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Diagnostic Value of Intraoperative Frozen Section in Breast-Conserving Surgery: A Systematic Review and Meta-analysis. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2021. [DOI: 10.5812/ijcm.114082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Context: According to previous studies, using the frozen section procedure during breast surgery reduces the rate of error and the need for re-surgery. We aimed at performing a comprehensive systematic review and meta-analysis to provide reliable evidence on the diagnostic value of frozen section procedures in breast-conserving surgery (BCS). Data Sources: A thorough search was performed in PubMed, Embase, Cochrane Library, and Web of Science databases for human diagnostic studies that used the frozen section in BCS. Meta-analyses were done to find the sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR). Study Selection: Human diagnostic studies used the frozen section in breast-conserving surgery and studies that reported the sensitivity and specificity of the frozen section in BCS or contained data that could be calculated the desired parameters were selected for this meta-analysis. Data Extraction: Assessment of studies quality was done and data was extracted from included papers. Then, the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess the quality of included papers. Results: Thirty-five papers were entered into our study. The meta-analysis indicated the high sensitivity (83.47, 95%CI 79.61 - 87.32) and specificity (99.29, 95%CI 98.89 - 99.68) for the frozen section in BCS, which resulted in an accuracy of 93.77 (95%CI 92.45 - 95.10). We also found a significant PPV (93.26, 95%CI 91.25 - 95.27), NPV (92.17, 95%CI 90.22 - 94.11), PLR (7.99, 95%CI 6.01 - 9.96), and NLR (0.18, 95%CI 0.14 - 0.23). Conclusions: The findings showed that intraoperative frozen section analysis has high sensitivity and specificity for evaluating lumpectomy margins in patients with early-stage breast cancer and significantly reduces the need for re-operation. Accordingly, re-operation costs are not imposed on the patient and reduce the anxiety of the patients.
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van der Noordaa MEM, Ioan I, Rutgers EJ, van Werkhoven E, Loo CE, Voorthuis R, Wesseling J, van Urk J, Wiersma T, Dezentje V, Vrancken Peeters MJTFD, van Duijnhoven FH. Breast-Conserving Therapy in Patients with cT3 Breast Cancer with Good Response to Neoadjuvant Systemic Therapy Results in Excellent Local Control: A Comprehensive Cancer Center Experience. Ann Surg Oncol 2021; 28:7383-7394. [PMID: 33978889 DOI: 10.1245/s10434-021-09865-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 03/02/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Many cT3 breast cancer patients are treated with mastectomy, regardless of response to neoadjuvant systemic therapy (NST). We evaluated local control of cT3 patients undergoing breast-conserving therapy (BCT) based on magnetic resonance imaging (MRI) evaluation post-NST. In addition, we analyzed predictive characteristics for positive margins after breast-conserving surgery (BCS). METHODS All cT3 breast cancer patients who underwent BCS after NST between 2002 and 2015 at the Netherlands Cancer Institute were included. Local recurrence-free interval (LRFI) was estimated using the Kaplan-Meier method, and predictors for positive margins were analyzed using univariable analysis and multivariable logistic regression. RESULTS Of 114 patients undergoing BCS post-NST, 75 had negative margins, 16 had focally positive margins, and 23 had positive margins. Of those with (focally) positive margins, 12 underwent radiotherapy, 6 underwent re-excision, and 21 underwent mastectomy. Finally, 93/114 patients were treated with BCT (82%), with an LRFI of 95.9% (95% confidence interval [CI] 91.5-100%) after a median follow-up of 7 years. Predictors for positive margins in univariable analysis were hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) subtype, lobular carcinoma, and non-mass enhancement (NME) on pre-NST MRI. MRI response was not correlated to positive margins. In multivariable regression, the odds of positive margins were decreased in patients with HER2-positive (HER2+; odds ratio [OR] 0.27, 95% CI 0.10-0.73; p = 0.01) and TN tumors (OR 0.17, 95% CI 0.03-0.82; p = 0.028). A trend toward positive margins was observed in patients with NME (OR 2.38, 95% CI 0.98-5.77; p = 0.055). CONCLUSION BCT could be performed in 82% of cT3 patients in whom BCT appeared feasible on post-NST MRI. Local control in these patients was excellent. In those patients with HR+/HER2- tumors, NME on MRI, or invasive lobular carcinoma, the risk of positive margins should be considered preoperatively.
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Affiliation(s)
| | - Ileana Ioan
- Department of Radiology, Policlinico San Donato, Milan, Italy
| | - Emiel J Rutgers
- Department of Surgical Oncology, NKI-AVL, Amsterdam, The Netherlands.,Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Claudette E Loo
- Department of Radiology, NKI-AVL, Amsterdam, The Netherlands
| | - Rosie Voorthuis
- Department of Surgical Oncology, NKI-AVL, Amsterdam, The Netherlands
| | - Jelle Wesseling
- Department of Pathology, NKI-AvL and Leiden University Medical Center, Amsterdam, The Netherlands
| | - Japke van Urk
- Department of Radiology, NKI-AVL, Amsterdam, The Netherlands
| | - Terry Wiersma
- Department of Radiation Oncology, NKI-AVL, Amsterdam, The Netherlands
| | - Vincent Dezentje
- Department of Medical Oncology, NKI-AVL, Amsterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, NKI-AVL, Amsterdam, The Netherlands.,Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
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Shaikh A, Tariq MU, Khan SM, Idress R, Vohra LM, Shaikh SF, Waheed H. Concordance Between Clinical and Pathological Response Assessment After Neo-Adjuvant Chemotherapy in Patients With Invasive Lobular Carcinoma. Cureus 2021; 13:e14341. [PMID: 33972899 PMCID: PMC8103980 DOI: 10.7759/cureus.14341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Neo-adjuvant chemotherapy (NAC) is frequently administered in breast carcinoma patients. The clinical response to NAC guides further treatment. The pathological response is not only an independent prognostic factor, but it also guides further treatment and prognosis. Objectives The aim of our study was to find the degree of concordance between clinical and pathological response assessments after NAC in Invasive lobular Carcinoma (ILC) cases by using World Health Organization (WHO) criteria and different pathological systems, respectively. We also tried to identify any useful parameter of clinical assessment that could better correlate with pathologic assessment and provide a better estimation of residual tumor. Methods This retrospective study was conducted on 26 ILC tumors diagnosed in 24 patients who were treated with NAC followed by surgical resection between January 2009 and December 2020. Medical records and microscopy glass slides were reviewed for clinical and pathological response assessments, respectively. Results The pre-treatment tumor area ranged from 1.8-255 cm2 and the mean±SD was 52.2±66.8 cm2. After NAC, complete clinical response was observed in four (15.3%) cases. The clinically assessed mean tumor area significantly reduced from 52.2±66.8 cm2 to 17.2±22.6 cm2 (p-value<0.001). The pathologically assessed mean tumor area (27.4±24.1 cm2) didn't differ significantly from the clinically assessed mean tumor area (17.2±22.6 cm2) (p-value=0.114). Pathologically, the majority of the cases showed partial response, and a complete pathological response was achieved in only two (7.7%) cases. The concordance rates between clinical assessment by the WHO method and pathological assessment of the breast using the Sataloff method, Miller-Payne (MP) system, Residual Cancer Burden system, and Chevallier method were 26.7%, 15.8%, 9%, and 3.5%, respectively, with insignificant p-values. Percentage reduction in clinical size and percentage reduction in tumor cellularity differed significantly (p-value=0.038). Conclusion Clinical response assessment provides a less accurate estimation of residual disease, as it shows poor concordance with pathological assessment using different assessment systems/methods.
