A comparison of intra-operative margin management techniques in breast-conserving surgery: a standardised approach reduces the likelihood of residual disease without increasing operative time

Rapid Assessment of Resection Margins During Breast Conserving Surgery Using Intraoperative Flow Cytometry

BACKGROUND

Positive margins are the most important factor for recurrence of the disease after breast-conserving surgery. Several methods have been developed throughout the years to evaluate the margin status during surgery in an attempt to assist the surgeon in excising the whole tumor at once, a goal that has not yet been accomplished.

PATIENTS AND METHODS

In our study, we compared intraoperative flow cytometry (iFC) with cytology and pathology in order to evaluate 606 samples of margins and tumors corresponding to 99 patients with invasive ductal carcinoma of no special type and invasive lobular carcinoma obtained from breast-conserving surgeries.

RESULTS

Using the pathology as the gold standard, flow cytometry had 93.3% sensitivity, 92.4% specificity, and 92.5% accuracy. Cytology had 82.3% sensitivity, 94.6% specificity, and 94.2% accuracy.

CONCLUSIONS

Our data support the suggestion that iFC is a novel, reliable technique that allows rapid evaluation of the excision margins of lumpectomies, thus improving the precision of breast-conserving surgery. Among the advantages of iFC are that it does not rely on the expertise of a pathologist or cytologist, it is low cost, and it has no additional psychological effect on patients, because no re-operation is needed.

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.

Utility of Taking Additional Margins When Performing Breast-Conserving Surgery with Intraoperative Radiation Therapy for Early Breast Cancer

INTRODUCTION

Intraoperative radiation therapy (IORT) is an alternative to external beam radiation therapy (EBRT) after lumpectomy, in which radiation is delivered before the final margin analysis. Practices vary regarding excision of close or positive margins pre- and post-IORT.

MATERIALS AND METHODS

In a retrospective cohort of women with hormone receptor-positive, clinically node-negative breast cancer undergoing lumpectomy with IORT and selective EBRT at our institution from 2011 to 2015, we compared the impact of pre- and post-IORT margin excisions on in-breast tumor recurrence. Additional pre-IORT margins were taken at surgical team discretion. Re-excisions post-IORT were performed for positive/close margins. We describe rate of invasive or in situ malignancy in additional pre-IORT and post-IORT re-excised specimens and compare IBTR using Chi-squared tests.

RESULTS

There were 195 cases in 193 women (2 bilateral breast cancer). Pre-IORT, ≥1 additional margin was obtained in 139 (71%). The final margin on the initial lumpectomy was positive in 13 (9%) and ≤2 mm in 72 (52%). Additional pre-IORT margins contained in situ/invasive cancer in 16 (12%). Thirty-one patients (16%) underwent post-IORT re-excision and nine (29%) contained invasive/in situ malignancy. Twenty-three (12%) received EBRT. In 45.6-month mean follow-up, 13 had IBTR (7%) with no difference by additional pre-IORT margin excision (5 vs. 11%, p = 0.150), post-IORT margin re-excision (10 vs. 6%, p = 0.464), or EBRT (0 vs. 8%, p = 0.172). Adjuvant endocrine therapy was associated with lower IBTR (4 vs. 17%, p = 0.003).

CONCLUSIONS

Taking additional pre-IORT margins and re-excising close/positive margins post-IORT improved margin clearance rates but had an unclear effect on IBTR. Adjuvant endocrine therapy significantly reduced IBTR.

