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Mo KC, Ortiz-Babilonia C, Musharbash FN, Raad M, Aponte JS, Neuman BJ, Jain A, Kebaish KM. Inflation-adjusted medicare physician reimbursement for adult spinal deformity surgery substantially declined from 2002 to 2020. Spine Deform 2024; 12:263-270. [PMID: 38036867 DOI: 10.1007/s43390-023-00779-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/14/2023] [Indexed: 12/02/2023]
Abstract
PURPOSE Physician fees for orthopaedic surgeons by the Centers for Medicare and Medicaid Services (CMS) are increasingly scrutinized. The present retrospective review aims to assess whether adult spinal deformity (ASD) surgeries are properly valued for Medicare reimbursement. METHODS Current Procedural Terminology (CPT) codes related to posterior fusion of spinal deformity of ≤ 6, 7-12, and ≥ 13 vertebral levels, as well as additional arthrodesis and osteotomy levels, were assessed for (1) Compound annual growth rate (CAGR) from 2002 to 2020, calculated using physician fee data from the CMS Physician Fee Schedule Look-Up Tool; and (2) work relative value units (RVUs) per operative minute, using data from the National Surgical Quality Improvement Program. RESULTS From 2002 to 2020, all CPT codes for ASD surgery had negative inflation-adjusted CAGRs (range, - 18.49% to - 27.66%). Mean physician fees for spinal fusion declined by 26.02% (CAGR, - 1.66%) in ≤ 6-level fusion, 27.91% (CAGR, - 1.80%) in 7- to 12-level fusion, and 28.25% (CAGR, - 1.83%) ≥ 13-level fusion. Fees for both 7-12 (P < 0.00001) and ≥ 13 levels (P < 0.00001) declined more than those for fusion of ≤ 6 vertebral levels. RVU per minute was lower for 7- to 12-level and ≥ 13-level (P < 0.00001 for both) ASD surgeries than for ≤ 6-level. CONCLUSIONS Reimbursement for ASD surgery declined overall. CAGR for fusions of ≥ 7 levels were lower than those for fusions of ≤ 6 levels. For 2012-2018, ≥ 7-level fusions had lower RVU per minute than ≤ 6-level fusions. Revaluation of Medicare reimbursement for longer-level ASD surgeries may be warranted. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kevin C Mo
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Carlos Ortiz-Babilonia
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Farah N Musharbash
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Juan Silva Aponte
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, JHOC 5223, Baltimore, MD, 21287, USA.
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McLeod M, Leung K, Pramesh CS, Kingham P, Mutebi M, Torode J, Ilbawi A, Chakowa J, Sullivan R, Aggarwal A. Quality indicators in surgical oncology: systematic review of measures used to compare quality across hospitals. BJS Open 2024; 8:zrae009. [PMID: 38513280 PMCID: PMC10957165 DOI: 10.1093/bjsopen/zrae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/16/2023] [Accepted: 12/17/2023] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Measurement and reporting of quality indicators at the hospital level has been shown to improve outcomes and support patient choice. Although there are many studies validating individual quality indicators, there has been no systematic approach to understanding what quality indicators exist for surgical oncology and no standardization for their use. The aim of this study was to review quality indicators used to assess variation in quality in surgical oncology care across hospitals or regions. It also sought to describe the aims of these studies and what, if any, feedback was offered to the analysed groups. METHODS A literature search was performed to identify studies published between 1 January 2000 and 23 October 2023 that applied surgical quality indicators to detect variation in cancer care at the hospital or regional level. RESULTS A total of 89 studies assessed 91 unique quality indicators that fell into the following Donabedian domains: process indicators (58; 64%); outcome indicators (26; 29%); structure indicators (6; 7%); and structure and outcome indicators (1; 1%). Purposes of evaluating variation included: identifying outliers (43; 48%); comparing centres with a benchmark (14; 16%); and supplying evidence of practice variation (29; 33%). Only 23 studies (26%) reported providing the results of their analyses back to those supplying data. CONCLUSION Comparisons of quality in surgical oncology within and among hospitals and regions have been undertaken in high-income countries. Quality indicators tended to be process measures and reporting focused on identifying outlying hospitals. Few studies offered feedback to data suppliers.
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Affiliation(s)
- Megan McLeod
- Department of Health Policy, London School of Economics and Political Science, London, UK
- Department of Otolaryngology—Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kari Leung
- Department of Oncology, Guy’s & St Thomas’ NHS Trust, London, UK
| | - C S Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Miriam Mutebi
- Department of Surgery, Aga Khan University, Nairobi, Kenya
| | - Julie Torode
- Institute of Cancer Policy, Centre for Cancer, Society & Public Health, King’s College London, London, UK
| | - Andre Ilbawi
- Department of Universal Health Coverage, World Health Organization, Geneva, Switzerland
| | | | - Richard Sullivan
- Institute of Cancer Policy, Global Oncology Group, Centre for Cancer, Society & Public Health, King’s College London, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Bhimani F, Lin S, McEvoy M, Cavalli A, Obaid L, Chen Y, Gupta A, Pastoriza J, Shihabi A, Feldman S. Does Nipple-Ward Positive Margin Contribute to a Higher Rate of Re-Excision Procedures After a Lumpectomy with Pathology-Confirmed Positive Margins? A Retrospective Study. BREAST CANCER (DOVE MEDICAL PRESS) 2024; 16:41-50. [PMID: 38405107 PMCID: PMC10894517 DOI: 10.2147/bctt.s425863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/10/2023] [Indexed: 02/27/2024]
Abstract
Background Positive margins on lumpectomy specimens are associated with a twofold increased risk of local breast tumor recurrence. Prior literature has demonstrated various techniques and modalities for assessing margin status to reduce re-excision rates. However, there is paucity of literature analyzing which margin contributes to the highest re-excision rates. Therefore, the primary aim of the study was to investigate whether the nipple-ward margins resulted in a higher rate of re-excision in our patient population. Methods A retrospective chart review was performed on patients who had re-excision surgery. Nipple-ward margin was identified by correlating radiological and pathological reports. A cut-off of more than 25% was used to demonstrate correlation between nipple-ward margin and re-excision rate. Results A total of 98 patients' data were analyzed, with 41 (41.8%), 14 (14.3%), 5 (5.1%), and 38 (38.8%) diagnosed with DCIS, IDC, ILC, and mixed pathology on their margins, respectively. Overall, 48% (n=47) of the positive margins were nipple-ward, with 44.7% (n=21) reporting DCIS. Upon stratification, 45 (45.9%) cases were single-margin positive, with 26 (57.8%) being nipple-ward. Furthermore, the remaining 53 (54.1%) patients had multiple positive margins, with 21 (39.6.7%) nipple-ward cases. Conclusion Positive nipple-ward margins significantly contribute to a higher re-excision rate p < 0.001; 48% of re-excision surgeries had positive nipple-ward margins, and 57.8% of positive single-margin cases were nipple-ward. Taking an additional shave during initial lumpectomy decreases re-excision rates. However, planning a lumpectomy procedure with a more elliptical rather than a spherical resection with additional cavity shave (ie, larger volume) in the nipple-ward direction and minimizing the remaining cavity shaves so the total volume resected remains unchanged. Nevertheless, future studies with larger sample sizes are required to bolster our findings.
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Affiliation(s)
- Fardeen Bhimani
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
| | - Sophie Lin
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
| | - Maureen McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Liane Obaid
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Yu Chen
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
| | - Anjuli Gupta
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jessica Pastoriza
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Areej Shihabi
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, New York, USA
- Albert Einstein College of Medicine, Bronx, New York, USA
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Garg N, Thorat MA. Letter to the Editor: Cost-Efficacy Analysis of Use of Frozen Section Histology for Margin Assessment During Breast Conservation Surgery in Breast Cancer Patients. World J Surg 2023; 47:3451-3452. [PMID: 37782394 DOI: 10.1007/s00268-023-07186-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Nidhi Garg
- Breast Services, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mangesh A Thorat
- Breast Services, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.
- Cancer Prevention Unit, Centre for Cancer Prevention, Detection and Diagnosis, Wolfson Institute of Population Health, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
- School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
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Kong J, Bandyopadhyay S, Chen W, Al-Mufarrej F, Choi L, Kosir MA. Improved Rate of Negative Margins for Inflammatory Breast Cancer Using Intraoperative Frozen Section Analysis. Cancers (Basel) 2023; 15:4597. [PMID: 37760566 PMCID: PMC10526412 DOI: 10.3390/cancers15184597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer with a poor survival rate. Modified radical mastectomy (MRM) with negative pathologic margins is critical for improved survival. We aim to study the potential benefit of intraoperative frozen section analysis (FSA) to improve disease-free margins. METHODS This prospective, monocentric study included 19 patients who underwent MRM for IBC. For each patient, a 2 mm continuous skin edge was sent for FSA to guide further resection. The rate of tumor-free margins and the concurrence between the FSA and permanent pathological results were analyzed. RESULTS Overall, 15 of the 19 patients achieved negative margins, including four patients who would have had positive margins without FSA. The odds ratio of achieving a negative final margin with FSA was infinity (p = 0.031), and there was a strong agreement between the FSA and permanent pathological results (Kappa-0.83; p < 0.0001). CONCLUSIONS The FSA technique decreased the number of positive margins in IBC patients undergoing MRM, thereby potentially reducing the need for re-operation, allowing immediate wound closure, and preventing delays in the administration of adjuvant radiation therapy. More extensive trials are warranted to establish the use of intraoperative FSA in IBC treatment.
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Affiliation(s)
- Joshua Kong
- Department of Surgery, Wayne State University, 4160 John R, Suite 400, Detroit, MI 48201, USA
| | - Sudeshna Bandyopadhyay
- Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201, USA (W.C.)
- Department of Pathology, Wayne State University, 540 E. Canfield, Ste. 9374, Detroit, MI 48201, USA
| | - Wei Chen
- Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201, USA (W.C.)
| | - Faisal Al-Mufarrej
- Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201, USA (W.C.)
- Division of Plastic Surgery, Department of Surgery, Wayne State University, 4160 John R, Suite 400, Detroit, MI 48201, USA
| | - Lydia Choi
- Department of Surgery, Wayne State University, 4160 John R, Suite 400, Detroit, MI 48201, USA
- Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201, USA (W.C.)
| | - Mary A. Kosir
- Department of Surgery, Wayne State University, 4160 John R, Suite 400, Detroit, MI 48201, USA
- Karmanos Cancer Institute, 4100 John R, Detroit, MI 48201, USA (W.C.)
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Casey VJ, McNamara LM. Instrumental in Surgery: A Narrative Review on Energy-based Surgical Cutting Devices and Surgical Smoke. Ann Surg 2023; 278:e457-e465. [PMID: 36762559 PMCID: PMC10414159 DOI: 10.1097/sla.0000000000005816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
OBJECTIVE To provide an informed understanding of existing energy-based surgical cutting technologies and aerosol-generating surgical procedures. We provide a perspective on the future innovation and research potential in this space for the benefit of surgeons, physicians, engineers, and researchers alike. BACKGROUND Surgery is a treatment for many medical conditions, the success of which depends on surgical cutting instruments that enable surgeons to conduct surgical procedures for tissue cutting and manipulation. Energy-based surgical cutting tools improve accuracy and limit unnecessary destruction of healthy tissues and cells, but can generate surgical smoke and aerosols, which can be handled using surgical smoke evacuation technology. METHODS A narrative review was conducted to explore existing literature describing the history and development of energy-based surgical instruments, their mechanisms of action, aerosol-generating medical procedures, surgical smoke and aerosols from aerosol-generating medical procedures, and the recommended mitigation strategies, as well as research on rapid biological tissue analyzing devices to date. CONCLUSIONS Smoke evacuation technology may provide diagnostic information regarding tissue pathology, which could eliminate health concerns and revolutionize surgical accuracy. However, further research into surgical smoke is required to quantify the measurable risk to health it poses, the cutting conditions, under which it is generated and to develop advanced diagnostic approaches using this information.
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Affiliation(s)
- Vincent J. Casey
- Mechanobiology and Medical Devices Research Group (MMDRG), Biomedical Engineering, University of Galway, Ireland
- CÚRAM, SFI Research Centre for Medical Devices, Galway, Ireland
| | - Laoise M. McNamara
- Mechanobiology and Medical Devices Research Group (MMDRG), Biomedical Engineering, University of Galway, Ireland
- CÚRAM, SFI Research Centre for Medical Devices, Galway, Ireland
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Woon CY, Goh SSN, Soh LS, Yeo CFC, Ong MW, Wong B, Leong JHT, Goo JTT, Chia CLK. Surgical margins assessment reduces re-excision rates in breast-conserving surgery. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023. [DOI: 10.47102/annals-acadmedsg.2021454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Koppiker C, Joshi S, Mishra R, Kelkar DA, Chigurupati P, Joshi A, John J, Kadu S, Bagdia A, Thakkar D, Deshmukh C, Allampati H, Sharan G, Dhar U, Nare S, Nagarkar S, Busheri L, Varghese B, Pai M. Therapeutic mammoplasty: a "wise" oncoplastic choice-lessons from the largest single-center cohort from Asia. Front Oncol 2023; 13:1131951. [PMID: 37124516 PMCID: PMC10141318 DOI: 10.3389/fonc.2023.1131951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/06/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction The majority of breast cancer patients from India usually present with advanced disease, limiting the scope of breast conservation surgery. Therapeutic mammoplasty (TM), an oncoplastic technique that permits larger excisions, is quite promising in such a scenario and well suited to breast cancer in medium-to-large-sized breasts with ptosis and in some cases of large or multifocal/multicentric tumors. Here, we describe our TM cohort of 205 (194 malignant and 11 benign) patients from 2012 to 2019 treated at a single surgeon center in India, the largest Asian dataset for TM. Methods All patients underwent treatment after careful discussions by a multidisciplinary tumor board and patient counseling. We report the clinicopathological profiles and surgical, oncological, cosmetic, and patient-related outcomes with different TM procedures. Results The median age of breast cancer patients was 49 years; that of benign disease patients was 41 years. The breast cancer cohort underwent simple (n = 84), complex (n = 71), or extreme (n = 44) TM surgeries. All resection margins were analyzed through intra-operative frozen-section assessment with stringent rad-path analysis protocols. The margin positivity rate was found to be 1.4%. A majority of the cohort was observed to have pT1-pT2 tumors, and the median resection volume was 180 cc. Low post-operative complication rates and good-to-excellent cosmetic scores were observed. The median follow-up was 39 months. We observed 2.07% local and 5.7% distal recurrences, and disease-specific mortality was 3.1%. At median follow-up, the overall survival was observed to be 95.9%, and disease-free survival was found to be 92.2%. The patient-reported outcome measures (PROMs) showed good-to-excellent scores for all types of TMs across BREAST-Q domains. Conclusion We conclude that in India, a country where women present with large and locally advanced tumors, TM safely expands the indications for breast conservation surgery. Our results show oncological and cosmetic outcomes at acceptable levels. Most importantly, PROM scores suggest improved overall wellbeing and better satisfaction with the quality of life. For patients with macromastia, this technique not only focuses on cancer but also improves self-image and reduces associated physical discomfort often overlooked by women in the Indian setting. The popularization of this procedure will enable Indian patients with breast cancer to receive the benefits of breast conservation.