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Affiliation(s)
- Aisha Shaikh
- Surgery, Aga Khan University Hospital, Karachi, PAK.,Surgery, Shaheed Mohtarma Benazir Bhutto Medical University, Larkana, PAK
| | - Muhammad Usman Tariq
- Histopathology, Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, PAK
| | | | - Romana Idress
- Histopathology, Aga Khan University Hospital, Karachi, PAK
| | | | | | - Hira Waheed
- Radiology, Aga Khan University Hospital, Karachi, PAK
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4
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Cen C, Chun J, Kaplowitz E, Axelrod D, Shapiro R, Guth A, Schnabel F. Margin Assessment and Re-excision Rates for Patients Who Have Neoadjuvant Chemotherapy and Breast-Conserving Surgery. Ann Surg Oncol 2021; 28:5142-5148. [PMID: 33635409 DOI: 10.1245/s10434-020-09524-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/10/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) has enabled more patients to be eligible for breast-conservation surgery (BCS). Achieving negative lumpectomy margins, however, is challenging due to changes in tissue composition and potentially scattered residual carcinoma in the tumor bed. Data regarding BCS after NAC have shown variable re-excision rates. MarginProbe (Dilon Technologies, Newport News, VA, USA) has been shown to identify positive resection margins intraoperatively and to reduce the number of re-excisions in primary BCS, but has not been studied in NAC+BCS cases. This study aimed to investigate the clinicopathologic characteristics, margin status, and re-excision rates for NAC+BCS patients with and without the use of MarginProbe. METHODS The Institutional Breast Cancer Database was queried for patients who received NAC and had BCS from 2010 to 2019. The variables of interest were demographics, tumor characteristics, pathologic complete response (pCR), MarginProbe use, and re-excision rates. RESULTS The study population consisted of 214 patients who had NAC, 61 (28.5 %) of whom had NAC+BCS. The median age of the patients was 53.5 years. A pCR was achieved for 19 of the patients (31.1 %). Of the remaining 42 patients, 9 (21 %) had close or positive margins that required re-excision. Re-excision was associated with a larger residual tumor size (p = 0.025) and estrogen receptor (ER)-positive disease before NAC (p = 0.041). MarginProbe use was associated with a lower re-excision rate for the patients who had NAC+BCS (6 % vs. 31 %, respectively). CONCLUSION The patients with a larger residual tumor burden and ER-positive disease had a greater risk for inadequate margins at surgery. MarginProbe use was associated with a lower re-excision rate. Techniques to reduce the need for re-excision will support the use of BCS after NAC.
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Affiliation(s)
- Cindy Cen
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Jennifer Chun
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Elianna Kaplowitz
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Deborah Axelrod
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Richard Shapiro
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Amber Guth
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Freya Schnabel
- Department of Surgery, New York University Langone Health, New York, NY, USA.
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5
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Devane LA, Baban CK, O'Doherty A, Quinn C, McDermott EW, Prichard RS. The Impact of Neoadjuvant Chemotherapy on Margin Re-excision in Breast-Conserving Surgery. World J Surg 2021; 44:1547-1551. [PMID: 32002582 DOI: 10.1007/s00268-020-05383-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) can improve cosmesis by reducing resection volume. Breast-conserving surgery (BCS) aims to achieve clear excision margins while optimizing cosmesis. However, the influence of NAC on margin re-excision after BCS is unclear. This study examines the rate and determinants of margin re-excision in patients undergoing BCS following NAC in our institution. METHODS From 2011-2015, all patients treated with NAC prior to BCS were identified from a prospectively maintained database. Mann-Whitney and Fisher's exact test tests were used to compare variables in patients who did and did not require re-excision. Patients undergoing primary surgical treatment in 2015 comprised an unmatched comparison group. RESULTS Of 211 patients treated with NAC, 69 initially underwent BCS. The re-excision rate was 32% (n = 22) compared to 17% in the primary operable group (38 of 221, p = 0.02). Re-excision rates were lowest in triple-negative and HER2+ tumors (0% and 10%, respectively). Lobular carcinoma and ER+ tumors had a significantly higher rate of re-excision (100% and 42%, respectively). Of 22 patients undergoing re-excision, 9 had further BCS and 13 had a mastectomy. CONCLUSION The re-excision rate following NAC is almost twice that of patients who underwent primary operative management. Her2+ and triple-negative tumors have lower re-excision rates and may represent a selected cohort most suitable for BCS. Patients with invasive lobular carcinoma or ER+ disease have significantly higher rates of margin positivity, and these patients should be considered for a cavity shave during primary surgery to reduce the rates of re-excision.
