Surgeon performed continuous intraoperative ultrasound guidance decreases re-excisions and mastectomy rates in breast cancer

A comparative study of learning curves among general surgery residents for intraoperative ultrasound-guided breast-conserving surgery

Breast-conserving surgery (BCS) followed by radiotherapy is preferred for early-stage breast cancer because its survival rate is equivalent to that of mastectomy. Achieving negative surgical margins in BCS is crucial to minimize the risk of recurrence. Intraoperative ultrasound (IOUS) enhances surgical accuracy, but its efficacy is operator dependent. This study aimed to compare the success of achieving negative margins using IOUS between an experienced breast surgeon and general surgical residents and to evaluate the learning curve for the residents. A prospective study involving 96 patients with BCS who underwent IOUS guidance was conducted. Both the breast surgeon and residents assessed the surgical margins using IOUS, with the breast surgeon making the final margin adequacy decision. Permanent histopathological analysis was used to confirm the status of the margins and was considered the gold standard for comparison. The breast surgeon accurately assessed the margin status in all 96 cases (100% accuracy), with 93 negative and three positive margins. All of these were ductal carcinomas in situ. Initially, the residents demonstrated low accuracy rates in predicting margin positivity using intraoperative ultrasonography. However, the learning curves of the three residents demonstrated that, with an average 12th case onwards, a significant improvement in the cumulative accuracy rates was observed, which reached the level of the breast surgeon. IOUS is an effective tool for accurately predicting the margin status in BCS, with an acceptable learning curve for novice surgeons. Training and experience are pivotal for optimizing surgical outcomes. These findings support the integration of IOUS training into surgical education programs to enhance proficiency and improve patient outcomes.

Resection Ratios and Tumor Eccentricity in Breast-Conserving Surgery Specimens for Surgical Accuracy Assessment

This study aims to evaluate several defined specimen parameters that would allow to determine the surgical accuracy of breast-conserving surgeries (BCS) in a representative population of patients. These specimen parameters could be used to compare surgical accuracy when using novel technologies for intra-operative BCS guidance in the future. Different specimen parameters were determined among 100 BCS patients, including the ratio of specimen volume to tumor volume (resection ratio) with different optimal margin widths (0 mm, 1 mm, 2 mm, and 10 mm). Furthermore, the tumor eccentricity [maximum tumor-margin distance - minimum tumor-margin distance] and the relative tumor eccentricity [tumor eccentricity ÷ pathological tumor diameter] were determined. Different patient subgroups were compared using Wilcoxon rank sum tests. When using a surgical margin width of 0 mm, 1 mm, 2 mm, and 10 mm, on average, 19.16 (IQR 44.36), 9.94 (IQR 18.09), 6.06 (IQR 9.69) and 1.35 (IQR 1.78) times the ideal resection volume was excised, respectively. The median tumor eccentricity among the entire patient population was 11.29 mm (SD = 3.99) and the median relative tumor eccentricity was 0.66 (SD = 2.22). Resection ratios based on different optimal margin widths (0 mm, 1 mm, 2 mm, and 10 mm) and the (relative) tumor eccentricity could be valuable outcome measures to evaluate the surgical accuracy of novel technologies for intra-operative BCS guidance.

Intraoperative Ultrasound-Guided Conserving Surgery for Breast Cancer: No More Time for Blind Surgery

BACKGROUND

Breast-conserving surgery (BCS) still remains a blind surgery despite all available tumor localization methods. Intraoperative ultrasound (IOUS) allows real-time visualization during all resection phases.

METHODS

This was a prospective observational cohort study conducted at the Veneto Institute of Oncology between January 2021 and June 2022. Patients with ductal carcinoma in situ, T1-2 invasive cancer, or post-neoadjuvant tumors, suitable for BCS, were recruited. All breast cancer lesion types were included, i.e. solid palpable, solid non-palpable, non-solid non-palpable, and post-neoadjuvant treatment residual lesions. Eligible participants were randomly assigned to either IOUS or traditional surgery (TS) in a 1:1 ratio. The main outcomes were surgical margin involvement, reoperation rate, closest margin width, main specimen and cavity shaving margin volumes, excess healthy tissue removal, and calculated resection ratio (CRR).