Clinical outcomes of an intraoperative surgical margin assessment using the fresh frozen section method in patients with invasive breast cancer undergoing breast-conserving surgery - a single center analysis

Breast conserving treatment (BCT) is a safe standard therapeutic method in patients with early invasive breast cancer. However, it is associated with an increased risk of residual neoplastic tissues in surgical margins. The aim of this study was to assess the outcome of the use of the intraoperative pathologic analysis by the frozen section (FS) method for evaluation of the extent of the primary lumpectomy. The study concerns a retrospective analysis of a group of 1102 patients who underwent BCT between Jan 2015 and Dec 2016. The assessment focused on the frequency of the intraoperative pathologic analysis of the primary lumpectomy extent (fresh frozen section method). The influence of the BCT specimen analysis method on the free margins width, as well as the rate and the cause of reoperation were evaluated. The intraoperative lumpectomy evaluation was performed in 45.8% (505/1102) of patients (Group I), while in the remaining 54.2% of the cases it was decided to abandon this procedure (Group II). Although in 72 (14.3%) patients the intraoperative analysis gave negative results, the margins contained residual tumor tissue (vs. 16.9% in Group II). In Group I, conversion from the previously planned BCT to mastectomy was necessary in 5.9% (30/505) patients (vs. 9.7% in Group II). The duration of surgery was 48.9 ± 17.3 minutes (Group I) and 42.9 ± 13.6 minutes (Group II). In patients undergoing BCT, the use of the intraoperative pathologic analysis by the FS method resulted in a reduction of the total number of reoperations performed due to residual tumor found in the margins following the primary lumpectomy. However, it statistically significantly extended the duration of the surgery.

Towards the use of diffuse reflectance spectroscopy for real-time in vivo detection of breast cancer during surgery

Background

Breast cancer surgeons struggle with differentiating healthy tissue from cancer at the resection margin during surgery. We report on the feasibility of using diffuse reflectance spectroscopy (DRS) for real-time in vivo tissue characterization.

Methods

Evaluating feasibility of the technology requires a setting in which measurements, imaging and pathology have the best possible correlation. For this purpose an optical biopsy needle was used that had integrated optical fibers at the tip of the needle. This approach enabled the best possible correlation between optical measurement volume and tissue histology. With this optical biopsy needle we acquired real-time DRS data of normal tissue and tumor tissue in 27 patients that underwent an ultrasound guided breast biopsy procedure. Five additional patients were measured in continuous mode in which we obtained DRS measurements along the entire biopsy needle trajectory. We developed and compared three different support vector machine based classification models to classify the DRS measurements.

Results

With DRS malignant tissue could be discriminated from healthy tissue. The classification model that was based on eight selected wavelengths had the highest accuracy and Matthews Correlation Coefficient (MCC) of 0.93 and 0.87, respectively. In three patients that were measured in continuous mode and had malignant tissue in their biopsy specimen, a clear transition was seen in the classified DRS measurements going from healthy tissue to tumor tissue. This transition was not seen in the other two continuously measured patients that had benign tissue in their biopsy specimen.

Conclusions

It was concluded that DRS is feasible for integration in a surgical tool that could assist the breast surgeon in detecting positive resection margins during breast surgery.

Trail registration NIH US National Library of Medicine–clinicaltrails.gov, NCT01730365. Registered: 10/04/2012 https://clinicaltrials.gov/ct2/show/study/NCT01730365

Predicting initial margin status in breast cancer patients during breast-conserving surgery

Background

We sought to develop and validate a model for prediction of initial margin status during breast-conserving surgery (BCS).

Methods

We included eligible breast cancer patients receiving BCS in Sun Yat-sen Memorial Hospital from January 2003 to December 2014. All patients received intraoperative frozen-section analysis for initial margin assessment. We used univariate and multivariate logistic regression analyses to screen for predictors. A nomogram was developed in the training cohort (n=1,193) from the south branch of the hospital and externally validated in the validation cohort (n=499) from the north branch. We used the area under the receiver-operating characteristic curve and Hosmer–Lemeshow tests to assess the discrimination and accuracy of the nomogram.

Results

The initial margin-positivity rates were 19.5% and 25.2% in the training and validation cohorts, respectively. Preoperative tumor size, preoperative lymph-node status, suspicion of multifocality, hormone-receptor status, and HER2 status were significantly associated with margin status. The model included these five variables. The discrimination and calibration of the model were considered acceptable in both cohorts.