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Affiliation(s)
- Liam A Devane
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Chwanrow K Baban
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - A O'Doherty
- Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Cecily Quinn
- Department of Pathology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Enda W McDermott
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ruth S Prichard
- Department of Breast Surgery, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
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Jamaris S, Akpolat-Basci L, Stephanou M, Wetzig S, Cubuk Y, Gerharz J, Bittner AK, See MH, Liedtke C, Kolberg HC. 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. Breast Care (Basel) 2019; 14:302-307. [PMID: 31798390 DOI: 10.1159/000493017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Suniza Jamaris
- Department of Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Leyla Akpolat-Basci
- Klinik für Gynäkologie und Senologie, Evangelisches Krankenhaus Wesel, Wesel, Germany
| | - Miltiades Stephanou
- Klinik für Gynäkologie und Geburtshilfe, Marienhospital Bottrop, Bottrop, Germany
| | - Sarah Wetzig
- Klinik für Gynäkologie und Geburtshilfe, Marienhospital Bottrop, Bottrop, Germany
| | - Yueksel Cubuk
- Klinik für Radiologie, Marienhospital Bottrop, Bottrop, Germany
| | | | - Ann-Kathrin Bittner
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Essen, Essen, Germany
| | - Mee Hoong See
- Department of Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Cornelia Liedtke
- Klinik für Gynäkologie mit Brustzentrum, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Tummers QRJG, Hoogstins CES, Gaarenstroom KN, de Kroon CD, van Poelgeest MIE, Vuyk J, Bosse T, Smit VTHBM, van de Velde CJH, Cohen AF, Low PS, Burggraaf J, Vahrmeijer AL. Intraoperative imaging of folate receptor alpha positive ovarian and breast cancer using the tumor specific agent EC17. Oncotarget 2017; 7:32144-55. [PMID: 27014973 PMCID: PMC5078003 DOI: 10.18632/oncotarget.8282] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 02/11/2016] [Indexed: 12/20/2022] Open
Abstract
Introduction Intraoperative fluorescence imaging of the folate-receptor alpha (FRα) could support completeness of resection in cancer surgery. Feasibility of EC17, a FRα-targeting agent that fluoresces at 500nm, was demonstrated in a limited series of ovarian cancer patients. Our objective was to evaluate EC17 in a larger group of ovarian cancer patients. In addition, we assessed the feasibility of EC17 in patients with breast cancer. Methods Two-to-three hours before surgery 0.1mg/kg EC17 was intravenously administered to 12 patients undergoing surgery for ovarian cancer and to 3 patients undergoing surgery for biopsy-proven FRα-positive breast cancer. The number of lesions/positive margins detected with fluorescence and concordance between fluorescence and tumor- and FRα-status was assessed in addition to safety and pharmacokinetics. Results Fluorescence imaging in ovarian cancer patients allowed detection of 57 lesions of which 44 (77%) appeared malignant on histopathology. Seven out of these 44 (16%) were not detected with inspection/palpation. Histopathology demonstrated concordance between fluorescence and FRα- and tumor status. Fluorescence imaging in breast cancer patients, allowed detection of tumor-specific fluorescence signal. At the 500nm wavelength, autofluorescence of normal breast tissue was present to such extent that it interfered with tumor identification. Conclusions FRα is a favorable target for fluorescence-guided surgery as EC17 produced a clear fluorescent signal in ovarian and breast cancer tissue. This resulted in resection of ovarian cancer lesions that were otherwise not detected. Notwithstanding, autofluorescence caused false-positive lesions in ovarian cancer and difficulty in discriminating breast cancer-specific fluorescence from background signal. Optimization of the 500nm fluorophore, will minimize autofluorescence and further improve intraoperative tumor detection.
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Affiliation(s)
- Quirijn R J G Tummers
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.,Centre for Human Drug Research, Leiden, The Netherlands
| | - Charlotte E S Hoogstins
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.,Centre for Human Drug Research, Leiden, The Netherlands
| | - Katja N Gaarenstroom
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cor D de Kroon
- Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jaap Vuyk
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tjalling Bosse
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vincent T H B M Smit
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Adam F Cohen
- Centre for Human Drug Research, Leiden, The Netherlands
| | - Philip S Low
- Department of Chemistry, Purdue University, West Lafayette, IN, USA
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8
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Neoadjuvant chemotherapy in breast-conserving surgery – Consequences on margin status and excision volumes. Eur J Surg Oncol 2016; 42:986-93. [DOI: 10.1016/j.ejso.2016.02.252] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 02/21/2016] [Accepted: 02/24/2016] [Indexed: 11/20/2022] Open
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9
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Bouzón A, Acea B, García A, Iglesias Á, Mosquera J, Santiago P, Seoane T. Risk factors for positive margins in conservative surgery for breast cancer after neoadjuvant chemotherapy. Cir Esp 2016; 94:379-84. [PMID: 27158077 DOI: 10.1016/j.ciresp.2016.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 03/15/2016] [Accepted: 03/18/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Breast conservative surgery after neoadjuvant chemotherapy intends to remove any residual tumor with negative margins. The purpose of this study was to analyze the preoperative clinical-pathological factors influencing the margin status after conservative surgery in breast cancer patients receiving neoadjuvant chemotherapy. METHODS A retrospective study of 91 breast cancer patients undergoing neoadjuvant chemotherapy (92 breast lesions) during the period 2006 to 2013. A Cox regression analysis to identify baseline tumor characteristics associated with positive margins after breast conservative surgery was performed. RESULTS Of all cases, 71 tumors were initially treated with conservative surgery after neoadjuvant chemotherapy. Pathologic exam revealed positive margins in 16 of the 71 cases (22.5%). The incidence of positive margins was significantly higher in cancers with initial size >5cm (P=.021), in cancers with low tumor grade (P=.031), and in patients with hormone receptor-positive cancer (P=.006). After a median follow-up of 45.2 months, 7 patients of the 71 treated with conservative surgery had disease recurrence (9.8%). There was no significant difference in terms of disease-free survival according to the margin status (P=.596). CONCLUSIONS A baseline tumor size >5cm, low tumor grade and hormone receptor-positive status increase the risk for surgical margin involvement in breast conservative surgery after neoadjuvant chemotherapy.
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Affiliation(s)
- Alberto Bouzón
- Unidad de Mama, Servicio de Cirugía General, Complexo Hospitalario Universitario A Coruña, La Coruña, España
| | - Benigno Acea
- Unidad de Mama, Servicio de Cirugía General, Complexo Hospitalario Universitario A Coruña, La Coruña, España.
| | - Alejandra García
- Unidad de Mama, Servicio de Cirugía General, Complexo Hospitalario Universitario A Coruña, La Coruña, España
| | - Ángela Iglesias
- Unidad de Mama, Servicio de Cirugía General, Complexo Hospitalario Universitario A Coruña, La Coruña, España
| | - Joaquín Mosquera
- Unidad de Mama, Servicio de Cirugía General, Complexo Hospitalario Universitario A Coruña, La Coruña, España
| | - Paz Santiago
- Unidad de Mama, Servicio de Cirugía General, Complexo Hospitalario Universitario A Coruña, La Coruña, España
| | - Teresa Seoane
- Unidad de Mama, Servicio de Cirugía General, Complexo Hospitalario Universitario A Coruña, La Coruña, España
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11
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Vriens BEPJ, de Vries B, Lobbes MBI, van Gastel SM, van den Berkmortel FWPJ, Smilde TJ, van Warmerdam LJC, de Boer M, van Spronsen DJ, Smidt ML, Peer PGM, Aarts MJ, Tjan-Heijnen VCG. Ultrasound is at least as good as magnetic resonance imaging in predicting tumour size post-neoadjuvant chemotherapy in breast cancer. Eur J Cancer 2015; 52:67-76. [PMID: 26650831 DOI: 10.1016/j.ejca.2015.10.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 08/30/2015] [Accepted: 10/15/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the accuracy of clinical imaging of the primary breast tumour post-neoadjuvant chemotherapy (NAC) related to the post-neoadjuvant histological tumour size (gold standard) and whether this varies with breast cancer subtype. In this study, results of both magnetic resonance imaging (MRI) and ultrasound (US) were reported. METHODS Patients with invasive breast cancer were enrolled in the INTENS study between 2006 and 2009. We included 182 patients, of whom data were available for post-NAC MRI (n=155), US (n=123), and histopathological tumour size. RESULTS MRI estimated residual tumour size with <10-mm discordance in 54% of patients, overestimated size in 28% and underestimated size in 18% of patients. With US, this was 63%, 20% and 17%, respectively. The negative predictive value in hormone receptor-positive tumours for both MRI and US was low, 26% and 33%, respectively. The median deviation in clinical tumour size as percentage of pathological tumour was 63% (P25=26, P75=100) and 49% (P25=22, P75=100) for MRI and US, respectively (P=0.06). CONCLUSIONS In this study, US was at least as good as breast MRI in providing information on residual tumour size post-neoadjuvant chemotherapy. However, both modalities suffered from a substantial percentage of over- and underestimation of tumour size and in addition both showed a low negative predictive value of pathologic complete remission (Gov nr: NCT00314977).
