1
|
Cozzi A, Di Leo G, Houssami N, Gilbert FJ, Helbich TH, Álvarez Benito M, Balleyguier C, Bazzocchi M, Bult P, Calabrese M, Camps Herrero J, Cartia F, Cassano E, Clauser P, de Lima Docema MF, Depretto C, Dominelli V, Forrai G, Girometti R, Harms SE, Hilborne S, Ienzi R, Lobbes MBI, Losio C, Mann RM, Montemezzi S, Obdeijn IM, Aksoy Ozcan U, Pediconi F, Pinker K, Preibsch H, Raya Povedano JL, Rossi Saccarelli C, Sacchetto D, Scaperrotta GP, Schlooz M, Szabó BK, Taylor DB, Ulus SÖ, Van Goethem M, Veltman J, Weigel S, Wenkel E, Zuiani C, Sardanelli F. Preoperative breast MRI positively impacts surgical outcomes of needle biopsy-diagnosed pure DCIS: a patient-matched analysis from the MIPA study. Eur Radiol 2024; 34:3970-3980. [PMID: 37999727 PMCID: PMC11166778 DOI: 10.1007/s00330-023-10409-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/16/2023] [Accepted: 10/11/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVES To investigate the influence of preoperative breast MRI on mastectomy and reoperation rates in patients with pure ductal carcinoma in situ (DCIS). METHODS The MIPA observational study database (7245 patients) was searched for patients aged 18-80 years with pure unilateral DCIS diagnosed at core needle or vacuum-assisted biopsy (CNB/VAB) and planned for primary surgery. Patients who underwent preoperative MRI (MRI group) were matched (1:1) to those who did not receive MRI (noMRI group) according to 8 confounding covariates that drive referral to MRI (age; hormonal status; familial risk; posterior-to-nipple diameter; BI-RADS category; lesion diameter; lesion presentation; surgical planning at conventional imaging). Surgical outcomes were compared between the matched groups with nonparametric statistics after calculating odds ratios (ORs). RESULTS Of 1005 women with pure unilateral DCIS at CNB/VAB (507 MRI group, 498 noMRI group), 309 remained in each group after matching. First-line mastectomy rate in the MRI group was 20.1% (62/309 patients, OR 2.03) compared to 11.0% in the noMRI group (34/309 patients, p = 0.003). The reoperation rate was 10.0% in the MRI group (31/309, OR for reoperation 0.40) and 22.0% in the noMRI group (68/309, p < 0.001), with a 2.53 OR of avoiding reoperation in the MRI group. The overall mastectomy rate was 23.3% in the MRI group (72/309, OR 1.40) and 17.8% in the noMRI group (55/309, p = 0.111). CONCLUSIONS Compared to those going directly to surgery, patients with pure DCIS at CNB/VAB who underwent preoperative MRI had a higher OR for first-line mastectomy but a substantially lower OR for reoperation. CLINICAL RELEVANCE STATEMENT When confounding factors behind MRI referral are accounted for in the comparison of patients with CNB/VAB-diagnosed pure unilateral DCIS, preoperative MRI yields a reduction of reoperations that is more than twice as high as the increase in overall mastectomies. KEY POINTS • Confounding factors cause imbalance when investigating the influence of preoperative MRI on surgical outcomes of pure DCIS. • When patient matching is applied to women with pure unilateral DCIS, reoperation rates are significantly reduced in women who underwent preoperative MRI. • The reduction of reoperations brought about by preoperative MRI is more than double the increase in overall mastectomies.