RESULTS

Overall, 160 patients were enrolled: 80 patients were allocated to the TS group and 80 to the IOUS group. IOUS significantly reduced specimen volumes (16.8 cm3 [10.5-28.9] vs. 24.3 cm3 [15.0-41.3]; p = 0.015), with wider closest resection margin width (2.0 mm [1.0-4.0] vs. 1.0 mm [0.5-2.0] after TS; p < 0.001). Tumor volume to specimen volume ratio was significantly higher after IOUS (4.7% [2.5-9.1] vs. 2.9% [0.8-5.2]; p < 0.001). IOUS yielded significantly better CRR (84.5% [46-120.8] vs. 114% [81.8-193.2] after TS; p < 0.001), lower involved margin rate (2.5 vs. 15%; p = 0.009) and reduced re-excision rate (2.5 vs. 12.5%; p = 0.032).

CONCLUSIONS

IOUS allows real-time resection margin visualization and continuous control during BCS. It showed clear superiority over TS in both oncological and surgical outcomes for all breast cancer lesion types. These results disfavor the paradigm of blind breast surgery.

Ultrasound Guided Intraoperative Wire Localization Under General Anesthesia in Breast-Conserving Surgery

Breast-conserving surgery (BCS) is becoming an increasingly preferred surgical technique for treating breast cancer. For the last several decades, using a preoperative wire placed by a radiologist has been the gold standard to help guide surgeons to excise a suspicious mass. In recent years, there has been an increasing focus on using surgeon-performed intraoperative ultrasound (IOUS) during breast-conserving therapy, suggesting improved cosmetic outcomes and a decreased need for re-excision. However, studies have also highlighted that ultrasound may be uncomfortable for surgeons who have become most familiar with a wire-localization technique. Wire localization and intraoperative ultrasound are valuable tools that can improve the accuracy of tumor localization and reduce the need for re-excision. We present a 45-year-old female with a right breast mass, measuring breast imaging reporting and data system (BIRADS) 4A on preoperative ultrasound. Intraoperative wire-localization was performed by the surgeon utilizing ultrasound guidance. The right breast lesion was successfully excised with negative margins. The patient was discharged home and recovered well. Surgeon-performed intraoperative ultrasound can be combined with surgeon-performed wire localization to reduce the need for re-excision surgery and allow the surgeon to retain the familiarity of utilizing a gold-standard technique. Further research is needed to determine the optimal use of surgeon-performed IOUS and wire-localization, and its impact on long-term outcomes.

Three-dimensional virtual reality in surgical planning for breast cancer with reconstruction

Breast surgery is performed to achieve local control in patients with breast cancer. Visualization of the anatomy with a virtual reality software platform reconstructed from magnetic resonance imaging data improves surgical planning with regards to volume and localization of the tumor, lymph nodes, blood vessels, and surrounding tissue to perform oncoplastic tissue rearrangement. We report the use and advantages of virtual reality added to the magnetic resonance imaging assessment in a 36-year-old woman with breast cancer who underwent nipple sparing mastectomy with tissue expander reconstruction.

The impact of intraoperative cavity shaving on re-excision rates in breast-conserving surgery

BACKGROUND AND OBJECTIVES

This trial aimed to investigate the effects of circumferential shaving on reducing the reoperation rates during breast-conserving surgery (BCS).

METHODS

In the study, before 2014, 404 (39.9%) breast cancers (BCs) out of a total of 1012 BCs underwent BCS without intraoperative cavity shaving (ICS) and constituted the no-ICS group. After this date, ICS was added to 608 (60.1%) BCSs (ICS group) and intraoperative margin analysis was not requested from pathologists during these second BCS procedures.

RESULTS

The patient and BC characteristics in the no-ICS and ICS groups were similar. Carcinoma detection at the margin and reoperation rates were 13.9% in the no-ICS group and 7.6% in the ICS group (p = 0.001). No significant difference was detected between patients who underwent BCS with intraoperative frozen section analysis (FSA) and patients who underwent BCS with additional ICS (5.6% vs. 7.6%, p = 0.383).

CONCLUSIONS

ICS decreased the rates of positive margins and reoperations among patients with BCS to an acceptable level compared with intraoperative FSA. It may be concluded that ICS is feasible to achieve BC margin control.

Localization Techniques for Non-Palpable Breast Lesions: Current Status, Knowledge Gaps, and Rationale for the MELODY Study (EUBREAST-4/iBRA-NET, NCT 05559411)

BACKGROUND

Surgical excision of a non-palpable breast lesion requires a localization step. Among available techniques, wire-guided localization (WGL) is most commonly used. Other techniques (radioactive, magnetic, radar or radiofrequency-based, and intraoperative ultrasound) have been developed in the last two decades with the aim of improving outcomes and logistics.