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Affiliation(s)
- Chaitanyanand Koppiker
- Orchids Breast Health Centre, Prashanti Cancer Care Mission, Pune, India
- Centre for Translational Cancer Research: A Joint Initiative of Indian Institute of Science Education and Research (IISER), Pune and Prashanti Cancer Care Mission (PCCM), Pune, India
- International School of Oncoplastic Surgery, Pune, India
- Jehangir Hospital, Pune, India
- *Correspondence: Chaitanyanand Koppiker,
| | - Sneha Joshi
- Centre for Translational Cancer Research: A Joint Initiative of Indian Institute of Science Education and Research (IISER), Pune and Prashanti Cancer Care Mission (PCCM), Pune, India
| | - Rupa Mishra
- Centre for Translational Cancer Research: A Joint Initiative of Indian Institute of Science Education and Research (IISER), Pune and Prashanti Cancer Care Mission (PCCM), Pune, India
| | - Devaki A. Kelkar
- Centre for Translational Cancer Research: A Joint Initiative of Indian Institute of Science Education and Research (IISER), Pune and Prashanti Cancer Care Mission (PCCM), Pune, India
| | | | - Anjali Joshi
- Centre for Translational Cancer Research: A Joint Initiative of Indian Institute of Science Education and Research (IISER), Pune and Prashanti Cancer Care Mission (PCCM), Pune, India
| | - Jisha John
- Centre for Translational Cancer Research: A Joint Initiative of Indian Institute of Science Education and Research (IISER), Pune and Prashanti Cancer Care Mission (PCCM), Pune, India
| | - Shweta Kadu
- Centre for Translational Cancer Research: A Joint Initiative of Indian Institute of Science Education and Research (IISER), Pune and Prashanti Cancer Care Mission (PCCM), Pune, India
| | | | - Deepti Thakkar
- International School of Oncoplastic Surgery, Pune, India
| | - Chetan Deshmukh
- Orchids Breast Health Centre, Prashanti Cancer Care Mission, Pune, India
| | | | - Gautam Sharan
- Department of Radiation Oncology, Inlaks and Budhrani Hospital, Pune, India
| | - Upendra Dhar
- Orchids Breast Health Centre, Prashanti Cancer Care Mission, Pune, India
- Jehangir Hospital, Pune, India
| | - Smeeta Nare
- Orchids Breast Health Centre, Prashanti Cancer Care Mission, Pune, India
- Centre for Translational Cancer Research: A Joint Initiative of Indian Institute of Science Education and Research (IISER), Pune and Prashanti Cancer Care Mission (PCCM), Pune, India
| | - Sanket Nagarkar
- Centre for Translational Cancer Research: A Joint Initiative of Indian Institute of Science Education and Research (IISER), Pune and Prashanti Cancer Care Mission (PCCM), Pune, India
| | - Laleh Busheri
- Orchids Breast Health Centre, Prashanti Cancer Care Mission, Pune, India
| | - Beenu Varghese
- Orchids Breast Health Centre, Prashanti Cancer Care Mission, Pune, India
| | - Mugdha Pai
- Orchids Breast Health Centre, Prashanti Cancer Care Mission, Pune, India
- Centre for Translational Cancer Research: A Joint Initiative of Indian Institute of Science Education and Research (IISER), Pune and Prashanti Cancer Care Mission (PCCM), Pune, India
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Automated breast ultrasound (ABUS) for intraoperative margin control on surgical specimens in breast conserving surgery. Arch Gynecol Obstet 2022; 307:1949-1955. [PMID: 36503976 DOI: 10.1007/s00404-022-06837-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 10/23/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE As breast-conserving surgery (BCS) has become the standard for treatment of early breast cancer, the need for new technologies to improve intraoperative margin assessment has become clear. Close or positive margins during BCS lead to additional surgeries, treatment delay, additional stress for patients and increasing healthcare cost. Automated three-dimensional breast ultrasound (ABUS) systems are meant to overcome the shortcomings of hand-held ultrasound (HHUS). In this study, we investigate the feasibility of ABUS to conduct ultrasound on surgical specimens in breast conserving therapy. METHODS In this monocentric, non-interventional study, specimens of 40 women were examined via ABUS. A construction with isotonic saline solution, gel pads and ABUS membranes was invented by our team to produce images of breast cancer specimens using ABUS. Evaluation of the ABUS images was carried out by two independent physicians trained on ABUS evaluation. RESULTS ABUS was conducted on 40 specimens. 90% of the generated images were of high quality. Measured tumor sizes with ABUS were bigger than measured tumor size with HHUS (mean tumor size 22.9 vs. 18.1 mm, CI 2.38-7.35, p < 0.05). The mean difference between the ABUS tumor size and the pathological tumor size was 1.8 mm (CI - 0.84-4.53, p = 0.17). The mean difference between the HHUS tumor size and the pathological tumor size was 3.2 mm (CI - 5.35 to - 1.03, p = 0.005). CONCLUSION ABUS seems to be a suitable method to conduct specimen ultrasound. Further studies are required to evaluate the accuracy of ABUS for intraoperative margin assessment and possible implementation in clinical work routine.
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De la Flor M, Delgado C, Martínez S, Arenas M, Gómez M, Reig R. Rate of effect of surgical margins after breast conserving surgery and estimation of direct costs. Cir Esp 2022; 100:702-708. [PMID: 35850474 DOI: 10.1016/j.cireng.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/13/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Assessment of the reoperation rate in patients with positive resection margins after initial breast-conserving surgery for breast cancer and estimation of the cost to the hospital. METHOD 146 patients with diagnosis of invasive breast cancer were included, who were initially intervened with conservative surgery by the Gynecology and Obstetrics Service of Hospital Universitario de Tarragona Juan XXIII (HUTJ23) during the years 2018 and 2019. We calculated the rate of involvement of the surgical margins of the resection piece after initial conservative surgery, establishing in which cases it was necessary to carry out a second resection, estimating the added direct costs of the second surgical procedure, and comparing them with the costs established by the Catalan Health Service according to the level of the hospital and the Diagnosis-Related Groups (DRG) established by the National Health System. RESULTS The rate of positive margins after initial conservative surgery was 20.55% and 19.17% patients underwent reoperation, generating a total expense of € 129,696.89, € 82,654.34 in conservative surgeries (€ 3757.01 on average per patient) and € 47,042.55 in mastectomies (€ 6720.36 on average per patient). CONCLUSIONS Margin involvement after breast-conserving surgery is synonymous for reoperation, this involves a series of direct costs. It is advisable to control the factors related to affected margins to minimize their impact.
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Affiliation(s)
- Miriam De la Flor
- Unidad de Patología Mamaria, Servicio de Ginecología y Obstetricia, H.U. Tarragona Joan XXIII, URV, Tarragona, Spain.
| | - Cinthia Delgado
- Departamento de Medicina y Cirugía, Universitat Rovira i Virgili, Tarragona, Spain
| | - Salomé Martínez
- Unidad de Patología Mamaria, Servicio de Anatomía Patológica, H.U. Tarragona Joan XXIII, URV, Tarragona, Spain
| | - Meritxell Arenas
- Unidad de Patología Mamaria, Servicio de Oncología Radioterápica, H.U. Sant Joan Reus, URV, Tarragona, Spain
| | - María Gómez
- Unidad de Patología Mamaria, Servicio de Oncología Radioterápica, H.U. Sant Joan Reus, URV, Tarragona, Spain
| | - Rosaura Reig
- Dirección Médica, H.U. Tarragona Joan XXIII, Tarragona, Spain
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Evolution of Frozen Section in Carcinoma Breast: Systematic Review. Int J Breast Cancer 2022; 2022:4958580. [PMID: 35655582 PMCID: PMC9152418 DOI: 10.1155/2022/4958580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 03/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background. The frozen section (FS) has been a good technique in surgical management of breast lesions since many years. But complete agreement and cooperation have not been achieved everywhere among surgeons and pathologists especially in the developing countries. FS undergoes continuous criticism due to various shortcomings but continued to be evaluated especially in developing countries. Objectives. This review was conducted to synthesize information on the use of frozen section in carcinoma breast. Data Sources. The MEDLINE database for frozen section since its origin and its implication in recent breast surgery techniques was studied. Study Eligibility Criteria. Sixty-five articles were reviewed with complete analysis on FS in both benign and malignant breast lesions. Study Appraisal and Synthesis Methods. The analysis of frozen section was done as a diagnostic tool in breast lesions, margin status in breast conservative surgery in carcinoma breast, and sentinel lymph node and use of immunohistochemistry for sentinel lymph node FS. Results. It was analysed that the FS gives accurate results in margin status analysis, decreasing rerecurrence. Conclusion. The accuracy of FSA, low recurrence rate, avoidance of reoperation, and good cosmesis are the key points of its use in breast conservative surgery. Its use in sentinel lymph node biopsy (SLNB) is equivocal. However, application of immunohistochemistry on frozen section of SLNB is an evolving trend in today’s era.
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Kubo A, Tanei T, R Pradipta A, Morimoto K, Fujii M, Sota Y, Miyake T, Kagara N, Shimoda M, Naoi Y, Motoyama Y, Morii E, Tanaka K, Shimazu K. Comparison of “click-to-sense” assay with frozen section analysis using simulated surgical margins in breast cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1520-1526. [DOI: 10.1016/j.ejso.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/18/2022] [Accepted: 04/07/2022] [Indexed: 10/18/2022]
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Omidifar N, Chogani E, Zangouri V, Keshavarz K, Talei A. Cost-Effectiveness Analysis of Intraoperative Frozen Section in Women with Breast Cancer: Evidence from South of Iran. IRANIAN JOURNAL OF MEDICAL SCIENCES 2022; 47:143-151. [PMID: 35291436 PMCID: PMC8919313 DOI: 10.30476/ijms.2021.88887.1960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/08/2021] [Accepted: 03/13/2021] [Indexed: 11/04/2022]
Abstract
Background Breast cancer is one of the most prevalent malignancies in women worldwide, and the rate of breast cancer is increasing among Iranian women. The purpose of this study is to determine the cost-effectiveness of intraoperative frozen section analysis in women with breast cancer. Methods This study was a cost-effectiveness analysis, which was implemented as a cross-sectional study from a societal perspective. In this case, total direct and indirect costs were calculated, and the study outcome was involved in preventing reoperation. A data collection form has been used to collect the cost and effectiveness data. The sample size was comprised of all the patients referred to the hospitals of Shiraz University of Medical Sciences for breast cancer surgery in 2019. The patients were studied in two different groups, including individuals who received frozen counseling during surgery, and individuals who did not receive it. A one-way sensitivity analysis was performed for this case. Moreover, the Tree Age and Microsoft Excel Software were employed for analyzing processes. Results The results demonstrated that the mean costs of frozen and non-frozen patients were 4168$ and 3843$ purchasing power parity (PPP), respectively. In addition, the effectivenesses were 0.996 for the former and 0.8 for the latter. Furthermore, the incremental cost-effectiveness ratio (ICER) was 1658.2 PPP$. This issue revealed that the frozen section procedure during surgery was more cost-effective than the other case. Because, the cost-effectiveness of this option was below the threshold. Besides, the one-way sensitivity analysis confirmed the robustness of the study results. Conclusion The results showed that performing frozen sections during surgery in women with breast cancer was more cost-effective than ignoring them. Indeed, the frozen section can prevent the costs of subsequent reoperations.
