Completion mastectomy after breast conserving surgery

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

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.

Extent of margin involvement, lymphovascular invasion, and extensive intraductal component predict for residual disease after wide local excision for breast cancer

In the present study, we identified predictors of residual disease after an inadequate wide local excision. Residual tumor was more likely when tumor was present at the inked margin, when more than a single radial margin was affected, and in tumors associated with lymphovascular invasion and an extensive intraductal component.

BACKGROUND

Positive margins after wide local excision (WLE) increase the probability of residual disease, and additional surgery is often recommended. However, residual tumor will be found in only two thirds of cases, suggesting that additional surgery can be avoided in many instances. In the present study, we sought to establish the frequency of residual tumor when the surgical margins are inadequate and to identify factors that predict for residual tumor.

MATERIALS AND METHODS

A retrospective review was performed of 720 consecutive patients who had undergone WLE for ductal carcinoma in situ and nonmetastatic breast cancer at a single unit from January 1, 2004 to December 31, 2010.

RESULTS

At least a single radial margin was affected (either involved or close, defined as tumor < 1 mm from the margin) in 244 patients who had undergone WLE, and either the anterior or posterior margin was affected in another 103 patients. Reoperation was performed in 215 patients with affected radial margins and 9 others with affected anterior or posterior margins. Residual disease was found in 98 of 224 patients (43.8%) and was more likely when tumor was present at the inked margin, when > 1 radial margin was affected, and when lymphovascular invasion (LVI) or an extensive intraductal component (EIC) was present. The association with tumor size was of borderline significance. No association was found with tumor histologic type or patient age.

CONCLUSION

Additional evaluation is needed to determine whether additional surgery can be safely omitted in women with tumors without LVI or EIC when a single radial margin has been deemed to be close.

Perioperative measures to optimize margin clearance in breast conserving surgery

Margin status is one of the most important determinants of local recurrence following breast conserving surgery. The fact that up to 60% of patients undergoing breast conserving surgery require re-excision highlights the importance of optimizing margin clearance. In this review we summarize the following perioperative measures that aim to enhance margin clearance: (1) patient risk stratification, specifically risk factors and nomograms, (2) preoperative imaging, (3) intraoperative techniques including wire-guided localization, radioguided surgery, intraoperative ultrasound-guided resection, intraoperative specimen radiography, standardized cavity shaving, and ink-directed focal re-excision; (4) and intraoperative pathology assessment techniques, namely frozen section analysis and imprint cytology. Novel surgical techniques as well as emerging technologies are also reviewed. Effective treatment requires accurate preoperative planning, developing and implementing a consistent definition of margin clearance, and using tools that provide detailed real-time intraoperative information on margin status.

Analysis of margin index as a method for predicting residual disease after breast-conserving surgery in a European cancer center

INTRODUCTION

Breast-conserving surgery (BCS), followed by appropriate adjuvant therapies is established as a standard treatment option for women with early-stage invasive breast cancers. A number of factors have been shown to correlate with local and regional disease recurrence. Although margin status is a strong predictor of disease recurrence, consensus is yet to be established on the optimum margin necessary. Margenthaler et al. recently proposed the use of a "margin index," combining tumor size and margin status as a predictor of residual disease after BCS. We applied this new predictive tool to a population of patients with primary breast cancer who presented to a symptomatic breast unit to determine its suitability in predicting those who require reexcision surgery.

METHODS

Retrospective analysis of our breast cancer database from January 1, 2000 to June 30, 2010 was performed, including all patients who underwent BCS. Of 531 patients who underwent BCS, 27.1% (144/531) required further reexcision procedures, and 55 were eligible for inclusion in the study. Margin index was calculated as: margin index = closest margin (mm)/tumor size (mm) × 100, with index >5 considered optimum.

RESULTS

Of the 55 patients included, 31% (17/55) had residual disease. Fisher's exact test showed margin index not to be a significant predictor of residual disease on reexcision specimen (P = 0.57). Of note, a significantly higher proportion of our patients presented with T2/3 tumors (60% vs. 38%).

CONCLUSIONS

Although an apparently elegant tool for predicting residual disease after BCS, we have shown that it is not applicable to a symptomatic breast unit in Ireland.