METHODS

We performed a systematic review on localization techniques for non-palpable breast cancer.

RESULTS

For most techniques, oncological outcomes such as lesion identification and clear margin rate seem either comparable with or better than for WGL, but evidence is limited to small cohort studies for some of the devices. Intraoperative ultrasound is associated with significantly higher negative margin rates in meta-analyses of randomized clinical trials (RCTs). Radioactive techniques were studied in several RCTs and are non-inferior to WGL. Smaller studies show higher patient preference towards wire-free localization, but little is known about surgeons' and radiologists' attitudes towards these techniques.

CONCLUSIONS

Large studies with an additional focus on patient, surgeon, and radiologist preference are necessary. This review aims to present the rationale for the MELODY (NCT05559411) study and to enable standardization of outcome measures for future studies.

The Use of Intraoperative Ultrasound During Breast Conserving Surgery

OBJECTIVES

The purpose of this study is to evaluate the utilization of intraoperative ultrasound (IOUS) for tumor localization in breast-conserving surgery and to examine its impact on margin positivity and re-excision rates. Additionally, the study seeks to identify factors contributing to surgeon utilization of IOUS.

METHODS

A retrospective chart review was conducted of patients with preoperative diagnosis of breast cancer undergoing breast-conserving surgery by breast surgeons at multiple centers within a single healthcare system. Characteristics such as lesion size, palpability, histology, receptor status, and use of neoadjuvant chemotherapy were recorded. Re-excision rates were determined based on localization technique and surgeons' status of breast ultrasound certification.

RESULTS

A total of 671 cases were performed, with 322 meeting study inclusion. 57 cases utilized IOUS, 250 utilized preoperative wire-guided localization (WGL), 10 used both methods and 5 cases used neither method. There was no significant difference in re-excision rates between IOUS and WGL or among the four surgeons. Ultrasound-certified surgeons were more likely to utilize IOUS, and re-excision rates trended higher for WGL, which may be clinically significant.

CONCLUSION

Increasing familiarity with and utilization of IOUS during breast-conserving surgery may be clinically advantageous over traditional localization techniques. Ultrasound certification may lead to increased use of IOUS among surgeons.

Computational Imaging to Compensate for Soft-Tissue Deformations in Image-Guided Breast Conserving Surgery

OBJECTIVE

During breast conserving surgery (BCS), magnetic resonance (MR) images aligned to accurately display intraoperative lesion locations can offer improved understanding of tumor extent and position relative to breast anatomy. Unfortunately, even under consistent supine conditions, soft tissue deformation compromises image-to-physical alignment and results in positional errors.

METHODS

A finite element inverse modeling technique has been developed to nonrigidly register preoperative supine MR imaging data to the surgical scene for improved localization accuracy during surgery. Registration is driven using sparse data compatible with acquisition during BCS, including corresponding surface fiducials, sparse chest wall contours, and the intra-fiducial skin surface. Deformation predictions were evaluated at surface fiducial locations and subsurface tissue features that were expertly identified and tracked. Among n = 7 different human subjects, an average of 22 ± 3 distributed subsurface targets were analyzed in each breast volume.

RESULTS

The average target registration error (TRE) decreased significantly when comparing rigid registration to this nonrigid approach (10.4 ± 2.3 mm vs 6.3 ± 1.4 mm TRE, respectively). When including a single subsurface feature as additional input data, the TRE significantly improved further (4.2 ± 1.0 mm TRE), and in a region of interest within 15 mm of a mock biopsy clip TRE was 3.9 ± 0.9 mm.

CONCLUSION

These results demonstrate accurate breast deformation estimates based on sparse-data-driven model predictions.

SIGNIFICANCE

The data suggest that a computational imaging approach can account for image-to-surgery shape changes to enhance surgical guidance during BCS.

Innovative Standards in Oncoplastic Breast Conserving Surgery: From Radical Mastectomy to Extreme Oncoplasty

BACKGROUND

Oncoplastic breast conserving surgery (OBCS), which is the current procedure of choice for eligible BC patients, describes a philosophy that prioritizes oncologic and cosmetic outcomes. However, knowledge gaps regarding training, acceptance, and practice preclude standardization and make it difficult to design algorithmic guidelines to optimize individualized management in the era of precision medicine.