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Affiliation(s)
- Navid Omidifar
- Department of Pathology, School of Medicine, Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elham Chogani
- Student Research Committee, Department of Health Economics, School of Management and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vahid Zangouri
- Department of Surgery, School of Medicine, Breast Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Khosro Keshavarz
- Health Human Resources Research Center, School of Management and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abdolrasoul Talei
- Department of Surgery, School of Medicine, Breast Diseases Research Center, Shahid Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Yoo TK, Kang YJ, Jeong J, Song JY, Kang SH, Lee HY, Kim ET, Yi O, Lee HB, Choi S, Park HS, Gwak G, Kim JI, Kim MK, Lee J, Kang HJ, Chae BJ. A Randomized Controlled Trial for Doing vs. Omitting Intraoperative Frozen Section Biopsy for Resection Margin Status in Selected Patients Undergoing Breast-Conserving Surgery (OFF-MAP Trial). J Breast Cancer 2022; 24:569-577. [PMID: 34979601 PMCID: PMC8724377 DOI: 10.4048/jbc.2021.24.e51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/04/2021] [Accepted: 12/06/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Intraoperative frozen section biopsy is used to reduce the margin positive rate and re-excision rate and has been reported to have high diagnostic accuracy. A majority of breast surgeons in the Republic of Korea routinely perform frozen section biopsy to assess margins intraoperatively, despite its long turnaround time and high resource requirements. This study aims to determine whether omitting frozen section biopsy for intraoperative margin evaluation in selected patients is non-inferior to performing frozen section biopsy in terms of resection margin positivity rate. Methods This study is a phase III, randomized controlled, parallel-group, multicenter non-inferiority clinical trial. Patients meeting the inclusion criteria and providing written informed consent will be randomized to the “frozen section biopsy” or “frozen section biopsy omission” group after lumpectomy. Patients with clinical stage T1–T3 disease who are diagnosed with invasive breast cancer by core-needle biopsy and plan to undergo breast-conserving surgery will be included in this study. If a daughter nodule, non-mass enhancement, or microcalcification is identified on preoperative imaging, these features must be within 1 cm of the main mass for inclusion in the trial. The target sample size is 646 patients per arm. The primary endpoint will be the resection margin positive rate, and the secondary endpoints include the reoperation rate, operating time, residual cancer after reoperation, residual cancer after re-excision according to the frozen section biopsy result, resection volume, patient quality of life, and cost-effectiveness. Discussion This is the first randomized clinical trial utilizing frozen section biopsy for intraoperative margin evaluation and aims to determine the non-inferiority of omitting frozen section biopsy in selected patients compared to performing frozen section biopsy. We expect that this trial will help surgeons perform the procedure more efficiently while ensuring patient safety. Trial Registration ClinicalTrials.gov Identifier: NCT03975179; Clinical Research Information Service Identifier: KCT0004606
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Affiliation(s)
- Tae-Kyung Yoo
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Joon Kang
- Department of Surgery, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong-Yoon Song
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Sun Hee Kang
- Department of Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Hye Yoon Lee
- Department of Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Eui Tae Kim
- Department of Surgery, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
| | - Onvox Yi
- Department of Surgery, Dongnam Institute of Radiological and Medical Science, Busan, Korea
| | - Han-Byoel Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Soojeong Choi
- Department of Surgery, Seoul Medical Center, Seoul, Korea
| | - Hyung Seok Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Geumhee Gwak
- Department of Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jae Il Kim
- Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Min Kyoon Kim
- Department of Surgery, Chung-Ang University Hospital, Seoul, Korea
| | - Jeeyeon Lee
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Hee Joon Kang
- Division of Breast and Endocrine Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Byung Joo Chae
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. ,
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15
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Masood S. The continued role of intraoperative assessment of the surgical margins in lumpectomy samples. Breast J 2021; 27:795-796. [PMID: 34761478 DOI: 10.1111/tbj.14298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Shahla Masood
- Department of Pathology and Laboratory Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
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De la Flor M, Delgado C, Martínez S, Arenas M, Gómez M, Reig R. Rate of effect of surgical margins after breast conserving surgery and estimation of direct costs. Cir Esp 2021; 100:S0009-739X(21)00244-X. [PMID: 34399974 DOI: 10.1016/j.ciresp.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Assessment of the reoperation rate in patients with positive resection margins after initial breast-conserving surgery for breast cancer and estimation of the cost to the hospital. METHOD 146 patients with diagnosis of invasive breast cancer were included, who were initially intervened with conservative surgery by the Gynecology and Obstetrics Service of Hospital Universitario de Tarragona Juan XXIII (HUTJ23) during the years 2018 and 2019. We calculated the rate of involvement of the surgical margins of the resection piece after initial conservative surgery, establishing in which cases it was necessary to carry out a second resection, estimating the added direct costs of the second surgical procedure, and comparing them with the costs established by the Catalan Health Service according to the level of the hospital and the Diagnosis-Related Groups (DRG) established by the National Health System. RESULTS The rate of positive margins after initial conservative surgery was 20.55% and 19.17% patients underwent reoperation, generating a total expense of € 129.696,89, € 82.654,34 in conservative surgeries (€ 3.757,01 on average per patient) and € 47.042,55 in mastectomies (€ 6.720,36 on average per patient). CONCLUSIONS Margin involvement after breast-conserving surgery is synonymous for reoperation, this involves a series of direct costs. It is advisable to control the factors related to affected margins to minimize their impact.
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Affiliation(s)
- Miriam De la Flor
- Unidad de Patología Mamaria, Servicio de Ginecología y Obstetricia, H.U. Tarragona Joan XXIII, URV, Tarragona, España.
| | - Cinthia Delgado
- Departamento de Medicina y Cirugía, Universitat Rovira i Virgili, Tarragona, España
| | - Salomé Martínez
- Unidad de Patología Mamaria, Servicio de Anatomía Patológica, H.U. Tarragona Joan XXIII, URV, Tarragona, España
| | - Meritxell Arenas
- Unidad de Patología Mamaria, Servicio de Oncología Radioterápica, H.U. Sant Joan Reus, URV, Tarragona, España
| | - María Gómez
- Unidad de Patología Mamaria, Servicio de Oncología Radioterápica, H.U. Sant Joan Reus, URV, Tarragona, España
| | - Rosaura Reig
- Dirección Médica, H.U. Tarragona Joan XXIII, Tarragona, España
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Pradipta AR, Tanaka K. Application of Acrolein Imines to Organic Synthesis, Biofunctional Studies, and Clinical Practice. CHEM REC 2021; 21:646-662. [PMID: 33769681 DOI: 10.1002/tcr.202000146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 03/10/2021] [Indexed: 11/12/2022]
Abstract
N-alkyl unsaturated imines derived from acrolein, a toxin produced during oxidative stress, and biogenic alkyl amines occur naturally and are considered biologically relevant compounds. However, despite the recent conceptual and technological advances in organic synthesis, research on the new reactivity of these compounds is lacking. This personal account discusses research on the reactivity that has been overlooked in acrolein imines, including the discovery of new methods to synthesize biologically active compounds, the determination of new functions of relevant imines and their precursors, i. e., aldehydes and amines, and the application of these methods for clinical diagnosis.
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Affiliation(s)
- Ambara R Pradipta
- School of Materials and Chemical Technology, Department of Chemical Science and Engineering, Tokyo Institute of Technology, 2-12-1 Ookayama, Meguro-ku, Tokyo, 152-8552, Japan
| | - Katsunori Tanaka
- School of Materials and Chemical Technology, Department of Chemical Science and Engineering, Tokyo Institute of Technology, 2-12-1 Ookayama, Meguro-ku, Tokyo, 152-8552, Japan.,Biofunctional Synthetic Chemistry Laboratory, Cluster for Pioneering Research, RIKEN 2-1 Hirosawa, Wako, Saitama, 351-0198, Japan.,Biofunctional Chemistry Laboratory, A. Butlerov Institute of Chemistry, Kazan Federal University, 18 Kremlyovskaya Street, Kazan, 420008, Russian Federation
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Garcia MT, Mota BS, Cardoso N, Martimbianco ALC, Ricci MD, Carvalho FM, Gonçalves R, Soares Junior JM, Filassi JR. Accuracy of frozen section in intraoperative margin assessment for breast-conserving surgery: A systematic review and meta-analysis. PLoS One 2021; 16:e0248768. [PMID: 33735315 PMCID: PMC7971883 DOI: 10.1371/journal.pone.0248768] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/04/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES It is well established that tumor-free margin is an important factor for reducing local recurrence and reoperation rates. This systematic review with meta-analysis of frozen section intraoperative margin assessment aims to evaluate the accuracy, and reoperation and survival rates, and to establish its importance in breast-conserving surgery. METHODS A thorough review was conducted in all online publication-databases for the related literature up to March 2020. MeSH terms used: "Breast Cancer", "Segmental Mastectomy" and "Frozen Section". We included the studies that evaluated accuracy of frozen section, reoperation and survival rates. To ensure quality of the included articles, the QUADAS-2 tool (adapted) was employed. The assessment of publication bias by graphical and statistical methods was performed using the funnel plot and the Egger's test. The review protocol was registered in PROSPERO (CRD42019125682). RESULTS Nineteen studies were deemed suitable, with a total of 6,769 cases. The reoperation rate on average was 5.9%. Sensitivity was 0.81, with a Confidence Interval of 0.79-0.83, p = 0.0000, I2 = 95.1%, and specificity was 0.97, with a Confidence Interval of 0.97-0.98, p = 0.0000, I-2 = 90.8%, for 17 studies and 5,615 cases. Accuracy was 0.98. Twelve studies described local recurrence and the highest cumulative recurrence rate in 3 years was 7.5%. The quality of the included studies based on the QUADAS-2 tool showed a low risk of bias. There is no publication bias (p = 0.32) and the funnel plot showed symmetry. CONCLUSION Frozen section is a reliable procedure with high accuracy, sensitivity and specificity in intraoperative margin assessment of breast-conserving surgery. Therefore, this modality of margin assessment could be useful in reducing reoperation rates.
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Affiliation(s)
| | - Bruna Salani Mota
- Department of Gynaecology/Obstetrics, University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Rodrigo Gonçalves
- Department of Gynaecology/Obstetrics, University of São Paulo, São Paulo, Brazil
| | | | - José Roberto Filassi
- Department of Gynaecology/Obstetrics, University of São Paulo, São Paulo, Brazil
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Balasundaram G, Goh Y, Moothanchery M, Attia A, Lim HQ, Burton NC, Qiu Y, Putti TC, Chan CW, Hartmann M, Quek ST, Olivo M. Optoacoustic characterization of breast conserving surgery specimens - A pilot study. PHOTOACOUSTICS 2020; 19:100164. [PMID: 32420026 PMCID: PMC7215246 DOI: 10.1016/j.pacs.2020.100164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 01/22/2020] [Accepted: 01/28/2020] [Indexed: 05/04/2023]
Abstract
In this pilot study, we tested an ultrasound-guided optoacoustic tomography (US-OT) two-dimensional (2D) array scanner to understand the optoacoustic patterns of excised breastconserving surgery (BCS) specimens. We imaged 14 BCS specimens containing malignant tumors at eight wavelengths spanning 700-1100 nm. Spectral unmixing across multiple wavelengths allowed for visualizing major intrinsic chromophores in the breast tissue including hemoglobin and lipid up to a depth of 7 mm. We identified less/no lipid signals within the tumor and intense deoxy-hemoglobin (Hb) signals on the rim of the tumor as unique characteristics of malignant tumors in comparison to no tumor region. We also observed continuous broad lipid signals as features of negative margins and compromised lipid signals interrupted by vasculature as features of positive margins. These differentiating patterns can form the basis of US-OT to be explored as an alternate, fast and efficient intraoperative method for evaluation of tumor resection margins.
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Affiliation(s)
| | - Yonggeng Goh
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Mohesh Moothanchery
- Laboratory of Bio-Optical Imaging, Singapore Bioimaging Consortium, Singapore
| | - Amalina Attia
- Laboratory of Bio-Optical Imaging, Singapore Bioimaging Consortium, Singapore
| | - Hann Qian Lim
- Laboratory of Bio-Optical Imaging, Singapore Bioimaging Consortium, Singapore
| | | | - Yi Qiu
- iThera Medical GmbH, Germany
| | | | - Ching Wan Chan
- Department of Breast Surgery, National University Hospital, Singapore
| | - Mikael Hartmann
- Department of Breast Surgery, National University Hospital, Singapore
| | - Swee Tian Quek
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Malini Olivo
- Laboratory of Bio-Optical Imaging, Singapore Bioimaging Consortium, Singapore
- Corresponding author at: Singapore Bioimaging Consortium (SBIC). A⁎STAR Research Entities, 11 Biopolis Way, #02-02 Helios, 138667, Singapore.
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Tamanuki T, Namura M, Aoyagi T, Shimizu S, Suwa T, Matsuzaki H. Effect of Intraoperative Imprint Cytology Followed by Frozen Section on Margin Assessment in Breast-Conserving Surgery. Ann Surg Oncol 2020; 28:1338-1346. [PMID: 32815080 DOI: 10.1245/s10434-020-08955-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 07/11/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE Intraoperative margin assessment can reduce positive margins in patients undergoing breast-conserving surgery. However, reports on intraoperative margin assessment have described only the use of either imprint cytology or frozen section. This study was designed to elucidate the effect of intraoperative margin assessment using imprint cytology followed by frozen section. METHODS Overall, 522 patients were enrolled. First, the entire surgical margin was subjected to imprint cytology. Frozen section was performed only in cases with "positive" or "suspicious" imprint cytology results. An additional intraoperative excision was performed in patients with frozen section-positive lesion sites. All margins were evaluated using postoperative permanent sections after excision. RESULTS Among 522 patients, 136 (26.1%) were imprint cytology-positive, and 386 (73.9%) were imprint cytology-negative. Among the 386 imprint cytology-negative patients not subjected to frozen section, 11 (2.1%) were permanent sections-positive (imprint cytology-false-negative). In 47 of the 136 imprint cytology-positive patients, additional intraoperative excision was unnecessary due to the frozen section-negative diagnosis. Moreover, these patients could avoid reoperation, because they were permanent section-negative. The false-positive rate of imprint cytology alone was 13.4%, but adding frozen section to imprint cytology decreased the overall false-positive rate to 2.5%. After undergoing excision, four patients still had positive margins. The overall positive margin rate in the final pathology based on permanent sections was 2.9% (15/522). CONCLUSIONS Imprint cytology followed by frozen section led to a markedly decreased positive margin rate. This is considered the best method for intraoperative margin assessment, as it can overcome the limitations of cytology and histology performed individually.