Collapse
Affiliation(s)
- Andrea Cozzi
- Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097, San Donato Milanese, Italy
- Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Giovanni Di Leo
- Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097, San Donato Milanese, Italy
| | - Nehmat Houssami
- The Daffodil Centre, Faculty of Medicine and Health, The University of Sydney (Joint Venture with Cancer Council NSW), Sydney, Australia
| | - Fiona J Gilbert
- Department of Radiology, School of Clinical Medicine, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Thomas H Helbich
- Division of General and Paediatric Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Division of Molecular and Structural Preclinical Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Corinne Balleyguier
- Department of Radiology, Institut Gustave Roussy, Villejuif, France
- Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris-Saclay, Villejuif, France
| | - Massimo Bazzocchi
- Institute of Radiology, Department of Medicine, Ospedale Universitario S. Maria della Misericordia, Università degli Studi di Udine, Udine, Italy
| | - Peter Bult
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Massimo Calabrese
- Unit of Oncological and Breast Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Julia Camps Herrero
- Department of Radiology, Hospital Universitario de La Ribera, Alzira, Spain
- Ribera Salud Hospitals, Valencia, Spain
| | - Francesco Cartia
- Unit of Breast Imaging, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Enrico Cassano
- Breast Imaging Division, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Paola Clauser
- Division of General and Paediatric Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Catherine Depretto
- Unit of Breast Imaging, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Valeria Dominelli
- Breast Imaging Division, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Gábor Forrai
- Department of Radiology, MHEK Teaching Hospital, Semmelweis University, Budapest, Hungary
- Department of Radiology, Duna Medical Center, GE-RAD Kft, Budapest, Hungary
| | - Rossano Girometti
- Institute of Radiology, Department of Medicine, Ospedale Universitario S. Maria della Misericordia, Università degli Studi di Udine, Udine, Italy
| | - Steven E Harms
- Breast Center of Northwest Arkansas, Fayetteville, AR, USA
| | - Sarah Hilborne
- Department of Radiology, School of Clinical Medicine, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Raffaele Ienzi
- Department of Radiology, Di.Bi.MED, Policlinico Universitario Paolo Giaccone Università degli Studi di Palermo, Palermo, Italy
| | - Marc B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Claudio Losio
- Department of Breast Radiology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ritse M Mann
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Stefania Montemezzi
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Inge-Marie Obdeijn
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Umit Aksoy Ozcan
- Department of Radiology, Acıbadem Atasehir Hospital, Istanbul, Turkey
| | - Federica Pediconi
- Department of Radiological, Oncological and Pathological Sciences, Università degli Studi di Roma "La Sapienza", Rome, Italy
| | - Katja Pinker
- Division of General and Paediatric Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Heike Preibsch
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | | | | | - Daniela Sacchetto
- Kiwifarm S.R.L., La Morra, Italy
- Disaster Medicine Service 118, ASL CN1, Levaldigi, Italy
| | | | - Margrethe Schlooz
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Botond K Szabó
- Department of Radiology, Barking Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Donna B Taylor
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
- Department of Radiology, Royal Perth Hospital, Perth, Australia
| | - Sila Ö Ulus
- Department of Radiology, Acıbadem Atasehir Hospital, Istanbul, Turkey
| | - Mireille Van Goethem
- Gynecological Oncology Unit, Department of Obstetrics and Gynecology, Department of Radiology, Multidisciplinary Breast Clinic, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Jeroen Veltman
- Maatschap Radiologie Oost-Nederland, Oldenzaal, The Netherlands
| | - Stefanie Weigel
- Clinic for Radiology and Reference Center for Mammography, University of Münster, Münster, Germany
| | - Evelyn Wenkel
- Department of Radiology, University Hospital of Erlangen, Erlangen, Germany
| | - Chiara Zuiani
- Institute of Radiology, Department of Medicine, Ospedale Universitario S. Maria della Misericordia, Università degli Studi di Udine, Udine, Italy
| | - Francesco Sardanelli
- Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097, San Donato Milanese, Italy.
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy.