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Affiliation(s)
- Birgit E P J Vriens
- Department of Medical Oncology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bart de Vries
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marc B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | - Tineke J Smilde
- Department of Internal Medicine, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | | | - Maaike de Boer
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Petronella G M Peer
- Biostatistics, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Maureen J Aarts
- Department of Medical Oncology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Vivianne C G Tjan-Heijnen
- Department of Medical Oncology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
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12
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Truin W, Vugts G, Roumen RMH, Maaskant-Braat AJG, Nieuwenhuijzen GAP, van der Heiden-van der Loo M, Tjan-Heijnen VCG, Voogd AC. Differences in Response and Surgical Management with Neoadjuvant Chemotherapy in Invasive Lobular Versus Ductal Breast Cancer. Ann Surg Oncol 2015; 23:51-7. [PMID: 25980321 PMCID: PMC4695495 DOI: 10.1245/s10434-015-4603-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Indexed: 12/03/2022]
Abstract
Background This study was conducted to determine the impact of neoadjuvant chemotherapy (NAC) on the likelihood of breast-conserving surgery (BCS) performed for patients with invasive lobular breast carcinoma (ILC) and invasive ductal carcinoma (IDC). Methods Female patients with a diagnosis of ILC or IDC in The Netherlands between July 2008 and December 2012 were identified through the population-based Netherlands Cancer Registry. Results A total of 466 ILC patients received NAC compared with 3622 IDC patients. Downstaging by NAC was seen in 49.7 % of the patients with ILC and in 69.6 % of the patients with IDC, and a pathologic complete response (pCR) was observed in 4.9 and 20.2 % of these patients, respectively (P < 0.0001). Breast-conserving surgery was performed for 24.4 % of the patients with ILC receiving NAC versus 39.4 % of the patients with IDC. In the ILC group, 8.2 % of the patients needed surgical reinterventions after BCS due to tumor-positive resection margins compared with 3.4 % of the patients with IDC (P < 0.0001). Lobular histology was independently associated with a higher mastectomy rate (odds ratio 1.91; 95 % confidence interval 1.49–2.44). Among the patients with clinical T2 and T3 disease, BCS was achieved more often when NAC was administered in ILC as well as IDC. Conclusion The patients with ILC receiving NAC were less likely to experience a pCR and less likely to undergo BCS than the patients with IDC. With regard to BCS, the impact of NAC for ILC patients was lower than for patients receiving surgery without NAC. However, despite the high number to treating in order to achieve BCS, a small subset of ILC patients, especially cT2 and cT3 patients, still may benefit from NAC.
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Affiliation(s)
- W Truin
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands.
| | - G Vugts
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organization IKNL, Utrecht, The Netherlands
| | - R M H Roumen
- Department of Surgery, Máxima Medical Centre, Veldhoven, The Netherlands.,Department of Medical Oncology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | | | - V C G Tjan-Heijnen
- Department of Medical Oncology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - A C Voogd
- Department of Research, Netherlands Comprehensive Cancer Organization IKNL, Utrecht, The Netherlands.,Department of Medical Oncology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Epidemiology, Maastricht University Medical Centre, Maastricht, The Netherlands
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Pinder SE, Rakha EA, Purdie CA, Bartlett JMS, Francis A, Stein RC, Thompson AM, Shaaban AM. Macroscopic handling and reporting of breast cancer specimens pre- and post-neoadjuvant chemotherapy treatment: review of pathological issues and suggested approaches. Histopathology 2015; 67:279-93. [PMID: 25585651 DOI: 10.1111/his.12649] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Neoadjuvant chemotherapy (NACT) is used increasingly in the treatment of invasive breast cancer and presents challenges for the pathologist in the handling and interpretation of tissues. Potential issues include pathological identification and localization of the residual tumour site; how best to assess pathological response (given the diversity of scoring systems described); the timing and assessment of axillary node biopsy; and the value of retesting any residual tumour for dissonance between core biopsy and post-treatment residual cancer cells for biomarker expression such as oestrogen and progesterone receptors and human epidermal growth factor receptor 2 (HER2). The role of the pathologist is critical in modern NACT approaches to breast cancer and is likely to remain challenging as novel agents and newer biomarkers become available. In this manuscript we review these issues and describe some practical approaches to handling and reporting these samples in the routine histopathology laboratory.
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Affiliation(s)
- Sarah E Pinder
- Research Oncology, Division of Cancer Studies, King's College London, Guy's Hospital, London, UK
| | - Emad A Rakha
- Division of Cancer and Stem Cells, School of Medicine, University of Nottingham, Nottingham, UK
| | - Colin A Purdie
- Department of Pathology, Ninewells Hospital and Medical School, Dundee, UK
| | | | | | - Robert C Stein
- University College London Hospitals and Medical School, London, UK
| | - Alastair M Thompson
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Abeer M Shaaban
- Department of Cellular Pathology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Brennan M, Lim B. The Actual Role of Receptors as Cancer Markers, Biochemical and Clinical Aspects: Receptors in Breast Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2015; 867:327-37. [DOI: 10.1007/978-94-017-7215-0_20] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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15
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Truin W, Roumen RM, Siesling S, van der Heiden-van der Loo M, Duijm LEM, Tjan-Heijnen VCG, Voogd AC. Patients with Invasive Lobular Breast Cancer Are Less Likely to Undergo Breast-Conserving Surgery: A Population Based Study in The Netherlands. Ann Surg Oncol 2014; 22:1471-8. [DOI: 10.1245/s10434-014-4175-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Indexed: 11/18/2022]
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16
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Kikuyama M, Akashi-Tanaka S, Hojo T, Kinoshita T, Ogawa T, Seto Y, Tsuda H. Utility of intraoperative frozen section examinations of surgical margins: implication of margin-exposed tumor component features on further surgical treatment. Jpn J Clin Oncol 2014; 45:19-25. [DOI: 10.1093/jjco/hyu158] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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17
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Kümmel S, Holtschmidt J, Loibl S. Surgical treatment of primary breast cancer in the neoadjuvant setting. Br J Surg 2014; 101:912-24. [DOI: 10.1002/bjs.9545] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 11/11/2022]
Abstract
Abstract
Background
Neoadjuvant chemotherapy (NACT) is a standard treatment option for primary operable breast cancer when adjuvant chemotherapy is indicated.