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Affiliation(s)
- Tamaki Tamanuki
- Department of Breast Surgical Oncology, Funabashi Municipal Medical Center, 1-21-1 Kanasugi, Funabashi, Chiba, 273-8588, Japan.
| | - Maki Namura
- Department of Breast Surgical Oncology, Funabashi Municipal Medical Center, 1-21-1 Kanasugi, Funabashi, Chiba, 273-8588, Japan
| | - Tomoyoshi Aoyagi
- Department of Breast Surgical Oncology, Funabashi Municipal Medical Center, 1-21-1 Kanasugi, Funabashi, Chiba, 273-8588, Japan
| | - Sinichirou Shimizu
- Department of Pathology, Funabashi Municipal Medical Center, Funabashi, Chiba, Japan
| | - Tomoko Suwa
- Department of Pathology, Funabashi Municipal Medical Center, Funabashi, Chiba, Japan
| | - Hiroshi Matsuzaki
- Department of Breast Surgical Oncology, Funabashi Municipal Medical Center, 1-21-1 Kanasugi, Funabashi, Chiba, 273-8588, Japan
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Partain N, Calvo C, Mokdad A, Colton A, Pouns K, Clifford E, Farr D, Huth J, Wooldridge R, Leitch AM. Differences in Re-excision Rates for Breast-Conserving Surgery Using Intraoperative 2D Versus 3D Tomosynthesis Specimen Radiograph. Ann Surg Oncol 2020; 27:4767-4776. [PMID: 32740738 DOI: 10.1245/s10434-020-08877-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/19/2020] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Natalia Partain
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Carissia Calvo
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ali Mokdad
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Andrea Colton
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Katherine Pouns
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Edward Clifford
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Deborah Farr
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James Huth
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rachel Wooldridge
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - A Marilyn Leitch
- Division of Surgical Oncology, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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22
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Racz JM, Glasgow AE, Keeney GL, Degnim AC, Hieken TJ, Jakub JW, Cheville JC, Habermann EB, Boughey JC. Intraoperative Pathologic Margin Analysis and Re-Excision to Minimize Reoperation for Patients Undergoing Breast-Conserving Surgery. Ann Surg Oncol 2020; 27:5303-5311. [PMID: 32623609 DOI: 10.1245/s10434-020-08785-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Reoperation rates following breast-conserving surgery (BCS) range from 10 to 40%, with marked surgeon and institutional variation. OBJECTIVE The aim of this study was to identify factors associated with intraoperative margin re-excision, evaluate for any differences in local recurrence based on margin re-excision and determine reoperation rates with use of intraoperative margin analysis. PATIENTS AND METHODS We analyzed consecutive patients with ductal carcinoma in situ (DCIS) or invasive breast cancer who underwent BCS at our institution between 1 January 2005 and 31 December 2016. Routine intraoperative frozen section margin analysis was performed and positive or close margins were re-excised intraoperatively. Univariate analysis was used to compare margin status and the Kaplan-Meier method was used to compare recurrence. Multivariable logistic regression was utilized to analyze factors associated with re-excision. RESULTS We identified 3201 patients who underwent BCS-688 for DCIS and 2513 for invasive carcinoma. Overall, 1513 (60.2%) patients with invasive cancer and 434 (63.1%) patients with DCIS had close or positive margins that underwent intraoperative re-excision. Margin re-excision was associated with larger tumor size in both groups. The permanent pathology positive margin rate among all patients was 1.2%, and the 30-day reoperation rate for positive margins was 1.1%. Five-year local recurrence rates were 0.6% and 1.2% for patients with DCIS and invasive cancer, respectively. There was no difference in recurrence between patients with and without intraoperative margin re-excision (p = 0.92). CONCLUSION Both DCIS and invasive carcinoma had similar rates of intraoperative margin re-excision. Although intraoperative margin re-excision was common, the reoperation rate was extremely low and there was no difference in recurrence between those with or without intraoperative re-excision.
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Affiliation(s)
| | - Amy E Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - Gary L Keeney
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Amy C Degnim
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tina J Hieken
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - James W Jakub
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - John C Cheville
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
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23
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Pradipta AR, Tanei T, Morimoto K, Shimazu K, Noguchi S, Tanaka K. Emerging Technologies for Real-Time Intraoperative Margin Assessment in Future Breast-Conserving Surgery. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2020; 7:1901519. [PMID: 32382473 PMCID: PMC7201251 DOI: 10.1002/advs.201901519] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 01/16/2020] [Accepted: 02/14/2020] [Indexed: 05/23/2023]
Abstract
Clean surgical margins in breast-conserving surgery (BCS) are essential for preventing recurrence. Intraoperative pathologic diagnostic methods, such as frozen section analysis and imprint cytology, have been recognized as crucial tools in BCS. However, the complexity and time-consuming nature of these pathologic procedures still inhibit their broader applicability worldwide. To address this situation, two issues should be considered: 1) the development of nonpathologic intraoperative diagnosis methods that have better sensitivity, specificity, speed, and cost; and 2) the promotion of new imaging algorithms to standardize data for analyzing positive margins, as represented by artificial intelligence (AI), without the need for judgment by well-trained pathologists. Researchers have attempted to develop new methods or techniques; several have recently emerged for real-time intraoperative management of breast margins in live tissues. These methods include conventional imaging, spectroscopy, tomography, magnetic resonance imaging, microscopy, fluorescent probes, and multimodal imaging techniques. This work summarizes the traditional pathologic and newly developed techniques and discusses the advantages and disadvantages of each method. Taking into consideration the recent advances in analyzing pathologic data from breast cancer tissue with AI, the combined use of new technologies with AI algorithms is proposed, and future directions for real-time intraoperative margin assessment in BCS are discussed.
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Affiliation(s)
- Ambara R. Pradipta
- Biofunctional Synthetic Chemistry LaboratoryRIKEN Cluster for Pioneering Research2‐1 HirosawaWakoSaitama351‐0198Japan
- School of Materials and Chemical TechnologyDepartment of Chemical Science and EngineeringTokyo Institute of Technology2‐12‐1 Ookayama, Meguro‐kuTokyo152‐8552Japan
| | - Tomonori Tanei
- Department of Breast and Endocrine SurgeryGraduate School of MedicineOsaka University2‐2‐E10 Yamadaoka, SuitaOsaka565‐0871Japan
| | - Koji Morimoto
- Biofunctional Synthetic Chemistry LaboratoryRIKEN Cluster for Pioneering Research2‐1 HirosawaWakoSaitama351‐0198Japan
| | - Kenzo Shimazu
- Department of Breast and Endocrine SurgeryGraduate School of MedicineOsaka University2‐2‐E10 Yamadaoka, SuitaOsaka565‐0871Japan
| | - Shinzaburo Noguchi
- Department of Breast and Endocrine SurgeryGraduate School of MedicineOsaka University2‐2‐E10 Yamadaoka, SuitaOsaka565‐0871Japan
| | - Katsunori Tanaka
- Biofunctional Synthetic Chemistry LaboratoryRIKEN Cluster for Pioneering Research2‐1 HirosawaWakoSaitama351‐0198Japan
- School of Materials and Chemical TechnologyDepartment of Chemical Science and EngineeringTokyo Institute of Technology2‐12‐1 Ookayama, Meguro‐kuTokyo152‐8552Japan
- Biofunctional Chemistry LaboratoryA. Butlerov Institute of ChemistryKazan Federal University18 Kremlyovskaya StreetKazan420008Russia
- GlycoTargeting Research LaboratoryRIKEN Baton Zone Program2‐1 HirosawaWakoSaitama351‐0198Japan
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24
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Schwarz J, Schmidt H. Technology for Intraoperative Margin Assessment in Breast Cancer. Ann Surg Oncol 2020; 27:2278-2287. [PMID: 32350717 DOI: 10.1245/s10434-020-08483-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND As breast-conserving surgery (BCS) has become standard for treatment of breast cancer, the need for new technology to improve intraoperative margin assessment (IMA) has become clear. Close or positive margins during BCS lead to additional surgeries, treatment delay, additional stress for patients, and healthcare cost. Academia and industry have developed a diverse field of new technologies to allow surgeons to assess margins in the operating room. These technologies aim to reduce current rates of positive margins on final pathology. METHODS We selected recently developed IMA technologies, some of which have undergone large clinical trials and others that are still in early stage development. Technologies were categorized based on underlying methodology to differentiate malignant and normal tissue: spectroscopy, electrical properties, optical imaging and molecular imaging. Additionally, this review details clinical investigations, relevant statistical analysis as well as strengths and weaknesses of the various technologies. CONCLUSION Numerous technical innovations are being implemented to diminish rates of positive margins at breast tumor resection. Close collaboration among cross-disciplinary teams to further develop many of these technologies as well as completion of larger scale clinical studies are required to define an optimal approach. Development with an eye toward prioritizing sensitivity/specificity as well as healthcare cost containment has the potential to make a significant impact on this ongoing clinical need in breast cancer surgery.
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Affiliation(s)
- Julia Schwarz
- Dubin Breast Center, Tisch Cancer Institute, New York, USA.,Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Breast Surgical Oncology, The Mount Sinai Hospital, New York, NY, USA
| | - Hank Schmidt
- Dubin Breast Center, Tisch Cancer Institute, New York, USA. .,Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Breast Surgical Oncology, The Mount Sinai Hospital, New York, NY, USA.
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25
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Mariscotti G, Durando M, Pavan LJ, Tagliafico A, Campanino PP, Castellano I, Bussone R, Ala A, De Sanctis C, Bergamasco L, Fonio P, Houssami N. Intraoperative breast specimen assessment in breast conserving surgery: comparison between standard mammography imaging and a remote radiological system. Br J Radiol 2020; 93:20190785. [PMID: 32101449 DOI: 10.1259/bjr.20190785] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To compare standard specimen mammography (SSM) with remote intraoperative specimen mammography (ISM) assessment in breast conserving-surgery (BCS) based on operative times, intraoperative additional excision (IAE) and re-intervention rates. METHODS AND MATERIALS We retrospectively compared 129 consecutive patients (136 lesions) who had BCS with SSM at our centre between 11/2011 and 02/2013 with 138 consecutive patients (144 lesions) who underwent BCS with ISM between 08/2014 and 02/2015.SSM or ISM were performed to confirm the target lesions within the excised specimen and margin adequacy. The utility of SMM and ISM was evaluated considering pathology as gold-standard, using χ2 or Fisher's exact tests for comparison of categorical variables, and non-parametric Mann-Whitney test for continuous variables. RESULTS The two groups did not statistically differ for age (p = 0.20), lesion size (p = 0.29) and morphology (p = 0.82) or tumor histology type (p = 0.65). Intraoperative time was significantly longer (p < 0.00001) for SSM (132 ± 43 min) than for ISM (90 ± 42 min). The proportions requiring IAE did not significantly differ between SSM group (39/136 lesions (40%)) and ISM group (52/144 lesions (57%)) (p = 0.19), overall and in stratified analysis by mammographic features. Re-intervention rates were not statistically different between the two groups [SSM:19/136 (14%), ISM:13/144 (9%); p = 0.27]. CONCLUSION The introduction of ISM in BCS significantly reduced surgical time but did not change IAE and re-intervention rates, highlighting facilitated communication between surgeons and radiologists. ADVANCES IN KNOWLEDGE Compared to standard mammography imaging, the use of ISM significantly reduced surgical time.
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Affiliation(s)
- Giovanna Mariscotti
- Department of Diagnostic Imaging and Radiotherapy, Radiology Institute, University of Turin, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero Molinette Via Genova 3, 10126 Torino, Italy
| | - Manuela Durando
- Department of Diagnostic Imaging and Radiotherapy, Radiology Institute, University of Turin, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero Molinette Via Genova 3, 10126 Torino, Italy
| | - Luca Jacopo Pavan
- Department of Diagnostic Imaging and Radiotherapy, Radiology Institute, University of Turin, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero Molinette Via Genova 3, 10126 Torino, Italy
| | - Alberto Tagliafico
- Department of Experimental Medicine, University of Genoa IRCCS AOU San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, 16132 Genoa, Italy
| | - Pier Paolo Campanino
- Breast Imaging Service. Ospedale Koelliker.C.so Galileo Ferraris 256 - 10100, Torino, Italy
| | - Isabella Castellano
- Department of Medical Sciences, University of Turin, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero Molinette, Via Santena, 7, Torino, Italy
| | - Riccardo Bussone
- Breast Surgery, Presidio Sanitario Ospedale Cottolengo Via S. Giuseppe Benedetto Cottolengo, 9 - 10152, Torino, Italy
| | - Ada Ala
- Breast Surgery, Department of Surgery, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero S. Anna, Via Ventimiglia, 1, 10126, Torino, Italy
| | - Corrado De Sanctis
- Department of Gynecology and Obstetrics, Breast Unit, A.O.U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero S. Anna, Via Ventimiglia, 1, 10126 Torino, Italy
| | - Laura Bergamasco
- Department of Surgical Sciences, University of Torino, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero Molinette, C.so Bramante 88, 10126 Torino, Italy
| | - Paolo Fonio
- Department of Diagnostic Imaging and Radiotherapy, Radiology Institute, University of Turin, A. O. U. Città della Salute e della Scienza di Torino, Presidio Ospedaliero Molinette Via Genova 3, 10126 Torino, Italy
| | - Nehmat Houssami
- Screening and Test Evaluation Program, School of Public Health, Sydney Medical School, University of Sydney, Sydney, 2006, NSW, Australia
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26
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DiCorpo D, Tiwari A, Tang R, Griffin M, Aftreth O, Bautista P, Hughes K, Gershenfeld N, Michaelson J. The role of Micro-CT in imaging breast cancer specimens. Breast Cancer Res Treat 2020; 180:343-357. [PMID: 32020431 DOI: 10.1007/s10549-020-05547-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 01/22/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE The goal of breast cancer surgery is to remove all of the cancer with a minimum of normal tissue, but absence of full 3-dimensional information on the specimen makes this difficult to achieve. METHOD Micro-CT is a high resolution, X-ray, 3D imaging method, widely used in industry but rarely in medicine. RESULTS We imaged and analyzed 173 partial mastectomies (129 ductal carcinomas, 14 lobular carcinomas, 28 DCIS). Imaging was simple and rapid. The size and shape of the cancers seen on Micro-CT closely matched the size and shape of the cancers seen at specimen dissection. Micro-CT images of multicentric/multifocal cancers revealed multiple non-contiguous masses. Micro-CT revealed cancer touching the specimen edge for 93% of the 114 cases judged margin positive by the pathologist, and 28 of the cases not seen as margin positive on pathological analysis; cancer occupied 1.55% of surface area when both the pathologist and Micro-CT suggested cancer at the edge, but only 0.45% of surface area for the "Micro-CT-Only-Positive Cases". Thus, Micro-CT detects cancers that touch a very small region of the specimen surface, which is likely to be missed on sectioning. CONCLUSIONS Micro-CT provides full 3D images of breast cancer specimens, allowing one to identify, in minutes rather than hours, while the patient is in OR, margin-positive cancers together with information on where the cancer touches the edge, in a fashion more accurate than possible from the histology slides alone.