SUMMARY

The harmony between patient expectations and oncologic goals creates the state of the art of OBCS. Nevertheless, to achieve these goals, multidisciplinary approach is a must. Surgical decisions require a comprehensive evaluation including patient factors, tumor biology, genetics, technical considerations, and adjunct therapies. Moreover, the quality-of-life (QOL) issues should be considered as the highest level of priority with a shared decision making instituted on realistic discussions with the patient.

KEY MESSAGES

The standardization in OBCS should be initiated via defining a breast surgeon who should gain theorical and practical competence on techniques via national or international educational programs. The algorithmic patient assessment with appropriate documentation before and after surgery should be established. A simple and safe global lexicon should be designed regarding techniques to be proposed and quality metrics to be considered. Additionally, international multicenter prospective trials should be instituted to overcome knowledge gaps. It is evident that OBCS is the perfect union of science with art. Nevertheless, at the very end, the question is not the nature of the surgeon/artist who would be the extremist, the innovator, or the conservative, but the patient's satisfaction, prognosis, and QOL that conclude the cascade of state of the art of OBCS.

Implementation of Intraoperative Ultrasound Localization for Breast-Conserving Surgery in a Large, Integrated Health Care System is Feasible and Effective

BACKGROUND

Intraoperative ultrasound (IUS) localization for breast cancer is a noninvasive localization technique. In 2015, an IUS program for breast-conserving surgery (BCS) was initiated in a large, integrated health care system. This study evaluated the clinical results of IUS implementation.

METHODS

The study identified breast cancer patients with BCS from 1 January to 31 October 2015 and from 1 January to 31 October 2019. Clinicopathologic characteristics were collected, and localization types were categorized. Clinical outcomes were analyzed, including localization use, surgeon adoption of IUS, day-of-surgery intervals, and re-excision rates. Multivariate logistic regression analysis was performed to evaluate predictors of re-excision.

RESULTS

The number of BCS procedures increased 23%, from 1815 procedures in 2015 to 2226 procedures in 2019. The IUS rate increased from 4% of lumpectomies (n = 79) in 2015 to 28% of lumpectomies (n = 632) in 2019 (p < 0.001). Surgeons using IUS increased from 6% (5 of 88 surgeons) in 2015 to 70% (42 of 60 surgeons) in 2019. In 2019, 76% of IUS surgeons performed at least 25% of lumpectomies with IUS. The mean time from admission to incision was shorter with IUS or seed localization than with wire localization (202 min with IUS, 201 with seed localization, 262 with wire localization in 2019; p < 0.001). The IUS re-excision rates were lower than for other localization techniques (13.6%, vs 19.6% for seed localization and 24.7% for wire localization in 2019; p = 0.006), and IUS predicted lower re-excision rates in a multivariable model (odds ratio [OR], 0.59).

CONCLUSIONS

In a high-volume integrated health system, IUS was adopted for BCS by a majority of surgeons. The use of IUS decreased the time from admission to incision compared with wire localization, and decreased re-excision rates compared with other localization techniques.

Impact of deformation on a supine-positioned image-guided breast surgery approach

PURPOSE

To reduce reoperation rates for image-guided breast-conserving surgery, the enhanced sensitivity of magnetic resonance (MR) supine imaging may be leveraged. However, accurate tissue correspondence between images and their physical counterpart in the surgical presentation is challenging due to breast deformations (e.g., from patient/arm position changes, and operating room table rotation differences). In this study, standard rigid registration methods are employed and tissue deformation is characterized.

METHODS

On n = 10 healthy breasts, surface displacements were measured by comparing intraoperative fiducial locations as the arm was moved from conventional MR scanning positions (arm-down and arm-up) to the laterally extended surgical configuration. Supine MR images in the arm-down and arm-up positions were registered to mock intraoperative presentations.

RESULTS

Breast displacements from a supine MR imaging configuration to a mock surgical presentation were 28.9 ± 9.2 mm with shifts occurring primarily in the inferior/superior direction. With respect to supine MR to surgical alignment, the average fiducial, target, and maximum target registration errors were 9.0 ± 1.7 mm, 9.3 ± 1.7 mm, and 20.0 ± 7.6 mm, respectively. Even when maintaining similar arm positions in the MR image and mock surgery, the respective averages were 6.0 ± 1.0 mm, 6.5 ± 1.1 mm, and 12.5 ± 2.8 mm.