Methods
This article reviews the use of NACT in breast cancer treatment.
Results
Pathological complete response (pCR) rates of up to 60 per cent have been reached for certain breast cancer subgroups. Patients achieving a pCR have a lower locoregional recurrence rate. Nevertheless, the rate of breast-conserving surgery seems to be stable at around 65–70 per cent, although more than 80 per cent of patients respond to NACT. The risk of local relapse does not appear to be higher after NACT, which supports the recommendation to operate within the new margins, as long as there is no tumour in the inked area of the surgical specimen. However, tumours do not shrink concentrically and the re-excision rate is higher after NACT. Mastectomy rates for lobular carcinomas remain high irrespective of tumour response. The role of sentinel lymph node biopsy (SLNB) in the context of NACT has been studied in recent years, and it is not yet completely clear which type of axillary staging is the most suitable. SLNB before NACT in clinically node-negative patients has been the preferred option. However, this practice is currently changing, and it seems advisable to have the SLNB after NACT to reduce the risk of a false-negative SLNB.
Conclusion
Overall, patients do benefit from NACT, especially those with human epidermal growth factor receptor 2-positive and triple-negative breast cancer, but surgical/local procedures need to be adapted.
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Affiliation(s)
- S Kümmel
- Kliniken Essen Mitte, Klinik für Senologie, Essen, Germany
| | - J Holtschmidt
- Kliniken Essen Mitte, Klinik für Senologie, Essen, Germany
| | - S Loibl
- German Breast Group, Neu-Isenburg, Germany
- Sana Klinikum Offenbach, Offenbach, Germany
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CHEN JEONHOR, BAHRI SHADFAR, MEHTA RITAS, CARPENTER PHILIPM, MCLAREN CHRISTINEE, CHEN WENPIN, FWU PETERT, HSIANG DAVIDJB, LANE KARENT, BUTLER JOHNA, SU MINYING. Impact of factors affecting the residual tumor size diagnosed by MRI following neoadjuvant chemotherapy in comparison to pathology. J Surg Oncol 2014; 109:158-67. [PMID: 24166728 PMCID: PMC4005994 DOI: 10.1002/jso.23470] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 09/26/2013] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND OBJECTIVES To investigate accuracy of magnetic resonance imaging (MRI) for measuring residual tumor size in breast cancer patients receiving neoadjuvant chemotherapy (NAC). METHODS Ninety-eight patients were studied. Several MRI were performed during NAC for response monitoring, and the residual tumor size was measured on last MRI after completing NAC. Covariates, including age, tumor characteristics, biomarkers, NAC regimens, MRI scanners, and time from last MRI to operation, were analyzed. Univariate and Multivariate linear regression models were used to determine the predictive value of these covariates for MRI-pathology size discrepancy as the outcome measure. RESULTS The mean (±SD) of the absolute difference between MRI and pathological residual tumor size was 1.0 ± 2.0 cm (range, 0-14 cm). Univariate regression analysis showed tumor type, morphology, HR status, HER2 status, and MRI scanner (1.5 T or 3.0 T) were significantly associated with MRI-pathology size discrepancy (all P < 0.05). Multivariate regression analyses demonstrated that only tumor type, tumor morphology, and biomarker status considering both HR and HER-2 were independent predictors (P = 0.0014, 0.0032, and 0.0286, respectively). CONCLUSION The accuracy of MRI in evaluating residual tumor size depends on tumor type, morphology, and biomarker status. The information may be considered in surgical planning for NAC patients.
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Affiliation(s)
- JEON-HOR CHEN
- Tu & Yuen Center for Functional Onco-Imaging, Department of Radiological Sciences, University of California, Irvine, California
- Department of Radiology, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan
| | - SHADFAR BAHRI
- Tu & Yuen Center for Functional Onco-Imaging, Department of Radiological Sciences, University of California, Irvine, California
| | - RITA S. MEHTA
- Department of Medicine, University of California, Irvine, California
| | | | | | - WEN-PIN CHEN
- Chao Family Comprehensive Cancer Center, University of California, Irvine, California
| | - PETER T. FWU
- Tu & Yuen Center for Functional Onco-Imaging, Department of Radiological Sciences, University of California, Irvine, California
| | | | - KAREN T. LANE
- Department of Surgery, University of California, Irvine, California
| | - JOHN A. BUTLER
- Department of Surgery, University of California, Irvine, California
| | - MIN-YING SU
- Tu & Yuen Center for Functional Onco-Imaging, Department of Radiological Sciences, University of California, Irvine, California
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Los márgenes de resección en la cirugía conservadora del cáncer de mama. Cir Esp 2013; 91:404-12. [DOI: 10.1016/j.ciresp.2013.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 02/07/2013] [Accepted: 02/21/2013] [Indexed: 11/19/2022]
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Clinical benefit from neoadjuvant chemotherapy in oestrogen receptor-positive invasive ductal and lobular carcinomas. Br J Cancer 2013; 108:285-91. [PMID: 23299541 PMCID: PMC3566807 DOI: 10.1038/bjc.2012.557] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: The aim of this study was to compare clinical and pathological outcomes after neoadjuvant chemotherapy between oestrogen receptor (ER)-positive invasive pure lobular carcinoma (ILC) and invasive ductal carcinoma (IDC). Methods: This analysis included 1895 patients (n=177 ILC; n=1718 IDC), with stage I–III breast cancer, who received neoadjuvant chemotherapy. Clinical and pathological response rates, the frequency of positive surgical margins and rate of breast-conserving surgery were compared. Results: There was a trend for fewer good clinical responses in ILC compared with IDC. Tumour downstaging was significantly less frequent in ILC. Positive or close surgical resection margins were more frequent in ILC, and breast-conserving surgery was less common (P<0.001). These outcome differences remained significant in multivariate analysis, including tumour size, nodal status, age, grade and type of chemotherapy. Invasive pure lobular carcinoma was also associated with a significantly lower pathological complete response (pCR) rate in univariate analysis, but this was no longer significant after adjusting for tumour size and grade. Conclusion: Neoadjuvant chemotherapy results in lower rates of clinical benefit, including less downstaging, more positive margins and fewer breast-conserving surgeries in ER-positive ILC compared with ER-positive IDC. Pathological complete responses are rare in both groups, but do not significantly differ after adjusting for other variables.