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Affiliation(s)
- Daniel DiCorpo
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Ankur Tiwari
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA.,Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Rong Tang
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Molly Griffin
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Owen Aftreth
- Department of Urology, Los Angeles Medical Center, Kaiser Permanente, Los Angeles, CA, USA
| | - Pinky Bautista
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Kevin Hughes
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, 02115, USA
| | - Neil Gershenfeld
- MIT Center for Bits and Atoms, Room E15-401, 20 Ames Street, Cambridge, MA, 02139, USA
| | - James Michaelson
- Laboratory for Quantitative Medicine, Massachusetts General Hospital, Boston, MA, 02115, USA. .,Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, 02115, USA. .,Department of Pathology, Massachusetts General Hospital, Boston, MA, 02115, USA. .,Department of Pathology, Harvard Medical School, Boston, MA, 02115, USA. .,, 12 Sheeps Crossing Lane, Woods Hole, USA.
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27
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Adams OE, Cruz SA, Balach T, Dirschl DR, Shi LL, Lee MJ. Do 30-Day Reoperation Rates Adequately Measure Quality in Orthopedic Surgery? Jt Comm J Qual Patient Saf 2020; 46:72-80. [PMID: 31899155 DOI: 10.1016/j.jcjq.2019.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Unplanned reoperation rates represent an important metric in monitoring quality in orthopedic surgery. Previous studies have focused on 30-day reoperation rates, not accounting for complications that may arise beyond this time. This study aimed to understand the frequency, timing, and procedure type of orthopedic reoperations, as well as the complications leading up to these reoperations over a 1-year period. METHODS A single-center, retrospective cohort study reviewed all orthopedic surgeries performed within a three-year period and subsequently identified reoperations within a year following the initial case. Exclusion criteria for reoperations included those that were planned, involved a different body part, or had a different laterality from the first operation. The cases were analyzed by procedure type, timing of reoperation, and causes of reoperation. RESULTS Of the 10,449 orthopedic surgeries performed between 2012 and 2015, 947 (9.1%) were unplanned reoperations within 1 year. Most (775; 81.8%) unplanned reoperations occurred after 30 days. Infections/wound complications (58.2%) were the most common reason for unplanned reoperations at 1 month from the initial operation, and mechanical complications (49.5%) predominated at the 6-months-to-1-year time frame. CONCLUSION This study demonstrated that the current paradigm of focusing on reoperations occurring within 30 days of the initial operation captures only a fraction of unplanned reoperations. Stratification of this metric by time and precipitating complication type provides additional information that quality improvement programs may target. A 1-year unplanned reoperation rate could be used as a broad indicator of surgical quality across institutions.
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28
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Elmore LC, Margenthaler JA. A tale of two operations: re-excision as a quality measure. Gland Surg 2019; 8:593-595. [PMID: 32042664 DOI: 10.21037/gs.2019.11.24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Leisha C Elmore
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Julie A Margenthaler
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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29
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Landercasper J, Bennie B, Ahmad HF, Linebarger JH. Opportunities to reduce reoperations and to improve inter-facility profiling after initial breast-conserving surgery for cancer. A report from the NCDB. Eur J Surg Oncol 2019; 45:2026-2036. [DOI: 10.1016/j.ejso.2019.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/24/2019] [Accepted: 07/02/2019] [Indexed: 12/21/2022] Open
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30
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Harbeck N, Penault-Llorca F, Cortes J, Gnant M, Houssami N, Poortmans P, Ruddy K, Tsang J, Cardoso F. Breast cancer. Nat Rev Dis Primers 2019; 5:66. [PMID: 31548545 DOI: 10.1038/s41572-019-0111-2] [Citation(s) in RCA: 1477] [Impact Index Per Article: 295.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2019] [Indexed: 12/24/2022]
Abstract
Breast cancer is the most frequent malignancy in women worldwide and is curable in ~70-80% of patients with early-stage, non-metastatic disease. Advanced breast cancer with distant organ metastases is considered incurable with currently available therapies. On the molecular level, breast cancer is a heterogeneous disease; molecular features include activation of human epidermal growth factor receptor 2 (HER2, encoded by ERBB2), activation of hormone receptors (oestrogen receptor and progesterone receptor) and/or BRCA mutations. Treatment strategies differ according to molecular subtype. Management of breast cancer is multidisciplinary; it includes locoregional (surgery and radiation therapy) and systemic therapy approaches. Systemic therapies include endocrine therapy for hormone receptor-positive disease, chemotherapy, anti-HER2 therapy for HER2-positive disease, bone stabilizing agents, poly(ADP-ribose) polymerase inhibitors for BRCA mutation carriers and, quite recently, immunotherapy. Future therapeutic concepts in breast cancer aim at individualization of therapy as well as at treatment de-escalation and escalation based on tumour biology and early therapy response. Next to further treatment innovations, equal worldwide access to therapeutic advances remains the global challenge in breast cancer care for the future.
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Affiliation(s)
- Nadia Harbeck
- LMU Munich, University Hospital, Department of Obstetrics and Gynecology, Breast Center and Comprehensive Cancer Center (CCLMU), Munich, Germany.
| | - Frédérique Penault-Llorca
- Department of Pathology and Biopathology, Jean Perrin Comprehensive Cancer Centre, UMR INSERM 1240, University Clermont Auvergne, Clermont-Ferrand, France
| | - Javier Cortes
- IOB Institute of Oncology, Quironsalud Group, Madrid and Barcelona, Spain.,Vall d´Hebron Institute of Oncology, Barcelona, Spain
| | - Michael Gnant
- Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Nehmat Houssami
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Philip Poortmans
- Department of Radiation Oncology, Institut Curie, Paris, France.,Université PSL, Paris, France
| | - Kathryn Ruddy
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Janice Tsang
- Hong Kong Breast Oncology Group, The University of Hong Kong, Hong Kong, China
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
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31
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Landercasper J, Borgert AJ, Fayanju OM, Cody H, Feldman S, Greenberg C, Linebarger J, Pockaj B, Wilke L. Factors Associated with Reoperation in Breast-Conserving Surgery for Cancer: A Prospective Study of American Society of Breast Surgeon Members. Ann Surg Oncol 2019; 26:3321-3336. [PMID: 31342360 PMCID: PMC6733824 DOI: 10.1245/s10434-019-07547-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Indexed: 11/18/2022]
Abstract
Background More than 20% of patients undergoing initial breast-conserving surgery (BCS) for cancer require reoperation. To address this concern, the American Society of Breast Surgeons (ASBrS) endorsed 10 processes of care (tools) in 2015 to be considered by surgeons to de-escalate reoperations. In a planned follow-up, we sought to determine which tools were associated with fewer reoperations. Methods A cohort of ASBrS member surgeons prospectively entered data into the ASBrS Mastery® registry on consecutive patients undergoing BCS in 2017. The association between tools and reoperations was estimated via multivariate and hierarchical ranking analyses. Results Seventy-one surgeons reported reoperations in 486 (12.3%) of 3954 cases (mean 12.7% [standard deviation (SD) 7.7%], median 11.5% [range 0–32%]). There was an eightfold difference between surgeons in the 10th and 90th percentile performance groups. Actionable factors associated with fewer reoperations included routine planned cavity side-wall shaves, surgeon use of ultrasound (US), neoadjuvant chemotherapy, intra-operative pathologic margin assessment, and use of a pre-operative diagnostic imaging modality beyond conventional 2D mammography. For patients with invasive cancer, ≥ 24% of those who underwent reexcision did so for reported margins of < 1 or 2 mm, representing noncompliance with the SSO-ASTRO margin guideline. Conclusions Although ASBrS member surgeons had some of the lowest rates of reoperation reported in any registry, significant intersurgeon variability persisted. Further efforts to lower rates are therefore warranted. Opportunities to do so were identified by adopting those processes of care, including improved compliance with the SSO-ASTRO margin guideline, which were associated with fewer reoperations.
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Affiliation(s)
- Jeffrey Landercasper
- Norma J. Vinger Center for Breast Cancer, Gundersen Health System, La Crosse, WI, USA. .,Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, 54601, USA.
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, 54601, USA
| | | | - Hiram Cody
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sheldon Feldman
- Montefiore Einstein Center for Cancer Care, Montefiore Medical Center, Bronx, NY, USA
| | - Caprice Greenberg
- University of Wisconsin School of Public Health and Medicine, Madison, WI, USA
| | - Jared Linebarger
- Norma J. Vinger Center for Breast Cancer, Gundersen Health System, La Crosse, WI, USA.,Department of Surgery, Gundersen Health System, La Crosse, WI, USA
| | | | - Lee Wilke
- University of Wisconsin School of Public Health and Medicine, Madison, WI, USA
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VanderVelde J, Walters JW, Hsu CH, Ferguson EMN, Lee J, Caruso DM, Komenaka IK. Awareness of residents' technical ability can affect margin status in breast conserving operations. Breast Cancer Res Treat 2019; 177:561-568. [PMID: 31292798 DOI: 10.1007/s10549-019-05344-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/02/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE The current study was performed to determine if awareness of the potential affect of residents could affect margin status. METHODS Retrospective review of all patients who underwent lumpectomy from July 2006 to May 2017 was evaluated. The effect of surgical residents' participation and their technical ability was evaluated to determine the effect on margin status. Logistic regression analysis was performed to determined factors which affect margin status. RESULTS Of 444 patients, 14% of patients had positive margins. The positive margin rate was lower during the second time period after the effect of technical ability of the residents was known 12% versus 19% (p = 0.10). Greater participation by the attending surgeon (32% vs. 21%) occurred in the second time period. In multivariate logistic regression analysis, operations done by residents with satisfactory technical skills or attending surgeon were less likely to have positive margins than those done by residents with unsatisfactory technical skills (OR 0.19, 95% CI 0.10-0.38; p = 0.0001). With mean follow-up of 48 months, 1.4% had local recurrences as a first event. CONCLUSIONS Technically ability of residents appears to affect margin status after lumpectomy. Increased intervention by the attending surgeon can improve this outcome.
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Affiliation(s)
- Joel VanderVelde
- Department of Surgery, Maricopa Medical Center, Hogan Building, 2nd Floor, 2601 E Roosevelt Street, Phoenix, AZ, 85008, USA
| | - Jarvis W Walters
- Department of Surgery, Maricopa Medical Center, Hogan Building, 2nd Floor, 2601 E Roosevelt Street, Phoenix, AZ, 85008, USA
| | - Chiu-Hsieh Hsu
- Arizona Cancer Center, University of Arizona, Tucson, AZ, USA.,Mel and Enid Zuckerman Arizona College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Elizabeth M N Ferguson
- Department of Surgery, Maricopa Medical Center, Hogan Building, 2nd Floor, 2601 E Roosevelt Street, Phoenix, AZ, 85008, USA
| | | | - Daniel M Caruso
- Department of Surgery, Maricopa Medical Center, Hogan Building, 2nd Floor, 2601 E Roosevelt Street, Phoenix, AZ, 85008, USA
| | - Ian K Komenaka
- Department of Surgery, Maricopa Medical Center, Hogan Building, 2nd Floor, 2601 E Roosevelt Street, Phoenix, AZ, 85008, USA. .,Arizona Cancer Center, University of Arizona, Tucson, AZ, USA.
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Murphy BL, Glasgow AE, Habermann EB, Hieken TJ. Returns to the operating room after breast surgery at a tertiary care medical center. Am J Surg 2019; 218:388-392. [PMID: 30824169 DOI: 10.1016/j.amjsurg.2019.02.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 02/07/2019] [Accepted: 02/18/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Evaluation of returns to the operating room (RORs) may spur practice modifications to improve patient outcomes and hospital practices. We determined the frequency and indications for RORs after breast operations. METHODS We identified patients ≥18 years who underwent a breast operation at our institution 1/1/14-1/13/17 and assessed ROR within 45-days. RORs were categorized as unplanned/planned, staged/unstaged, or unrelated procedures. Univariate and multivariable analyses compared variables between patients who did and did not have an ROR. RESULTS 2,914 patients underwent a breast operation of whom 117 (4.0%) had 121 RORs. Planned staged procedures accounted for 48 RORs (39.7%), while unplanned complications accounted for 65 (53.7%). On multivariable analysis, ROR was more common among patients undergoing total, skin-sparing, or nipple-sparing mastectomy (versus lumpectomy) all p < 0.03, while immediate breast reconstruction did not increase RORs. CONCLUSIONS RORs following breast operations occurred in 4% of patients, with approximately one-third for a staged oncologic procedure. Implementation of ROR documentation tools should be encouraged, as these data provide benchmarks for clinical practice improvement initiatives to improve the quality of patient care.
