breast-conserving surgery (BCS). There is a clear need for more accurate techniques to assess resection margins intraoperatively, because on average 20% of patients require further surgery to achieve clear margins. Cerenkov luminescence imaging (CLI) combines optical and molecular imaging by detecting light emitted by 18F-FDG. Its high-resolution and small size imaging equipment make CLI a promising technology for intraoperative margin assessment. A first-in-human study was conducted to evaluate the feasibility of 18F-FDG CLI for intraoperative assessment of tumor margins in BCS. Methods: Twenty-two patients with invasive breast cancer received 18F-FDG (5 MBq/kg) 45-60 min before surgery. Sentinel lymph node biopsy was performed using an increased 99mTc-nanocolloid activity of 150 MBq to facilitate nodal detection against the γ-probe background signal (cross-talk) from 18F-FDG. The cross-talk and 99mTc dose required was evaluated in 2 lead-in studies. Immediately after excision, specimens were imaged intraoperatively in an investigational CLI system. The first 10 patients were used to optimize the imaging protocol; the remaining 12 patients were included in the analysis dataset. Cerenkov luminescence images from incised BCS specimens were analyzed postoperatively by 2 surgeons blinded to the histopathology results, and mean radiance and margin distance were measured. The agreement between margin distance on CLI and histopathology was assessed. Radiation doses to staff were measured. Results: Ten of the 12 patients had an elevated tumor radiance on CLI. Mean radiance and tumor-to-background ratio were 560 ± 160 photons/s/cm2/sr and 2.41 ± 0.54, respectively. All 15 assessable margins were clear on CLI and histopathology. The agreement in margin distance and interrater agreement was good (κ = 0.81 and 0.912, respectively). Sentinel lymph nodes were successfully detected in all patients. The radiation dose to staff was low; surgeons received a mean dose of 34 ± 15 μSv per procedure. Conclusion: Intraoperative 18F-FDG CLI is a promising, low-risk technique for intraoperative assessment of tumor margins in BCS. A randomized controlled trial will evaluate the impact of this technique on reexcision rates.

Rapid evaporative ionisation mass spectrometry of electrosurgical vapours for the identification of breast pathology: towards an intelligent knife for breast cancer surgery

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.

Cost Analysis of a Surgical Consensus Guideline in Breast-Conserving Surgery

BACKGROUND

The Society of Surgical Oncology and American Society of Radiation Oncology consensus statement was the first professional guideline in breast oncology to declare "no ink on tumor" as a negative margin in patients with stages I/II breast cancer undergoing breast-conservation therapy. We sought to analyze the financial impact of this guideline at our institution using a historic cohort.

STUDY DESIGN

We identified women undergoing re-excision after breast-conserving surgery for invasive breast cancer from 2010 through 2013 using a prospectively maintained institutional database. Clinical and billing data were extracted from the medical record and from administrative resources using CPT codes. Descriptive statistics were used in data analysis.

RESULTS

Of 254 women in the study population, 238 (93.7%) had stage I/II disease and 182 (71.7%) had invasive disease with ductal carcinoma in situ. A subcohort of 83 patients (32.7%) who underwent breast-conservation therapy for stage I/II disease without neoadjuvant chemotherapy had negative margins after the index procedure, per the Society of Surgical Oncology and American Society of Radiation Oncology guideline. The majority had invasive ductal carcinoma (n = 70 [84.3%]) and had invasive disease (n = 45 [54.2%]), and/or ductal carcinoma in situ (n = 49 [59.0%]) within 1 mm of the specimen margin. Seventy-nine patients underwent 1 re-excision and 4 patients underwent 2 re-excisions, accounting for 81 hours of operative time. Considering facility fees and primary surgeon billing alone, the overall estimated cost reduction would have been $195,919, or $2,360 per affected patient, under the guideline recommendations.

CONCLUSIONS

Implementation of the Society of Surgical Oncology and American Society of Radiation Oncology consensus guideline holds great potential to optimize resource use. Application of the guideline to a retrospective cohort at our institution would have decreased the overall re-excision rate by 5.6% and reduced costs by nearly $200,000. Additional analysis of patient outcomes and margin assessment methods is needed to define the long-term impact on surgical practice.

Burden of preoperative cardiovascular disease risk factors on breast cancer surgery outcomes

BACKGROUND

Cardiovascular comorbidities have been studied sporadically in breast cancer surgery. No study has provided a comprehensive assessment of the severity and relative influence of preoperative cardiac risk factors on surgical outcomes.

METHODS

78,338 breast cancer surgery patients were identified from the 2006 to 2012 National Surgical Quality Improvement Program (NSQIP) database. We estimated the impact of chronic conditions (diabetes, hypertension, obesity, smoking), acute cardiac events (myocardial infarction, congestive heart disease, angina), and past cardiac procedures (cardiac surgery, percutaneous coronary intervention) on 30-day postoperative complications, reoperation, and readmission.

RESULTS

Nearly 65% of patients had chronic conditions, <1% had acute events, and 3% had past procedures. The prevalence of outcomes was low: 5% had complications, 4% underwent reoperation, and 4% were readmitted. Over 65% of complications were wound-related. All risk factor categories were associated with complications (ORs from 1.26 to 4.18). Acute events had the strongest effect on overall (OR 3.54, CI 2.55-4.91) and medical (OR 4.18, CI 2.73-6.41) complications. Chronic conditions and past procedures also predicted reoperation and readmission (ORs from 1.57 to 2.68). The odds of all outcomes increased with the number of chronic conditions (ptrend  < 0.001).

CONCLUSIONS

Cardiovascular disease has a significant impact on outcomes even in minimal-risk breast cancer surgery. J. Surg. Oncol. 2016;114:144-149. © 2016 Wiley Periodicals, Inc.