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Maes-Carballo M, Martín-Díaz M, Mignini L, Khan KS, Trigueros R, Bueno-Cavanillas A. Quality indicators for the diagnosis and treatment of breast cancer integrated assistance: A critical appraisal. Semergen 2024; 50:102067. [PMID: 37827047 DOI: 10.1016/j.semerg.2023.102067] [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: 06/18/2023] [Accepted: 07/11/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Quality indicators (QIs) are essential for adequate control of the health care management process, recognizing areas of improvement and providing solutions. We aimed to evaluate the Integrated Breast Cancer (BC) Care Process QIs. METHODS We studied 487 consecutive BC cases diagnosed from November 1st, 2013, to November 30th, 2019, in a Spanish healthcare area, and we estimated the associated QIs. RESULTS Four indicators did not meet the standards and were analysed based on related sociodemographic and clinical variables. The surgical delay after a multidisciplinary team discussion (mean 64%, IQR 59.6-68.5) was lower in elder people (p=0.027), and early histological grades (p=0.019) and stages (p=0.008). The adjuvant treatment delay (mean 55.7%, IQR 51.1-60.3) was lower in advance stages (p=0.002) and when there was no reoperation (p=0.001). The surgical delay after inclusion (mean 83.2%, IQR 79.3-87.2) was lower in early histological grades (p=0.048). The immediate reconstruction (mean 42.3%, IQR 34.0-50.5) reached 72.3% in young women compared to 11.8% in older than 70 years (p=0.001) and it was higher in early stages (45.3% vs 36.2%; p=0.049). CONCLUSION The study of QIs evaluated their compliance and analysed the variables influencing them to propose improvement measures. Not all the indicators were equally valuable. Some depended on the available resources, and others on the mix of patients or complementary treatments. It would be essential to identify the specific target populations to estimate the indicators or provide standards stratified by the related variables.
Collapse
Affiliation(s)
- M Maes-Carballo
- Academic Department of General Surgery, Complexo Universitario Hospitalario de Ourense, Spain; Academic Department of General Surgery, Hospital Público de Verín, Spain; Department of Preventive Medicine and Public Health, University of Granada, Spain.
| | - M Martín-Díaz
- Academic Department of General Surgery, Hospital Santa Ana de Motril, Spain
| | - L Mignini
- Unidad de Mastología de Grupo Oroño, Rosario, Argentina
| | - K S Khan
- Department of Preventive Medicine and Public Health, University of Granada, Spain; CIBER of Epidemiology and Public Health (CIBERESP), Spain
| | - R Trigueros
- Department of Psychology, University of Almeria, Spain
| | - A Bueno-Cavanillas
- Department of Preventive Medicine and Public Health, University of Granada, Spain; CIBER of Epidemiology and Public Health (CIBERESP), Spain; Instituto de Investigación Biosanitaria IBS, Granada, Spain
| |
Collapse
|
4
|
Chagpar AB. Change. Am J Surg 2023; 226:756-759. [PMID: 37328327 DOI: 10.1016/j.amjsurg.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/04/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Anees B Chagpar
- Department of Surgery, Yale University School of Medicine, United States.
| |
Collapse
|
5
|
Gilmore R, Chen J, Dembinski R, Reissis Y, Milek D, Cadena L, Habibi M. Cost minimization in breast conserving surgery: a comparative study of radiofrequency spectroscopy and full cavity shave margins. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:66. [PMID: 37716980 PMCID: PMC10504787 DOI: 10.1186/s12962-023-00477-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 09/09/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND In an effort to minimize positive margins and subsequent re-excision after breast conserving surgery (BCS), many providers and facilities have implemented either a Full Cavity Shave (FCS) approach or adding the MarginProbe Radiofrequency Spectroscopy System. OBJECTIVE We sought to create a functioning Pro-Forma for use by facilities and payers to evaluate and compare the cost savings of implementing FCS or MarginProbe based on personalized variable inputs. METHODS A decision tree demonstrating three possible surgical pathways, BCS, BCS + FCS, and BCS + MarginProbe was developed with clinical inputs for re-excision rate, mastectomy as 2nd surgery, rate of reconstruction, and rate of 3rd surgery derived by a literature review. A surgical pathway cost formula was created using the decision tree and financial inputs derived by utilizing the nation's largest database of privately billed health insurance claims and Medicare claims data (fairhealth.org). Using the surgical pathway formula and financial inputs, a customizable Pro-Forma was created for immediate cost savings analysis of BCS + FCS and BCS + Marginprobe using variable inputs. Costs are from the perspective of third-party payers. RESULTS Utilizing MarginProbe to reduce re-excisions for positive margins can be associated with better cost-savings than FCS due to the increased pathology processing costs by using an FCS approach. The reduction in re-excision provided by both FCS and MarginProbe offset their increased expense to various degrees with cost savings of each method improving as baseline re-excisions rates increase, until ultimately each may become cost-neutral or cost-prohibitive when compared to BCS alone. Our data suggest that in the privately insured population, MarginProbe provides a cost-savings over BCS alone when baseline re-excision rates are over 20% and that FCS becomes cost-saving when baseline re-excision rates are over 29%. For Medicare patients, MarginProbe provides a cost-savings when baseline re-excision rates exceed 34%, and FCS becomes cost-saving for re-excision rates over 52%. Our Pro-Forma allows an individual provider or institution to evaluate the cost savings of the FCS approach and/or utilization of the MarginProbe device such that the additional cost or cost-savings of utilizing one or both of these methods can be quickly calculated based on their facility's volume and baseline re-excision rate. CONCLUSIONS Our data suggest that utilizing either an FCS approach or the MarginProbe radiofrequency spectroscopy system may be a cost-saving solution to reducing the rate of re-excisions depending on a facility or practice's surgical volume and baseline re-excision rate. The degree to which each of these interventions provides an added cost or cost-savings to healthcare payers can be evaluated by utilizing the Pro-Forma outlined herein with customizable variable inputs.