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McConeghey JF, Cusick TE, Helmer SD, Tenofsky PL, Osland JS. Evaluation of changes in breast architecture after preoperative chemotherapy for breast cancer. Am J Surg 2012; 204:902-8; discussion 908-9. [PMID: 23026383 DOI: 10.1016/j.amjsurg.2012.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 05/21/2012] [Accepted: 05/22/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although use of preoperative chemotherapy for breast cancer is increasing, resultant changes in breast architecture have not been described. The purpose of this study was to examine breast architecture changes in response to chemotherapy by the placement of 4 peripheral clips. METHODS In a prospective case-series of breast cancer patients selected to undergo preoperative chemotherapy, 4 clips were placed peripherally to each mass using sonographic guidance. Mammograms documented tumor size and clip locations both before chemotherapy and after chemotherapy. Percentage reduction in area was calculated based on the tumor dimensions and distances between clips. RESULTS In 16 participants, 87.5% of lesions had a significant response to chemotherapy. Changes in clip measurements varied widely from significant reduction to significant increase and did not correlate with changes in tumor size. The Pearson correlation coefficient comparing changes in tumor size and clip measurements was .036 (P = .895). CONCLUSIONS There was no correlation between reduction in tumor size and change in clip measurements. Further research should be conducted using noncompression breast imaging modalities to eliminate possible distortion caused by mammographic compression.
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Affiliation(s)
- John F McConeghey
- Department of Surgery, University of Kansas School of Medicine-Wichita, 929 N. Saint Francis St., Room 3082, Wichita, KS 67214, USA
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Yang H, Jia W, Chen K, Zeng Y, Li S, Jin L, Wang L, Song E, Su F. Cavity margins and lumpectomy margins for pathological assessment: which is superior in breast-conserving surgery? J Surg Res 2012; 178:751-7. [PMID: 22683081 DOI: 10.1016/j.jss.2012.05.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 04/06/2012] [Accepted: 05/08/2012] [Indexed: 12/19/2022]
Abstract
PURPOSE This prospective cohort study aimed to compare the efficacy of cavity margins (CMs) and lumpectomy margins (LMs) for pathological assessment in breast-conserving surgery. METHODS We assessed the CMs and LMs of 163 breast cancer patients during breast-conserving surgery. We compared and analyzed the positivity rates of CM and LM. RESULTS The positivity rate of CM at the case level and individual margin level was 30.7% and 8.0%, respectively. The positivity rate of LM was 12.3%, 33.1%, and 45.4% at the case level and 1.8%, 6.2%, and 9.1% at the individual margin level, when we used the National Surgical Adjuvant Breast and Bowel Project criteria (ink-free), 1 mm-free criteria and 2 mm-free criteria, respectively. The positivity rate of LM with 1 mm-free criteria was similar to that of CM. Delivery of neoadjuvant chemotherapy increased the positivity rate of CM (50.0% versus 25.2%; P < 0.01) but not LM (41.6% versus 30.7%; P > 0.05) at the case level, whereas the positivity rate of CM and LM both increased after neoadjuvant chemotherapy at the margin level (CMs: 15.5% versus 5.6%, P < 0.001; and LMs: 10.7% versus 4.9%, P < 0.001). In univariate and multivariate analysis, delivery of neoadjuvant chemotherapy, higher node-positive stage, and presence of ductal carcinoma in situ component were correlated with positive CM, whereas positive human epidermal growth factor receptor 2 status and higher node-positive stage were associated with positive LM. CONCLUSIONS Ink-free criteria may be insufficient for LM assessment in breast-conserving surgery, and at least 1 mm width LM is suggested. After the delivery of neoadjuvant chemotherapy, CM assessment should be routinely performed in addition to LM assessment.
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Affiliation(s)
- Hua Yang
- Department of Breast Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, PR China
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Taffurelli M, Montroni I, Santini D, Zamagni C, Fiacchi M, Zanotti S, Pellegrini A, Ugolini G. The Neoadjuvant Net: a patient- and surgeon-friendly device to facilitate safe breast-conserving surgery in patients who underwent neoadjuvant treatment. Breast 2012; 21:499-502. [PMID: 22237294 DOI: 10.1016/j.breast.2011.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 11/29/2011] [Accepted: 12/20/2011] [Indexed: 11/26/2022] Open
Abstract
The primary goal of the study was to describe an innovative and helpful tool in defining the minimal surgical margins necessary during breast-conserving surgery (BCS) after neoadjuvant treatment: the Neoadjuvant Net (NN). The secondary endpoint was to assess its usefulness in achieving postoperative disease-free margins and reducing Ipsilateral Breast Tumor Recurrences (IBRTs). The breast-conserving surgical technique together with the use of the Neoadjuvant Net is herein reported. Age, stage at diagnosis, clinical and pathological response, lymph node status, type of surgery, margin status, and incidence of local and distant recurrence were retrospectively analyzed. Seventy-five patients underwent BCS following medical treatment from 2000 to 2011. The majority of the patients had significant size reduction (63/75, 84%). Twenty-two had a complete clinical response but only 11 (11/75, 14.7%) showed a complete pathological response. Two patients (2/75, 2.67%) had infiltrated surgical margins. After a mean follow-up of seventy months, 3 patients (3/75, 4%) had IBRTs and 4 women had distant metastases (4/75, 5.34%). The NN is an easy-to-use, non-invasive instrument designed with the purpose of facilitating the surgeon's task of reducing infiltrated margins and IBTRs.