CONCLUSION

From supine MR positioning to surgical presentation, the breast undergoes large displacements (9.9-70.1 mm). The data also suggest that significant nonrigid deformations (9.3 ± 1.7 mm with 20.0 mm average maximum) exist that need to be considered in image guidance and modeling applications.

Outcomes of intraoperative versus preoperative ultrasound-guided wire localization of nonpalpable breast lesions

Background: Nonpalpable breast lesions require localization, the gold standard for which is preoperative ultrasound-guided wire localization (PUGWL). Our unit also employs intraoperative ultrasound-guided wire localization (IUGWL). Here we evaluate PUGWL and IUGWL outcomes between 2014 and 2018. Primary outcomes were reoperation rates, complication rates and average specimen weights. Trainee feedback and cost analysis assessed IUGWL viability. Methods: Prospectively recorded data were collected. 511 patients were included (241 PUGWL and 270 IUGWL). Results: Reoperation rates: PUGWL 17.7% versus IUGWL 13.9% (p = 0.28) . Complication rates: PUGWL 5.8% versus IUGWL 6.6% (p = 0.72) . Average specimen weight: PUGWL 34.2 g versus IUGWL 24.3 g (p < 0.0001) . Trainees needed 15 supervised cases to be IUGWL competent. Performing IUGWL saves £289 per localization. Conclusion: IUGWL outcomes are comparable to those of PUGWL. IUGWL is cost-effective, patient-friendly and easy to learn and replicate. IUGWL merits wider dissemination and further planned research.

Intraoperative ultrasound-guided lumpectomy versus wire-guided excision for nonpalpable breast cancer

Objective

This study was designed to compare the margin clearance and re-excision rates of ultrasound (US)- and wire-guided excision in a large number of patients with nonpalpable breast cancer.

Methods

In total, 520 women who were histologically diagnosed with nonpalpable breast cancer were recruited in this study. All nonpalpable lesions were visible by US. The patients were randomly divided into two groups: those who underwent wire-guided breast-conserving surgery (BCS) and those who underwent US-guided BCS. Re-excision rates and positive surgical margins were recorded.

Results

A total of 262 patients underwent US-guided excision and 258 patients underwent wire-guided excision. No differences were found in tumor or patient characteristics. The positive margin rate was 4.6% in the US-guided group and 19.4% in the wire-guided group with a significant difference. Age, menopausal status, excision volume, histological grade, and tumor type significantly influenced the positive surgical margin rate. The intraoperative re-excision rate was significantly lower in the US-guided group than wire-guided group (11.1% vs. 24.0%, respectively).

Conclusions

US-guided BCS seems to be more effective than wire-guided BCS for treatment of nonpalpable breast cancers in terms of the margin clearance and re-excision rates. Patients can avoid the discomfort caused by preoperative wire placement.

Differences in Re-excision Rates for Breast-Conserving Surgery Using Intraoperative 2D Versus 3D Tomosynthesis Specimen Radiograph

BACKGROUND

Intraoperative specimen radiographs performed during breast conservation surgery for cancer reduces the need for re-excision for positive margins. We studied 2D versus 3D image-guided cavity margin excision and compared it to final pathology and need for additional surgery.

METHODS

We conducted a retrospective review of 657 breast-conserving operations performed for cancer from 2013 to 2018. Procedures were performed by four surgeons at a single tertiary institution with access intraoperatively to 2D and 3D radiographs. Data collected included demographics, intraoperative margin assessment, final pathology, and re-excision rates.

RESULTS

A total of 466 patients had 2D and 191 had 3D specimen imaging. The 2D group had a lower mean age and a higher body mass index and proportion of minority patients than the 3D group (P < 0.01). In the 3D group, there was a higher percentage of patients with mammographically denser breasts (P < 0.06); 58% of patients in the 3D group had additional imaging-directed cavity margins excised versus 32% of patients in the 2D group (P < 0.01). In the 2D group, 44 patients (9%) had positive final margins versus 8 patients (4%) in the 3D group (P = 0.02). No difference was found on total volume of excision (P = 0.56). The re-excision rate for the 2D group was 11% versus 5% for the 3D group (P = 0.02; adjusted odds ratio = 0.41, 95% confidence interval 0.19-0.86).