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Affiliation(s)
- Brittany L Murphy
- Departments of Surgery, Mayo Clinic, Rochester, MN, USA; The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - Amy E Glasgow
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Departments of Surgery, Mayo Clinic, Rochester, MN, USA; The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - Tina J Hieken
- Departments of Surgery, Mayo Clinic, Rochester, MN, USA.
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Sutinen M, Kontunen A, Karjalainen M, Kiiski J, Hannus J, Tolonen T, Roine A, Oksala N. Identification of breast tumors from diathermy smoke by differential ion mobility spectrometry. Eur J Surg Oncol 2019; 45:141-146. [DOI: 10.1016/j.ejso.2018.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/24/2018] [Indexed: 12/17/2022] Open
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35
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Tanei T, Pradipta AR, Morimoto K, Fujii M, Arata M, Ito A, Yoshida M, Saigitbatalova E, Kurbangalieva A, Ikeda J, Morii E, Noguchi S, Tanaka K. Cascade Reaction in Human Live Tissue Allows Clinically Applicable Diagnosis of Breast Cancer Morphology. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2019; 6:1801479. [PMID: 30693189 PMCID: PMC6343070 DOI: 10.1002/advs.201801479] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/31/2018] [Indexed: 05/30/2023]
Abstract
Clean operating margins in breast cancer surgery are important for preventing recurrence. However, the current methods for determining margins such as intraoperative frozen section analysis or imprint cytology are not satisfactory since they are time-consuming and cause a burden on the patient and on hospitals with a limited accuracy. A "click-to-sense" probe is developed based on the detection of acrolein, which is a substance released by oxidatively stressed cancer cells and can be visualized under fluorescence microscopy. Using live breast tissues resected from breast cancer patients, it is demonstrated that this method can quickly, selectively, and sensitively differentiate cancer lesion from normal breast gland or benign proliferative lesions. Since acrolein is accumulated in all types of cancers, this method could be used to quickly assess the surgical margins in other types of cancer.
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Affiliation(s)
- Tomonori Tanei
- Department of Breast and Endocrine SurgeryGraduate School of MedicineOsaka University2‐2‐E10 YamadaokaSuitaOsaka565‐0871Japan
| | - Ambara R. Pradipta
- Biofunctional Synthetic Chemistry LaboratoryRIKEN Cluster for Pioneering Research2‐1 HirosawaWakoSaitama351‐0198Japan
| | - Koji Morimoto
- Biofunctional Synthetic Chemistry LaboratoryRIKEN Cluster for Pioneering Research2‐1 HirosawaWakoSaitama351‐0198Japan
- Osaka Women's Junior College3‐8‐1 KasugaokaFujiideraOsaka583‐8558Japan
| | - Motoko Fujii
- Biofunctional Synthetic Chemistry LaboratoryRIKEN Cluster for Pioneering Research2‐1 HirosawaWakoSaitama351‐0198Japan
| | - Mayumi Arata
- Seed Compounds Exploratory Unit for Drug Discovery PlatformRIKEN Center for Sustainable Resource Science2‐1 HirosawaWakoSaitama351‐0198Japan
| | - Akihiro Ito
- Chemical Genomics Research GroupRIKEN Center for Sustainable Resource Science2‐1 HirosawaWakoSaitama351‐0198Japan
- School of Life SciencesTokyo University of Pharmacy and Life Sciences1432‐1 HorinouchiHachiojiTokyo192‐0392Japan
| | - Minoru Yoshida
- Seed Compounds Exploratory Unit for Drug Discovery PlatformRIKEN Center for Sustainable Resource Science2‐1 HirosawaWakoSaitama351‐0198Japan
- Chemical Genomics Research GroupRIKEN Center for Sustainable Resource Science2‐1 HirosawaWakoSaitama351‐0198Japan
| | - Elena Saigitbatalova
- Biofunctional Chemistry LaboratoryA. Butlerov Institute of ChemistryKazan Federal University18 Kremlyovskaya StreetKazan420008Russian Federation
| | - Almira Kurbangalieva
- Biofunctional Chemistry LaboratoryA. Butlerov Institute of ChemistryKazan Federal University18 Kremlyovskaya StreetKazan420008Russian Federation
| | - Jun‐ichiro Ikeda
- Department of Pathology (C3)Graduate School of MedicineOsaka University2‐2 YamadaokaSuitaOsaka565‐0871Japan
| | - Eiichi Morii
- Department of Pathology (C3)Graduate School of MedicineOsaka University2‐2 YamadaokaSuitaOsaka565‐0871Japan
| | - Shinzaburo Noguchi
- Department of Breast and Endocrine SurgeryGraduate School of MedicineOsaka University2‐2‐E10 YamadaokaSuitaOsaka565‐0871Japan
| | - Katsunori Tanaka
- Biofunctional Synthetic Chemistry LaboratoryRIKEN Cluster for Pioneering Research2‐1 HirosawaWakoSaitama351‐0198Japan
- GlycoTargeting Research LaboratoryRIKEN Baton Zone Program2‐1 HirosawaWakoSaitama351‐0198Japan
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36
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Carroll K, Mesman J, McLeod H, Boughey J, Keeney G, Habermann E. Seeing what works: identifying and enhancing successful interprofessional collaboration between pathology and surgery. J Interprof Care 2018; 35:490-502. [PMID: 30335537 DOI: 10.1080/13561820.2018.1536041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Utilising frozen section technologies, Mayo Clinic has one of the lowest reoperation rates for breast lumpectomy in the United States. The research reported on sought to understand the successful teamwork between the Breast Surgery Team and the Frozen Section Laboratory at Mayo Clinic. Researchers worked collaboratively with healthcare staff from breast surgery and the frozen section pathology laboratory to identify communication styles and strategies that contribute to the timely and accurate intraoperative evaluation of breast cancer specimens. Using the video-reflexive ethnography (VRE) methodology underpinned by a positive theoretical approach to researching quality and safety in healthcare, the researchers video-recorded the communications associated with specimen resections in surgery and the subsequent pathology diagnoses. Then, 57 staff from the breast surgery and frozen section laboratory teams attended video-reflexivity sessions to collaboratively analyse their communication practices and identify opportunities to optimize interprofessional communication. In this article, we focus on how the flexible, interdisciplinary, and cross-hierarchical communication within the frozen section laboratory supports a rapid and accurate intraoperative evaluation and communication, previously conceptualized by staff as being performed in a linear fashion. Moreover, we detail how the VRE methodology led surgeons and pathologists to implement new strategies and optimize their interprofessional communication.
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Affiliation(s)
- Katherine Carroll
- School of Sociology, Australian National University, Canberra, ACT, Australia
| | - Jessica Mesman
- Department of Technology and Society Studies, Faculty of Arts and Social Sciences, Maastricht University, Maastricht, The Netherlands
| | - Heidi McLeod
- Center for Pharmacy Innovation, Geisinger Health System, Pennsylvania, USA
| | - Judy Boughey
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Gary Keeney
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
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Aubertin K, Desroches J, Jermyn M, Trinh VQ, Saad F, Trudel D, Leblond F. Combining high wavenumber and fingerprint Raman spectroscopy for the detection of prostate cancer during radical prostatectomy. BIOMEDICAL OPTICS EXPRESS 2018; 9:4294-4305. [PMID: 30615702 PMCID: PMC6157766 DOI: 10.1364/boe.9.004294] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/16/2018] [Accepted: 08/02/2018] [Indexed: 05/14/2023]
Abstract
For prostate cancer (PCa) patients, radical prostatectomy (complete removal of the prostate) is the only curative surgical option. To date, there is no clinical technique allowing for real-time assessment of surgical margins to minimize the extent of residual cancer. Here, we present a tissue interrogation technique using a dual excitation wavelength Raman spectroscopy system capable of sequentially acquiring fingerprint (FP) and high wavenumber (HWN) Raman spectra. Results demonstrate the ability of the system to detect PCa in post-prostatectomy specimens. In total, 477 Raman spectra were collected from 18 human prostate slices. Each area measured with Raman spectroscopy was characterized as either normal or cancer based on histopathological analyses, and each spectrum was classified based on supervised learning using support vector machines (SVMs). Based on receiver operating characteristic (ROC) analysis, FP (area under the curve [AUC] = 0.89) had slightly superior cancer detection capabilities compared with HWN (AUC = 0.86). Optimal performance resulted from combining the spectral information from FP and HWN (AUC = 0.91), suggesting that the use of these two spectral regions may provide complementary molecular information for PCa detection. The use of leave-one-(spectrum)-out (LOO) or leave-one-patient-out (LOPO) cross-validation produced similar classification results when combining FP with HWN. Our findings suggest that the application of machine learning using multiple data points from the same patient does not result in biases necessarily impacting the reliability of the classification models.
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Affiliation(s)
- Kelly Aubertin
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Quebec H2X 0A9, Canada
- Institut du cancer Montréal (ICM), 900 rue St-Denis, Montréal, Quebec H2X 0A9, Canada
| | - Joannie Desroches
- Polytechnique Montréal, Department of Engineering Physics, CP 6079, Succ. Centre-Ville, Montréal, Quebec H3C 3A7, Canada
| | - Michael Jermyn
- Polytechnique Montréal, Department of Engineering Physics, CP 6079, Succ. Centre-Ville, Montréal, Quebec H3C 3A7, Canada
- Dartmouth College, Thayer School of Engineering, 14 Engineering Drive, Hanover, NH 03755, USA
| | - Vincent Quoc Trinh
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Quebec H2X 0A9, Canada
- Institut du cancer Montréal (ICM), 900 rue St-Denis, Montréal, Quebec H2X 0A9, Canada
- Centre hospitalier de l’Université de Montréal (CHUM), Laboratoire de pathologie et cytologie, 1100 rue Sanguinet, Montréal, Quebec H2X 0C2, Canada
- Université de Montréal, Department of Pathology and Cellular Biology, 2900 Boulevard Edouard-Montpetit, Montréal, Quebec H3T 1J4, Canada
| | - Fred Saad
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Quebec H2X 0A9, Canada
- Institut du cancer Montréal (ICM), 900 rue St-Denis, Montréal, Quebec H2X 0A9, Canada
- Centre hospitalier de l’Université de Montréal (CHUM), Division of Urology, 1051 rue Sanguinet, Montréal, Quebec H2X 0C1, Canada
- Université de Montréal, Department of Surgery, 2900 Boulevard Edouard-Montpetit, Montréal, Quebec H3T 1J4, Canada
| | - Dominique Trudel
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Quebec H2X 0A9, Canada
- Institut du cancer Montréal (ICM), 900 rue St-Denis, Montréal, Quebec H2X 0A9, Canada
- Centre hospitalier de l’Université de Montréal (CHUM), Laboratoire de pathologie et cytologie, 1100 rue Sanguinet, Montréal, Quebec H2X 0C2, Canada
- Université de Montréal, Department of Pathology and Cellular Biology, 2900 Boulevard Edouard-Montpetit, Montréal, Quebec H3T 1J4, Canada
| | - Frédéric Leblond
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), 900 rue St-Denis, Montréal, Quebec H2X 0A9, Canada
- Polytechnique Montréal, Department of Engineering Physics, CP 6079, Succ. Centre-Ville, Montréal, Quebec H3C 3A7, Canada
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Trippel M, Slotta-Huspenina J, Becker K, Rau T, Paepke S, Maurer-Marti F, Langer R. Macroscopic Evaluation of the Trimmed Frozen Block Is a Helpful Tool for Intraoperative Assessment of Resection Margins of Breast Cancer Specimens. Int J Surg Pathol 2018; 26:693-700. [PMID: 29953301 DOI: 10.1177/1066896918780346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The evaluation of the trimming surfaces (TS) of tissue blocks from frozen sections may serve as a supplementary examination tool for the intraoperative determination of resection margins of breast cancer specimens. This study aimed at the investigation of the feasibility and reliability of this technique, which has been described only very rarely in literature. METHODS Two observers assessed digital images from TS obtained from 57 resection margins. Findings were correlated with the diagnosis of the frozen section (FS) alone and the final diagnosis on formalin-fixed paraffin-embedded (FFPE) material. RESULTS The determination of the resection margin on TS was estimated as feasible for all cases. Interobserver congruence rate for TS was 96% (κ = 0.81), which was lower compared with FFPE (100%, κ = 1.0) but superior to FS (89%, κ = 0.67). Intraobserver congruence of the 2 reviewers was 96.5% and 93.0% between TS and FFPE, and 91.1% and 92.5% between FS and FFPE, respectively. The combination of both intraoperative consultation techniques showed similar congruence but a slight improvement for the sensitivity (0.75 to 0.875) for the diagnosis of tumor at the resection margin in FFPE for Reviewer 1 but was unchanged for Reviewer 2. CONCLUSION The additional evaluation of TS can be a helpful additional tool for intraoperative margin assessment of breast cancer specimens, in particular, when processing artifacts of FS are encountered.