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Affiliation(s)
- Mario Taffurelli
- Department of General Surgery, Emergency Surgery and Organ Transplantation, University of Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti, 9, 40138 Bologna, Italy
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Truin W, Voogd AC, Vreugdenhil G, van der Sangen MJ, van Beek MW, Roumen RM. Influence of histology on the effectiveness of adjuvant chemotherapy in patients with hormone receptor positive invasive breast cancer. Breast 2011; 20:505-9. [DOI: 10.1016/j.breast.2011.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 05/09/2011] [Accepted: 05/15/2011] [Indexed: 11/30/2022] Open
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Breast conservative surgery after neoadjuvant chemotherapy in breast cancer patients: Comparison of two tumor localization methods. Eur J Surg Oncol 2011; 37:1038-43. [DOI: 10.1016/j.ejso.2011.08.136] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 08/16/2011] [Accepted: 08/22/2011] [Indexed: 10/17/2022] Open
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Fitzal F, Mittlboeck M, Steger G, Bartsch R, Rudas M, Dubsky P, Riedl O, Jakesz R, Gnant M. Neoadjuvant chemotherapy increases the rate of breast conservation in lobular-type breast cancer patients. Ann Surg Oncol 2011; 19:519-26. [PMID: 21743980 DOI: 10.1245/s10434-011-1879-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Our study aims to determine whether patients with lobular-type breast cancer have significantly improved rates of breast conservation (BCT) after neoadjuvant chemotherapy (nCT). METHODS Patients who received nCT and surgery within three prospective trials between 1995 and 2007 at the Medical University of Vienna were retrospectively analyzed. RESULTS 325 patients had median follow-up of 53 months; 21% had lobular cancer, and 70% of these women were initially scheduled for mastectomy (MX). Twenty-one finally received BCT, yielding a MX-BCT turnover rate of 45%. Of patients primarily scheduled for BCT, 20% had to finally undergo MX in lobular cancer. The 256 patients with ductal-type breast cancer finally had a MX-BCT turnover rate of 52% (p = 0.561 versus lobular) and a BCT-MX turnover rate of 15% (p = 0.933 versus lobular). Secondary MX after initial BCT was necessary in 2% (ductal) and 10% (lobular, p = 0.110). There was no difference in local recurrence in lobular- as compared with ductal-type breast cancer patients after BCT (2.7% versus 10%, p = 0.135), nor was a difference seen in lobular breast cancer patients when comparing BCT with MX (2.7% versus 3.4%, p = 0.795). Tumor type was not an independent predictor for either BCT or local recurrence. CONCLUSION We do not suggest excluding patients with lobular-type breast cancer who are primarily scheduled for MX from nCT, since BCT rates may still increase by 45% without influencing the oncologic outcome.
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Affiliation(s)
- Florian Fitzal
- Department of Surgery, Breast Health Care Center, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria.
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Re-resection rates after breast-conserving surgery as a performance indicator. Eur J Surg Oncol 2011; 37:357-63. [DOI: 10.1016/j.ejso.2011.01.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 12/29/2010] [Accepted: 01/06/2011] [Indexed: 11/22/2022] Open
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The neoadjuvant approach in breast cancer treatment: it is not just about chemotherapy anymore. Curr Opin Obstet Gynecol 2011; 23:31-6. [PMID: 21124221 DOI: 10.1097/gco.0b013e3283416477] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Although the use of neoadjuvant chemotherapy (NCT) in breast cancer was once reserved for patients with locally advanced disease or inflammatory breast cancers, it is increasingly used in patients with early-stage tumors. This review outlines the pertinent research in the field over the last year and discusses the clinical implications. RECENT FINDINGS The present review will focus on three evolving areas in the neoadjuvant research field: factors determining response, use of endocrine and biologic therapies, and how to manage patients following response. SUMMARY NCT in breast cancer is a remarkable research platform providing insight into tumor biology and treatment efficacy in an expedited timeframe. Refining patient selection based on tumor and patient characteristics allows clinicians to limit potentially toxic therapy to those patients expected to receive the greatest benefit. Additionally, exploring new agents and sequencing of regimens based on these characteristics has great potential for impacting local-regional and systemic outcomes. Lastly, as the population of patients undergoing NCT grows, we must constantly adjust our treatment paradigms. We need to monitor them carefully and accurately, understand the implication of a treated tumor for future therapy, and determine how much additional therapy is necessary.
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Kennedy S, Geradts J, Bydlon T, Brown JQ, Gallagher J, Junker M, Barry W, Ramanujam N, Wilke L. Optical breast cancer margin assessment: an observational study of the effects of tissue heterogeneity on optical contrast. Breast Cancer Res 2010; 12:R91. [PMID: 21054873 PMCID: PMC3046432 DOI: 10.1186/bcr2770] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 10/05/2010] [Accepted: 11/05/2010] [Indexed: 01/06/2023] Open
Abstract
Introduction Residual cancer following breast conserving surgery increases the risk of local recurrence and mortality. Margin assessment presents an unmet clinical need. Breast tissue is markedly heterogeneous, which makes distinguishing small foci of cancer within the spectrum of normal tissue potentially challenging. This is further complicated by the heterogeneity as a function of menopausal status. Optical spectroscopy can provide surgeons with intra-operative diagnostic tools. Here, we evaluate ex-vivo breast tissue and determine which sources of optical contrast have the potential to detect malignancy at the margins in women of differing breast composition. Methods Diffuse reflectance spectra were measured from 595 normal and 38 malignant sites from the margins of 104 partial mastectomy patients. All statistical tests were performed using Wilcoxon Rank-Sum tests. Normal and malignant sites were compared before stratifying the data by tissue type and depth and computing statistical differences. The frequencies of the normal tissue types were separated by menopausal status and compared to the corresponding optical properties. Results The mean reduced scattering coefficient, < μs' >, and concentration of total hemoglobin, [THb]), showed statistical differences between malignant (< μs' > : 8.96 cm-1 ± 2.24MAD, [THb]: 42.70 μM ± 29.31MAD) compared to normal sites (< μs' > : 7.29 cm-1 ± 2.15MAD, [THb]: 32.09 μM ± 16.73MAD) (P < 0.05). The sites stratified according to normal tissue type (fibro-glandular (FG), fibro-adipose (FA), and adipose (A)) or disease type (invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS)) showed that FG exhibited increased < μs' > and A showed increased [β-carotene] within normal tissues. Scattering differentiated between most malignant sites, DCIS (9.46 cm-1 ± 1.06MAD) and IDC (8.00 cm-1 ± 1.81MAD), versus A (6.50 cm-1 ± 1.95MAD). [β-carotene] showed marginal differences between DCIS (19.00 μM ± 6.93MAD, and FG (15.30 μM ± 5.64MAD). [THb] exhibited statistical differences between positive sites (92.57 μM ± 18.46MAD) and FG (34.12 μM ± 22.77MAD), FA (28.63 μM ± 14.19MAD), and A (30.36 μM ± 14.86MAD). The diagnostic ability of the optical parameters was affected by distance of tumor from the margin as well as menopausal status. Due to decreased fibrous content and increased adipose content, normal sites in post-menopausal patients exhibited lower < μs' >, but higher [β-carotene] than pre-menopausal patients. Conclusions The data indicate that the ability of an optical parameter to differentiate benign from malignant breast tissues may be dictated by patient demographics. Scattering differentiated between malignant and adipose sites and would be most effective in post-menopausal women. [β-carotene] or [THb] may be more applicable in pre-menopausal women to differentiate malignant from fibrous sites. Patient demographics are therefore an important component to incorporate into optical characterization of breast specimens.