Conclusion

The nomogram can predict the likelihood of having positive initial margins during BCS and may be useful for clinical decision-making in the surgical treatment of breast cancer patients.

Novel techniques for intraoperative assessment of margin involvement

Breast conserving surgery (BCS) is now the standard of care for the majority of women with early stage breast cancer. There is a finite rate of ipsilateral breast tumour recurrence (IBTR) for breast conserving therapy (BCT) with annual rates of less than 1% for specialist breast practices. There has been recent consensus on the definition of an adequate resection margin for both invasive and noninvasive breast cancer treated with BCS, although some variation in margin policy persists with definitions of 'no tumour at ink', 1 and 2 mm margin mandates. Despite the development of methods for intraoperative assessment of margins, up to 20% of patients require further surgery (cavity re-excision or completion mastectomy) to achieve clear surgical margins. In the past decade, several novel technologies for intraoperative margin assessment have been explored with the aim of reducing rates of re-operation and its attendant patient anxiety, inconvenience and additional cost. Ongoing studies are addressing the safety, feasibility and cost-effectiveness of these novel technologies relative to methods in routine clinical usage.

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.

Cavity Shaving plus Lumpectomy versus Lumpectomy Alone for Patients with Breast Cancer Undergoing Breast-Conserving Surgery: A Systematic Review and Meta-Analysis

The margin status is a well-established prognostic predictor for patients undergoing breast-conserving surgery (BCS). Recent data suggested that cavity shaving in addition to lumpectomy might be a promising approach for improving the clinical outcomes. We aimed to compare the efficacy and safety between cavity shaving plus lumpectomy and lumpectomy alone with a systematic review and meta-analysis. We searched the PubMed, Embase, and Cochrane CENTRAL databases for studies comparing cavity shaving with lumpectomy before June 10, 2016. Both comparative studies and self-control studies were included. A random-effects model was used to estimate the odds ratios (ORs) for positive margin rate, reoperation rate, recurrence rate, and weighted mean difference (WMD) for excised tissue volume. Twenty-six studies were included in the meta-analysis. The cavity shaving group had a significantly lower positive margin rate than the BCS-alone group (16.4% vs. 31.9%; OR = 0.41, 95% CI 0.32-0.53, P < 0.05). Cavity shaving was associated with a significantly decreased rate of reoperation (OR = 0.42, 95% CI 0.30-0.59, P < 0.05). The overall locoregional rate was low for cavity shaving and BCS-alone (3% vs. 4%). Cavity shaving had no significant effect on the risk of locoregional recurrence (OR = 0.86, 95% CI 0.32-2.35; P = 0.78). The excised tissue volume did not differ substantially between cavity shaving and BCS alone (WMD = -23.88, 95% CI -55.20 to 7.44, P = 0.14). For patients undergoing BCS, additional cavity shaving was an effective method to decrease the positive margin rate and avoid reoperation. The addition of cavity shaving did not appear to have excessive excised tissue volume compared with partial mastectomy alone.

Preoperative localization and surgical margins in conservative breast surgery

Breast-conserving surgery (BCS) is the treatment of choice for early breast cancer. The adequacy of surgical margins (SM) is a crucial issue for adjusting the volume of excision and for avoiding local recurrences, although the precise definition of an adequate margins width remains controversial. Moreover, other factors such as the biological behaviour of the tumor and subsequent proper systemic therapies may influence the local recurrence rate (LRR). However, a successful BCS requires preoperative localization techniques or margin assessment techniques. Carbon marking, wire-guided, biopsy clips, radio-guided, ultrasound-guided, frozen section analysis, imprint cytology, and cavity shave margins are commonly used, but from the literature review, no single technique proved to be better among the various ones. Thus, an association of two or more methods could result in a decrease in rates of involved margins. Each institute should adopt its most congenial techniques, based on the senologic equipe experience, skills, and technologies.