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Affiliation(s)
| | | | - Karen Becker
- 2 Technische Universität München, München, Germany
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Tevis SE, Neuman HB, Mittendorf EA, Kuerer HM, Bedrosian I, DeSnyder SM, Thompson AM, Black DM, Scoggins ME, Sahin AA, Hunt KK, Caudle AS. Multidisciplinary Intraoperative Assessment of Breast Specimens Reduces Number of Positive Margins. Ann Surg Oncol 2018; 25:2932-2938. [PMID: 29947001 DOI: 10.1245/s10434-018-6607-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Successful breast-conserving surgery requires achieving negative margins. At our institution, the whole surgical specimen is imaged and then serially sectioned with repeat imaging. A multidisciplinary discussion then determines need for excision of additional margins. The goal of this study was to determine the benefit of each component of this approach in reducing the number of positive margin. METHODS This single-institution, prospective study included ten breast surgical oncologists who were surveyed to ascertain whether they would have taken additional margins based their review of whole specimen images (WSI) and review of serially sectioned images (SSI). These results were compared with the multidisciplinary decisions (MDD) and pathology results. Margin status was defined using consensus guidelines. RESULTS One hundred surveys were completed. Margins on the original specimen were positive or close in 21%. After WSI, surgeons reported that they would have taken additional margins in 26 cases, reducing the number of positive/close margins from 21 to 13% (p < 0.001). After SSI, 52 would have taken additional margins; however, the number of positive/close margins remained 13%. MDD resulted in additional margins taken in 56 cases, reducing the number of positive/close margins to 7% (p < 0.001 compared with SSI). CONCLUSIONS While surgeon review of specimen radiographs can decrease the number of positive or close margins from 21 to 13%, more rigorous multidisciplinary, intraoperative margin assessment reduces the number of close or positive margins to 7%.
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Affiliation(s)
- S E Tevis
- Department of Breast Surgical Oncology, University of Texas- MD Anderson Cancer Center, Houston, TX, USA
| | - H B Neuman
- University of Wisconsin, Madison, WI, USA
| | - E A Mittendorf
- Department of Breast Surgical Oncology, University of Texas- MD Anderson Cancer Center, Houston, TX, USA.,Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - H M Kuerer
- Department of Breast Surgical Oncology, University of Texas- MD Anderson Cancer Center, Houston, TX, USA
| | - I Bedrosian
- Department of Breast Surgical Oncology, University of Texas- MD Anderson Cancer Center, Houston, TX, USA
| | - S M DeSnyder
- Department of Breast Surgical Oncology, University of Texas- MD Anderson Cancer Center, Houston, TX, USA
| | - A M Thompson
- Department of Breast Surgical Oncology, University of Texas- MD Anderson Cancer Center, Houston, TX, USA
| | - D M Black
- Department of Breast Surgical Oncology, University of Texas- MD Anderson Cancer Center, Houston, TX, USA
| | - M E Scoggins
- Department of Breast Surgical Oncology, University of Texas- MD Anderson Cancer Center, Houston, TX, USA
| | - A A Sahin
- Department of Breast Surgical Oncology, University of Texas- MD Anderson Cancer Center, Houston, TX, USA
| | - K K Hunt
- Department of Breast Surgical Oncology, University of Texas- MD Anderson Cancer Center, Houston, TX, USA
| | - A S Caudle
- Department of Breast Surgical Oncology, University of Texas- MD Anderson Cancer Center, Houston, TX, USA.
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40
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Tan MP, Silva E. Addressing the paradox of increasing mastectomy rates in an era of de-escalation of therapy: Communication strategies. Breast 2018; 38:136-143. [DOI: 10.1016/j.breast.2017.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 11/13/2017] [Accepted: 12/14/2017] [Indexed: 12/18/2022] Open
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Murphy BL, Boughey JC, Keeney MG, Glasgow AE, Racz JM, Keeney GL, Habermann EB. Factors Associated With Positive Margins in Women Undergoing Breast Conservation Surgery. Mayo Clin Proc 2018; 93:429-435. [PMID: 29439832 DOI: 10.1016/j.mayocp.2017.11.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 11/03/2017] [Accepted: 11/27/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To identify factors predicting positive margins at lumpectomy prompting intraoperative reexcision in patients with breast cancer treated at a large referral center. PATIENTS AND METHODS We reviewed all breast cancer lumpectomy cases managed at our institution from January 1, 2012, through December 31, 2013. Associations between rates of positive margin and patient and tumor factors were assessed using χ2 tests and univariate and adjusted multivariate logistic regression, stratified by ductal carcinoma in situ (DCIS) or invasive cancer. RESULTS We identified 382 patients who underwent lumpectomy for definitive surgical resection of breast cancer, 102 for DCIS and 280 for invasive cancer. Overall, 234 patients (61.3%) required intraoperative reexcision for positive margins. The reexcision rate was higher in patients with DCIS than in those with invasive disease (78.4% [80 of 102] vs 56.4% [158 of 280]; univariate odds ratio, 2.80; 95% CI, 1.66-4.76; P<.001). Positive margin rates did not vary by patient age, surgeon, estrogen receptor, progesterone receptor, or ERBB2 status of the tumor. Among the 280 cases of invasive breast cancer, the only factor independently associated with lower odds of margin positivity was seed localization vs no localization (P=.03). CONCLUSION Ductal carcinoma in situ was associated with a higher rate of positive margins at lumpectomy than invasive breast cancer on univariate analysis. Within invasive disease, seed localization was associated with lower rates of margin positivity.
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MESH Headings
- Adult
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Female
- Humans
- Margins of Excision
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm Staging
- Neoplasm, Residual/prevention & control
- Retrospective Studies
- Risk Factors
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Affiliation(s)
- Brittany L Murphy
- Department of Surgery, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Michael G Keeney
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Amy E Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - Gary L Keeney
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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A novel modality for intraoperative margin assessment and its impact on re-excision rates in breast conserving surgery. Am J Surg 2018; 215:400-403. [DOI: 10.1016/j.amjsurg.2017.11.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 11/04/2017] [Accepted: 11/16/2017] [Indexed: 11/19/2022]
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43
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Reyna C, DeSnyder SM. Intraoperative Margin Assessment in Breast Cancer Management. Surg Oncol Clin N Am 2018; 27:155-165. [DOI: 10.1016/j.soc.2017.08.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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44
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Yoo TK, Kim SW, Kang E, Ahn SG, Hwang KT, Kim SK, Woo SU, Shin HJ, Song YJ, Jung EJ, Chang MC, Lee I, Park WC. The Practice Patterns and Perceptions of Korean Surgeons Regarding Margin Status after Breast-Conserving Surgery. J Breast Cancer 2017; 20:400-403. [PMID: 29285046 PMCID: PMC5744001 DOI: 10.4048/jbc.2017.20.4.400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 11/12/2017] [Indexed: 11/30/2022] Open
Abstract
Two consecutive surveys for breast surgeons in Korea were conducted to comprehend the practice patterns and perceptions on margin status after breast-conserving surgery. The surveys were conducted online in 2014 (initial) and 2016 (follow-up). A total of 126 and 88 responses were obtained in the initial and follow-up survey, respectively. More than 80% of the respondents replied to routinely apply frozen section biopsy for intraoperative margin assessment in both surveys. Re-excision recommendations of the margin for invasive cancer significantly changed from a close margin to a positive margin over time (p=0.033). Most of the respondents (73.8%) defined a negative margin as “no ink on tumor” in invasive cancer, whereas more diverse responses were observed in ductal carcinoma in situ cases. The influence of guideline establishment for negative margins has been identified. A high uptake rate of intraoperative frozen section biopsy was noted and routine use needs reconsideration.
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Affiliation(s)
- Tae-Kyung Yoo
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sung-Won Kim
- Department of Surgery, Daerim St. Mary's Hospital, Seoul, Korea
| | - Eunyoung Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ki-Tae Hwang
- Department of Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seung-Ki Kim
- Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Sang Uk Woo
- Department of Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Hyuk Jai Shin
- Department of Surgery, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
| | - Young-Jin Song
- Department of Surgery, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Eun-Jung Jung
- Department of Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Myung-Chul Chang
- Department of Surgery, Dankook University College of Medicine, Cheonan, Korea
| | - Ilkyun Lee
- Department of Surgery, International St. Mary's Hospital, Catholic Kwandong University, Incheon, Korea
| | - Woo-Chan Park
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Morrow M, Abrahamse P, Hofer TP, Ward KC, Hamilton AS, Kurian AW, Katz SJ, Jagsi R. Trends in Reoperation After Initial Lumpectomy for Breast Cancer: Addressing Overtreatment in Surgical Management. JAMA Oncol 2017; 3:1352-1357. [PMID: 28586788 DOI: 10.1001/jamaoncol.2017.0774] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance Surgery after initial lumpectomy to obtain more widely clear margins is common and may lead to mastectomy. Objective To describe surgeons' approach to surgical margins for invasive breast cancer, and changes in postlumpectomy surgery rates, and final surgical treatment following a 2014 consensus statement endorsing a margin of "no ink on tumor." Design, Setting, and Participants This was a population-based cohort survey study of 7303 eligible women ages 20 to 79 years with stage I and II breast cancer diagnosed in 2013 to 2015 and identified from the Georgia and Los Angeles County, California, Surveillance, Epidemiology, and End Results registries. A total of 5080 (70%) returned a survey. Those with bilateral disease, missing stage or treatment data, and with ductal carcinoma in situ were excluded, leaving 3729 patients in the analytic sample; 98% of these identified their attending surgeon. Between April 2015 and May 2016, 488 surgeons were surveyed regarding lumpectomy margins; 342 (70%) responded completely. Pathology reports of all patients having a second surgery and a 30% sample of those with 1 surgery were reviewed. Time trends were analyzed with multinomial regression models. Main Outcomes and Measures Rates of final surgical procedure (lumpectomy, unilateral mastectomy, bilateral mastectomy) and rates of additional surgery after initial lumpectomy over time, and surgeon attitudes toward an adequate lumpectomy margin. Results The 67% rate of initial lumpectomy in the 3729 patient analytic sample was unchanged during the study. The rate of final lumpectomy increased by 13% from 2013 to 2015, accompanied by a decrease in unilateral and bilateral mastectomy (P = .002). Surgery after initial lumpectomy declined by 16% (P < .001). Pathology review documented no significant association between date of treatment and positive margins. Of 342 responding surgeons, 69% endorsed a margin of no ink on tumor to avoid reexcision in estrogen receptor-positive progesterone receptor-positive cancer and 63% for estrogen receptor-negative progesterone- receptor-negative cancer. Surgeons treating more than 50 breast cancers annually were significantly more likely to report this margin as adequate (85%; n = 105) compared with those treating 20 cases or fewer (55%; n = 131) (P < .001). Conclusions and Relevance Additional surgery after initial lumpectomy decreased markedly from 2013 to 2015 concomitant with dissemination of clinical guidelines endorsing a minimal negative margin. These findings suggest that surgeon-led initiatives to address potential overtreatment can reduce the burden of surgical management in patients with cancer.
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Affiliation(s)
- Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul Abrahamse
- School of Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Timothy P Hofer
- School of Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor.,Veterans Affairs Center for Clinical Management Research, Health Services Research and Development Service Center of Innovation, Ann Arbor, Michigan
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Rollins School of Public Health, Atlanta, Georgia
| | - Ann S Hamilton
- Keck School of Medicine, Department of Preventive Medicine, University of Southern California, Los Angeles
| | - Allison W Kurian
- Departments of Medicine and Health Research and Policy, Stanford University, Stanford, California
| | - Steven J Katz
- School of Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor.,School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor
| | - Reshma Jagsi
- School of Medicine, Department of Radiation Oncology, University of Michigan, Ann Arbor
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Mattingly AE, Ma Z, Smith PD, Kiluk JV, Khakpour N, Hoover SJ, Laronga C, Lee MC. Early Postoperative Complications after Oncoplastic Reduction. South Med J 2017; 110:660-666. [PMID: 28973708 DOI: 10.14423/smj.0000000000000706] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Breast-conserving surgery with adjuvant radiation therapy (BCT) has been established as safe oncologically. Oncoplastic breast surgery uses both oncologic and plastic surgery techniques for breast conservation to improve cosmetic outcomes. We evaluated the risk factors associated with complications after oncoplastic breast reduction. METHODS A single-institution, institutional review board-approved, retrospective review of electronic medical records of female patients with breast cancer who underwent oncoplastic breast reduction from 2008 to 2014. A review of electronic medical records collected relevant medical history, clinical and pathological information, and data on postoperative complications within 6 months stratified into major or minor complications. Categorical variables analyzed with the χ2 exact method; continuous variables were analyzed with the Wilcoxon rank sum test exact method. RESULTS We identified 59 patients; 4 required re-excision for positive margins, and 1 moved on to completion mastectomy. The overall complication rate was 33.9% (n = 20): 12 major (20.3%) and 8 minor (13.6%). Of the continuous variables (age, body mass index, and tissue removed), increased age was associated with minor complications (P = 0.02). Among the categorical variables (stratified body mass index, prior breast surgery, hypertension, diabetes mellitus, hyperlipidemia, vascular disease, pulmonary disease, and stratified weight of tissue removed), none were associated with overall or major complications. Pulmonary disease was associated with minor complications (P = 0.03). Bilateral versus unilateral oncoplastic breast reduction showed no statistically significant increase in complications. CONCLUSIONS The overall complication rate after oncoplastic breast reduction was markedly higher than that in nationally published data for breast-conserving surgery. The complication rate resembled more closely the complication rate after bilateral mastectomy with immediate reconstruction. No risk factors were associated with major or overall complications. Age and pulmonary disease were associated with minor complications. Patients should be selected and counseled appropriately when considering oncoplastic breast reduction.