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Affiliation(s)
- Stephanie Kennedy
- Department of Biomedical Engineering, Duke University, Durham, NC 27708, USA.
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Purushotham A, Pinder S, Cariati M, Harries M, Goldhirsch A. Neoadjuvant Chemotherapy: Not the Best Option in Estrogen Receptor–Positive, HER2-Negative, Invasive Classical Lobular Carcinoma of the Breast? J Clin Oncol 2010; 28:3552-4. [DOI: 10.1200/jco.2009.27.8184] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Arnie Purushotham
- King's College London and Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | - Sarah Pinder
- King's College London and Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
| | | | - Mark Harries
- Guy's and St Thomas's NHS Foundation Trust, London, United Kingdom
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Silberfein EJ, Hunt KK, Broglio K, Shen J, Sahin A, Le-Petross H, Oh J, Litton J, Hwang RF, Mittendorf EA. Clinicopathologic factors associated with involved margins after breast-conserving surgery for invasive lobular carcinoma. Clin Breast Cancer 2010; 10:52-8. [PMID: 20133259 DOI: 10.3816/cbc.2010.n.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Obtaining negative margins for patients undergoing breast-conserving surgery (BCS) for invasive lobular carcinoma (ILC) can be difficult because of the unique histologic pattern of ILC. Our goal was to determine whether any specific patient- or disease-related factors influenced margin status. PATIENTS AND METHODS We retrospectively reviewed 211 patients with ILC treated from 1994 through 2004 to determine if specific clinical and pathologic factors influenced the ability to obtain negative margins. RESULTS We identified 110 patients (52%) who underwent total mastectomy and 101 (48%) who underwent BCS. Among patients who underwent BCS, 50 (50%) had close or positive margins. Patients with close or positive margins were more likely to have architectural distortion on ultrasonography (vs. mass or calcifications; P = .049), to have undergone excisional biopsy (vs. core or fine-needle aspiration; P = .008), and to have associated ductal carcinoma in situ (P = .021). On multivariate analysis, only biopsy method retained significance (P = .006). CONCLUSION Core needle biopsy is the preferred method of diagnostic biopsy before surgical intervention. With appropriate patient selection, most patients with early-stage ILC can undergo successful BCS.
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Affiliation(s)
- Eric J Silberfein
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Rapid noninvasive optical imaging of tissue composition in breast tumor margins. Am J Surg 2009; 198:566-74. [PMID: 19800470 DOI: 10.1016/j.amjsurg.2009.06.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 06/30/2009] [Accepted: 06/30/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND In women undergoing breast conserving surgery (BCS), up to 60% can require re-excision. Our objective is to develop an optically based technology which can differentiate benign from malignant breast tissues intraoperatively through differences in tissue composition factors. METHODS A prospective study of optical imaging of BCS margins is being performed. Optical images are transformed into tissue composition maps with parameters of total hemoglobin concentration, b-carotene concentration and scattering. The predicted outcome is then compared to the margin-level pathology. RESULTS Fifty-five margins from 48 patients have undergone assessment. Within 34 specimens with pathologically confirmed positive margins, the ratio map of b-carotene/scattering showed the most significant difference reflecting a decrease in adipose and an increase in cell density within malignant margins (p=.002). These differences were notable in both in-situ and invasive disease. CONCLUSIONS We present a novel optical spectral imaging device that provides a rapid, non-destructive assay of the tissue composition of breast tumor margins.
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Povoski SP, Jimenez RE, Wang WP, Xu RX. Standardized and reproducible methodology for the comprehensive and systematic assessment of surgical resection margins during breast-conserving surgery for invasive breast cancer. BMC Cancer 2009; 9:254. [PMID: 19635166 PMCID: PMC2724549 DOI: 10.1186/1471-2407-9-254] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Accepted: 07/27/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The primary goal of breast-conserving surgery (BCS) is to completely excise the tumor and achieve "adequate" or "negative" surgical resection margins while maintaining an acceptable level of postoperative cosmetic outcome. Nevertheless, precise determination of the adequacy of BCS has long been debated. In this regard, the aim of the current paper was to describe a standardized and reproducible methodology for comprehensive and systematic assessment of surgical resection margins during BCS. METHODS Retrospective analysis of 204 BCS procedures performed for invasive breast cancer from August 2003 to June 2007, in which patients underwent a standard BCS resection and systematic sampling of nine standardized re-resection margins (superior, superior-medial, superior-lateral, medial, lateral, inferior, inferior-medial, inferior-lateral, and deep-posterior). Multiple variables (including patient, tumor, specimen, and follow-up variables) were evaluated. RESULTS 6.4% (13/204) of patients had positive BCS specimen margins (defined as tumor at inked edge of BCS specimen) and 4.4% (9/204) of patients had close margins (defined as tumor within 1 mm or less of inked edge but not at inked edge of BCS specimen). 11.8% (24/204) of patients had at least one re-resection margin containing additional disease, independent of the status of the BCS specimen margins. 7.1% (13/182) of patients with negative BCS specimen margins (defined as no tumor cells seen within 1 mm or less of inked edge of BCS specimen) had at least one re-resection margin containing additional disease. Thus, 54.2% (13/24) of patients with additional disease in a re-resection margin would not have been recognized by a standard BCS procedure alone (P < 0.001). The nine standardized resection margins represented only 26.8% of the volume of the BCS specimen and 32.6% of the surface area of the BCS specimen. CONCLUSION Our methodology accurately assesses the adequacy of surgical resection margins for determination of which individuals may need further resection to the affected breast in order to minimize the potential risk of local recurrence while attempting to limit the volume of additional breast tissue excised, as well as to determine which individuals are not realistically amendable to BCS and instead need a completion mastectomy to successfully remove multifocal disease.
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Affiliation(s)
- Stephen P Povoski
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, 43210, USA
| | - Rafael E Jimenez
- Department of Pathology, The Ohio State University, Columbus, Ohio, 43210, USA
- Current address : Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, 55905, USA
| | - Wenle P Wang
- Department of Pathology, The Ohio State University, Columbus, Ohio, 43210, USA
- Current address : Department of Pathology, VA Medical Center at Baltimore, Baltimore, Maryland, 21201, USA
| | - Ronald X Xu
- Department of Biomedical Engineering, The Ohio State University, Columbus, Ohio, 43210, USA
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Gnant M. To measure the unmeasurable. World J Surg 2008; 33:52-3. [PMID: 19015915 DOI: 10.1007/s00268-008-9801-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Michael Gnant
- Department of Surgery, Medical University of Vienna, Austrian Breast and Colorectal Cancer Study Group, A-1090 Vienna, Waehringer, Guertel, 18-20, Austria.
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