CONCLUSIONS

Re-excision rates using both modalities are low. A lower re-excision rate is independently associated with 3D tomosynthesis. This allows surgeons to excise additional margins at the index operation, decreasing reoperations and anxiety/costs for patients.

Intraoperative ultrasonography-guided surgery: An effective modality for breast conservation after neo-adjuvant chemotherapy

Margin status is one of the significant prognostic factors for recurrence in breast-conserving surgery (BCS). The issue that merits consideration for oncologic safety and cost-effectiveness about the modalities to assure clear margins at initial surgical intervention remains controversial after neo-adjuvant chemotherapy (NAC). The presented study aimed to assess the impact of intraoperative ultrasound (IOUS)-guided surgery on accurate localization of tumor site, adequacy of excision with clear margins, and healthy tissue sacrifice in BCS after NAC. Patients who had IOUS-guided BCS ater NAC were reviewed. No patient had preoperative localization with wire or radiotracer. Intraoperative real-time sonographic localization, sonographic margin assessment during resection, macroscopic and sonographic examination of specimen, and cavity shavings (CS) were done as the standard procedure. No frozen assessment was performed. One hundred ninety-four patients were included, in which 42.5% had pCR. IOUS-guided surgery accomplished successful localization of the targeted lesions in all patients. Per protocol, all inked margins on CS specimens were reported to be tumor-free in permanent histopathology. No re-excision or mastectomy was required. For a setting without CS, the negative predictive value (NPV) of IOUS rate was 96%. IOUS was found to over and underestimate tumor response to NAC both in 2% of patients. IOUS-guided surgery seems to be an efficient modality to perform adequate BCS after NAC with no additional localization method. Especially, when CS is integrated as a standard to BCS, IOUS seems to provide safe surgery for patients with no false negativity and a high rate of NPV.

Intraoperative sonography for nonpalpable breast lesions: Additional indications for a consolidate technique

This prospective study evaluated the intraoperative ultrasound scan (IUSS) for nonpalpable breast lesions' detection. A total of 108 consecutive female patients underwent surgery using IUSS: Frozen sections demonstrated clear margins in 95.5% of neoplastic patients. Only four (4.5%) patients underwent local re-excision in the same operation. IUSS demonstrated to be quick, accurate, useful, effective, and safe for the intraoperative management of neoplastic nonpalpable breast lesions when performed by a surgeon who has undergone US training, particularly for people in whom alternative approaches can show some limitations due to contraindications or because of scheduling constraints, costs, and patient discomfort.

Intraoperative ultrasound in breast cancer surgery-from localization of non-palpable tumors to objectively measurable excision

Background

The utilization of intraoperative ultrasound (IOUS) in breast cancer surgery is a relatively new concept in surgical oncology. Over the last few decades, the field of breast cancer surgery has been striving for a more rational approach, directing its efforts towards removing the tumor entirely yet sparing tissue and structures not infiltrated by tumor cells. Further progress in objectivity and optimization of breast cancer excision is possible if we make the tumor and surrounding tissue visible and measurable in real time, during the course of the operation; IOUS seems to be the optimal solution to this complex requirement. IOUS was introduced into clinical practice as a device for visualization of non-palpable tumors, and compared to wire-guided localization (WGL), IOUS was always at least a viable, or much better alternative, in terms of both precision in identification and resection and for patients’ and surgeons’ comfort. In recent years, intraoperative ultrasound has been used in the surgery of palpable tumors to optimize resection procedures and overcome the disadvantages of classic palpation guided surgery.

Objective

The aim of this review is to show the role of IOUS in contemporary breast cancer surgery and its changes over time.

Methods

A PubMed database comprehensive search was conducted to identify all relevant articles according to assigned key words.

Conclusion

Over time, the use of IOUS has been transformed from being the means of localizing non-palpable lesions to an instrument yielding a reduced number of positive resection margins, with a smaller volume of healthy breast tissue excided around tumor, by making the excision of the tumor optimal and objectively measurable.

Breast-specific factors determine cosmetic outcome and patient satisfaction after breast-conserving therapy: Results from the randomized COBALT study

BACKGROUND AND OBJECTIVES

To identify breast-specific factors and the role of tumor, treatment, and patient-related items in influencing patient opinion on cosmesis and satisfaction after breast-conserving therapy (BCT).