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Affiliation(s)
- Anne E Mattingly
- From Breast Oncology, Biostatistics and Bioinformatics, and Plastic Surgery, H. Lee Moffitt Center and Cancer Institute, Tampa, Florida
| | - Zhenjun Ma
- From Breast Oncology, Biostatistics and Bioinformatics, and Plastic Surgery, H. Lee Moffitt Center and Cancer Institute, Tampa, Florida
| | - Paul D Smith
- From Breast Oncology, Biostatistics and Bioinformatics, and Plastic Surgery, H. Lee Moffitt Center and Cancer Institute, Tampa, Florida
| | - John V Kiluk
- From Breast Oncology, Biostatistics and Bioinformatics, and Plastic Surgery, H. Lee Moffitt Center and Cancer Institute, Tampa, Florida
| | - Nazanin Khakpour
- From Breast Oncology, Biostatistics and Bioinformatics, and Plastic Surgery, H. Lee Moffitt Center and Cancer Institute, Tampa, Florida
| | - Susan J Hoover
- From Breast Oncology, Biostatistics and Bioinformatics, and Plastic Surgery, H. Lee Moffitt Center and Cancer Institute, Tampa, Florida
| | - Christine Laronga
- From Breast Oncology, Biostatistics and Bioinformatics, and Plastic Surgery, H. Lee Moffitt Center and Cancer Institute, Tampa, Florida
| | - M Catherine Lee
- From Breast Oncology, Biostatistics and Bioinformatics, and Plastic Surgery, H. Lee Moffitt Center and Cancer Institute, Tampa, Florida
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47
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Tang SSK, Kaptanis S, Haddow JB, Mondani G, Elsberger B, Tasoulis MK, Obondo C, Johns N, Ismail W, Syed A, Kissias P, Venn M, Sundaramoorthy S, Irwin G, Sami AS, Elfadl D, Baggaley A, Remoundos DD, Langlands F, Charalampoudis P, Barber Z, Hamilton-Burke WLS, Khan A, Sirianni C, Merker LAMG, Saha S, Lane RA, Chopra S, Dupré S, Manning AT, St John ER, Musbahi A, Dlamini N, McArdle CL, Wright C, Murphy JO, Aggarwal R, Dordea M, Bosch K, Egbeare D, Osman H, Tayeh S, Razi F, Iqbal J, Ledwidge SFC, Albert V, Masannat Y. Current margin practice and effect on re-excision rates following the publication of the SSO-ASTRO consensus and ABS consensus guidelines: a national prospective study of 2858 women undergoing breast-conserving therapy in the UK and Ireland. Eur J Cancer 2017; 84:315-324. [PMID: 28865259 DOI: 10.1016/j.ejca.2017.07.032] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION There is variation in margin policy for breast conserving therapy (BCT) in the UK and Ireland. In response to the Society of Surgical Oncology and American Society for Radiation Oncology (SSO-ASTRO) margin consensus ('no ink on tumour' for invasive and 2 mm for ductal carcinoma in situ [DCIS]) and the Association of Breast Surgery (ABS) consensus (1 mm for invasive and DCIS), we report on current margin practice and unit infrastructure in the UK and Ireland and describe how these factors impact on re-excision rates. METHODS A trainee collaborative-led multicentre prospective study was conducted in the UK and Ireland between 1st February and 31st May 2016. Data were collected on consecutive BCT patients and on local infrastructure and policies. RESULTS A total of 79 sites participated in the data collection (75% screening units; average 372 cancers annually, range 70-900). For DCIS, 53.2% of units accept 1 mm and 38% accept 2-mm margins. For invasive disease 77.2% accept 1 mm and 13.9% accept 'no ink on tumour'. A total of 2858 patients underwent BCT with a mean re-excision rate of 17.2% across units (range 0-41%). The re-excision rate would be reduced to 15% if all units applied SSO-ASTRO guidelines and to 14.8% if all units followed ABS guidelines. Of those who required re-operation, 65% had disease present at margin. CONCLUSION There continues to be large variation in margin policy and re-excision rates across units. Altering margin policies to follow either SSO-ASTRO or ABS guidelines would result in a modest reduction in the national re-excision rate. Most re-excisions are for involved margins rather than close margins.
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MESH Headings
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Consensus
- Female
- Guideline Adherence/standards
- Healthcare Disparities/standards
- Humans
- Ireland
- Margins of Excision
- Mastectomy, Segmental/adverse effects
- Mastectomy, Segmental/methods
- Mastectomy, Segmental/standards
- Practice Guidelines as Topic/standards
- Practice Patterns, Physicians'/standards
- Prospective Studies
- Quality Indicators, Health Care/standards
- Reoperation
- Treatment Outcome
- United Kingdom
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Affiliation(s)
- Sarah Shuk-Kay Tang
- St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, England SW17 0QT, UK.
| | - Sarantos Kaptanis
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London, England E9 6SR, UK.
| | - James B Haddow
- Queen Mary University of London, Garrod Building, Turner Street, London, England E1 2AD, UK.
| | | | - Beatrix Elsberger
- Ninewells Hospital, James Arrott Drive, Dundee, Scotland DD1 9SY, UK.
| | | | - Christine Obondo
- Stobhill Hospital, 133 Balornock Road, Glasgow, Scotland G21 3UW, UK.
| | - Neil Johns
- Edinburgh Breast Unit, Western General Hospital, Crewe Road South, Edinburgh, Scotland EH42XU, UK.
| | - Wisam Ismail
- Bradford Royal Infirmary, Duckworth Lane, Bradford, England BD9 6RJ, UK.
| | - Asim Syed
- Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland AB25 2ZN, UK.
| | | | - Mary Venn
- Ipswich Hospital, Heath Road, Ipswich, England IP4 5PD, UK.
| | | | - Gareth Irwin
- Ulster Hospital, Upper Newtownards Road, Belfast, Northern Ireland BT16 1RH, UK.
| | - Amtul S Sami
- Lincoln County Hospital, Greetwell Road, Lincoln, England LN2 5QY, UK.
| | - Dalia Elfadl
- Royal Marsden Hospital, Downs Road, Sutton, England SM2 5PT, UK.
| | - Alice Baggaley
- Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland AB25 2ZN, UK.
| | | | - Fiona Langlands
- Castle Hill Hospital, Castle Road, Cottingham, Hull, England HU16 5JQ, UK.
| | | | - Zoe Barber
- Neville Hall Hospital, Brecon Road, Abergavenny, Wales NP7 7EG, UK.
| | | | - Ayesha Khan
- Royal Surrey County Hospital, Egerton Road, Guildford, England GU2 7XX, UK.
| | - Chiara Sirianni
- Betsi Cadwaladr University Local Health Board, Town Hall Newry Street, Holyhead, Wales LL65 1HN, UK.
| | | | - Sunita Saha
- Broomfield Hospital, Court Road, Chelmsford, England CM1 7ET, UK.
| | - Risha Arun Lane
- Darent Valley Hospital, Darenth Wood Road, Dartford, England DA2 8DA, UK.
| | - Sharat Chopra
- Abertawe Bro Morgannwg University Health Board, 1 Talbot Gateway, Port Talbot, Wales SA12 7BR, UK.
| | - Sophie Dupré
- Guy's Hospital, Great Maze Pond, London, England SE1 9RT, UK.
| | - Aidan T Manning
- University Hospital Waterford, Dunmore Road, Waterford, Ireland.
| | - Edward R St John
- Charing Cross Hospital, Fulham Palace Road, London, England W6 8RF, UK.
| | - Aya Musbahi
- University Hospital of North Tees, Hardwick Road, Stockton-On-Tees, England TS19 8PE, UK.
| | - Nokwanda Dlamini
- James Paget Hospital, Lowestoft Road, Great Yarmouth, England NR31 6LA, UK.
| | | | - Chloe Wright
- Bolton Breast Unit, Royal Bolton Hospital, Farnworth, Bolton, England BL4 0JR, UK.
| | - James O Murphy
- University Hospital Waterford, Dunmore Road, Waterford, Ireland.
| | - Ravi Aggarwal
- Hillingdon Hospital, Pield Heath Road, Uxbridge, England UB8 3NN, UK.
| | - Matei Dordea
- University Hospital of North Tees, Hardwick Road, Stockton-On-Tees, England TS19 8PE, UK.
| | - Karen Bosch
- Kings College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - Donna Egbeare
- Cardiff and Vale University Health Board, Heath Park, Cardiff, Wales CF14 4XW, UK.
| | - Hisham Osman
- Frimley Park Hospital, Portsmouth Road, Camberley, England GU16 7UJ, UK.
| | - Salim Tayeh
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London, England E9 6SR, UK.
| | - Faraz Razi
- North Hampshire Hospital, Aldermaston Road, Basingstoke, England RG24 9NA, UK.
| | - Javeria Iqbal
- Diana Princess of Wales Hospital, Scartho Road, Grimsby, England DN33 2BA, UK.
| | | | - Vanessa Albert
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London, England E9 6SR, UK
| | - Yazan Masannat
- Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland AB25 2ZN, UK; University of Aberdeen, Aberdeen, Scotland AB24 3FX, UK; University of East Anglia, Norwich, England NR4 7TJ, UK
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48
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Microfluidics for rapid cytokeratin immunohistochemical staining in frozen sections. J Transl Med 2017; 97:983-991. [PMID: 28553936 PMCID: PMC5533214 DOI: 10.1038/labinvest.2017.49] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 03/24/2017] [Accepted: 04/11/2017] [Indexed: 01/28/2023] Open
Abstract
Frozen sections (FS) of tumor samples represent a cornerstone of pathological intraoperative consultation and have an important role in the microscopic analysis of specimens during surgery. So far, immunohistochemical (IHC) stainings on FS have been demonstrated for a few markers using manual methods. Microfluidic technologies have proven to bring substantial improvement in many fields of diagnostics, though only a few microfluidic devices have been designed to improve the performance of IHC assays. In this work, we show optimization of a complete pan-cytokeratin chromogenic immunostaining protocol on FS using a microfluidic tissue processor into a protocol taking <12 min. Our results showed specificity and low levels of background. The dimensions of the microfluidic prototype device are compatible with the space constraints of an intraoperative pathology laboratory. We therefore anticipate that the adoption of microfluidic technologies in the field of surgical pathology can significantly improve the way FSs influence surgical procedures.
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49
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Patten CR, Walsh K, Sarantou T, Hadzikadic-Gusic L, Forster MR, Robinson M, White RL. Changes in margin re-excision rates: Experience incorporating the "no ink on tumor" guideline into practice. J Surg Oncol 2017; 116:1040-1045. [PMID: 28750136 DOI: 10.1002/jso.24770] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/24/2017] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Prior to the "no ink on tumor" SSO/ASTRO consensus guideline, approximately 20% of women with stage I/II breast cancers undergoing breast conservation surgery at our institution underwent margin re-excision. On May 20, 2013, our institution changed the definition of negative margins from 2 mm to "no ink on tumor." METHODS A retrospective review was conducted of patients who had surgery at our institution with clinical stage I/II breast cancers between June 1, 2011 and May 1, 2015. In the pre-guideline cohort (pre) and post-guideline cohort (post), negative margins were 2 mm and "no ink on tumor," respectively. RESULTS Implementation of the guideline resulted in a significant decrease in the positive/close margin rate (29.6% pre vs 10.1% post; P < 0.001) and numerical decrease in re-excision rate (20.4% pre vs 16.3% post; P = 0.104). No significant difference was found in local recurrence between the cohorts with limited follow-up (1.2% pre vs 1.5% post; P = 0.787). CONCLUSION The implementation of the "no ink on tumor" guideline at our institution has resulted in a significant decrease in positive margin rates and a numerical decrease in margin re-excisions. In addition to margin status, surgeons continue to use individual patient and histologic factors to decide for or against margin re-excision.
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Affiliation(s)
- Caitlin R Patten
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kendall Walsh
- Division of Surgical Oncology, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Terry Sarantou
- Division of Surgical Oncology, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Lejla Hadzikadic-Gusic
- Division of Surgical Oncology, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Meghan R Forster
- Division of Surgical Oncology, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Myra Robinson
- Division of Surgical Oncology, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Richard L White
- Division of Surgical Oncology, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
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50
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Unkart JT, Chen SL, Wapnir IL, González JE, Harootunian A, Wallace AM. Intraoperative Tumor Detection Using a Ratiometric Activatable Fluorescent Peptide: A First-in-Human Phase 1 Study. Ann Surg Oncol 2017; 24:3167-3173. [PMID: 28699134 DOI: 10.1245/s10434-017-5991-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Positive surgical margins remain a significant challenge in breast cancer surgery. This report describes the use of a novel, first-in-human ratiometric activatable cell-penetrating peptide in breast cancer surgery. METHODS A two-part, multi-institutional phase 1 trial of AVB-620 with a 3+3 dose escalation and dose-expansion cohorts was conducted. The patients received an infusion of AVB-620 2-20 h before planned lumpectomy/mastectomy and sentinel node biopsy/axillary dissection. Imaging analysis was performed on images obtained from the surgical field as well as post-excision surgical specimens. Pathology reports were obtained to correlate imaging results with histopathologic data. Information on physical adverse events and laboratory abnormalities were recorded. RESULTS A total of 27 patients received infusion of AVB-620 and underwent surgical excision of breast cancer. The findings showed no adverse events or laboratory values attributable to infusion of AVB-620. The 8-mg dose was selected from the dose-escalation cohort for use with the expansion cohort based on imaging data. Region-of-interest (ROI) imaging analysis from the 8-mg cohort demonstrated measurable changes between pathology confirmed tumor-positive and tumor-negative tissue. CONCLUSION Intraoperative imaging of surgical specimens after infusion with AVB-620 allowed for real-time tumor detection. Infusion of AVB-620 is safe and may improve intraoperative detection of malignant tissue during breast cancer operations.
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Affiliation(s)
- Jonathan T Unkart
- Department of Surgery, Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | | | - Irene L Wapnir
- Department of Surgery, Stanford University, Stanford, CA, USA
| | | | | | - Anne M Wallace
- Department of Surgery, Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA.
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