METHODS

Data from the randomized COBALT study was used. At 3, 12, and 36 months, 128 patients with T1-T2 breast cancer completed a questionnaire on breast-specific factors and overall cosmetic outcome and patient satisfaction, using a 4-point Likert scale.

RESULTS

There was a strong positive correlation between breast-specific factors, overall cosmetic outcome,and satisfaction at all time-points. Excellent/good cosmetic outcomes and satisfaction decreased during follow-up. A shift was noted in the degree of influence of the various breast-specific factors. At 3 years, symmetry factors such as size, shape, and nipple position largely determined a patient's opinion on the final cosmesis, followed by firmness. The risk of an unacceptable outcome was associated with young age and large excision volumes.

CONCLUSION

A questionnaire including breast-specific questions provides important information on final cosmetic results and satisfaction after BCT. These outcomes can also be of great value as quality indicators and pre-operative counseling. The major influence of breast-specific factors on asymmetry underlines the importance of achieving an optimal excision volume at the initial procedure.

Comparison of outcomes of surgeon-performed intraoperative ultrasonography-guided wire localization and preoperative wire localization in nonpalpable breast cancer patients undergoing breast-conserving surgery: A retrospective cohort study

This study aimed to determine the efficacy of intraoperative ultrasonography-guided wire localization guided breast-conserving surgery (BCS) for nonpalpable breast cancer and compare it to conventional preoperative wire localization (PWL) guided surgery.We retrospectively analyzed the medical charts of 214 consecutive nonpalpable breast cancer patients who underwent BCS using intraoperative ultrasonography-guided wire localization by a surgeon (IUWLS) and PWL, between April 2013 and March 2017. Positive surgical margins, reexcision rates, and resection volumes were investigated.Of the total cohort, 124 patients underwent BCS with IUWLS and 90 patients with PWL. The following did not differ between the IUWLS and PWL groups: positive margin status, re-excision rate, conversion rate, permanent positive margin status, reoperation rate, median optimal resection volume (ORV), median total resection volume (TRV), and median closest tumor-free margin. Rather, median (range) widest tumor-free margin was significantly smaller in the IUWLS group (9 mm [5-12]) than in the PWL group (14 mm [9-20]; P = .003]). Median (range) calculated resection ratio (CRR) was significantly lower in the IUWLS group (1.67 [0.87-9.38]) than in the PWL group (4.83 [1.63-21.04]; P = .02).In nonpalpable breast cancer patients undergoing BCS, IUWLS showed positive resection margins and reexcision rates equivalent to those of the conventional PWL method. Additionally, excision volume and widest tumor-free margin were smaller with IUWLS, confirming that healthy breast tissue is less likely to be resected with this method. Our results suggest that IUWLS offers an excellent alternative to PWL, while avoiding PWL-induced patient discomfort.

A Tumor Ultrasound-guided Incision (TUGI) Approach to Nipple-sparing Mastectomy: Balancing Oncologic Safety and Technical Outcomes

BACKGROUND

Nipple-sparing mastectomy (NSM) is a prevalent operation for patients with breast cancer. Indications have been limited to tumors accessible via radial, infra-mammary, or periareolar incisions out of concern for oncologic and technical safety. We study an alternative approach to NSM based on tumor ultrasound-guided incisions (TUGI) and report its oncologic and technical outcomes.

MATERIALS AND METHODS

A retrospective chart review examined patients who underwent TUGI NSM between 2013 and 2016. Operative notes, postoperative notes, pathology reports, and postoperative photography were analyzed.

RESULTS

Ninety-four patients had mastectomy with reconstruction performed over a 3-year period by the senior authors. Of those, 31 (33%) were NSM and 13 (14%) had the TUGI technique, forming the study group. The median tumor size was 1.5 cm, with a median distance from the nipple areolar complex of 5 cm. Sixty-two percent of the incisions were in the upper quadrants of the breast. Median operative time was 207 minutes. Zero patients had positive margins. One hundred percent of patients underwent immediate tissue expander placement, 46% with acellular dermal matrix. For final reconstruction, 23% had a free flap, 69% implant, and 8% are still pending. Eight percent of patients had wound infection, and 15% of patients had NAC necrosis. No cancer recurrence has been observed at a median follow-up of 17 months.

CONCLUSION

TUGI offers a valuable, oncologically sound alternative approach to traditional NSM. The technical results and outcomes support its use in selected patients with breast cancer undergoing NSM.