Collapse
Affiliation(s)
- Richard Gilmore
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Jennifer Chen
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Robert Dembinski
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Yannis Reissis
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - David Milek
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Lisa Cadena
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Mehran Habibi
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA.
- Department of Surgery, Northwell Health, Zucker School of Medicine, New York, United States.
| |
Collapse
|
6
|
Schumacher JR, Lawson EH, Kong AL, Weber JJ, May J, Landercasper J, Hanlon B, Marka N, Venkatesh M, Cartmill RS, Pavuluri Quamme S, Nikolay C, Greenberg CC. A Statewide Approach to Reducing Re-excision Rates for Women With Breast-conserving Surgery. Ann Surg 2022; 276:665-672. [PMID: 35837946 PMCID: PMC9529150 DOI: 10.1097/sla.0000000000005590] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Test the effectiveness of benchmarked performance reports based on existing discharge data paired with a statewide intervention to implement evidence-based strategies on breast re-excision rates. BACKGROUND Breast-conserving surgery (BCS) is a common breast cancer surgery performed in a range of hospital settings. Studies have demonstrated variations in post-BCS re-excision rates, identifying it as a high-value improvement target. METHODS Wisconsin Hospital Association discharge data (2017-2019) were used to compare 60-day re-excision rates following BCS for breast cancer. The analysis estimated the difference in the average change preintervention to postintervention between Surgical Collaborative of Wisconsin (SCW) and nonparticipating hospitals using a logistic mixed-effects model with repeated measures, adjusting for age, payer, and hospital volume, including hospitals as random effects. The intervention included 5 collaborative meetings in 2018 to 2019 where surgeon champions shared guideline updates, best practices/challenges, and facilitated action planning. Confidential benchmarked performance reports were provided. RESULTS In 2017, there were 3692 breast procedures in SCW and 1279 in nonparticipating hospitals; hospital-level re-excision rates ranged from 5% to >50%. There was no statistically significant baseline difference in re-excision rates between SCW and nonparticipating hospitals (16.1% vs. 17.1%, P =0.47). Re-excision significantly decreased for SCW but not for nonparticipating hospitals (odds ratio=0.69, 95% confidence interval=0.52-0.91). CONCLUSIONS Benchmarked performance reports and collaborative quality improvement can decrease post-BCS re-excisions, increase quality, and decrease costs. Our study demonstrates the effective use of administrative data as a platform for statewide quality collaboratives. Using existing data requires fewer resources and offers a new paradigm that promotes participation across practice settings.
Collapse
Affiliation(s)
| | - Elise H Lawson
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | - Amanda L Kong
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | | | - Jeanette May
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | | | - Bret Hanlon
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI
| | - Nicholas Marka
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN
| | - Manasa Venkatesh
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | - Randi S Cartmill
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | | | - Connor Nikolay
- Department of Surgery, University of Wisconsin-Madison, Madison, WI
| | | |
Collapse
|
7
|
Reid VJ, Falk JS, Police AM, Ridgeway CA, Cadena LL, Povoski SP. Minimizing re-excision after breast conserving surgery - a review of radiofrequency spectroscopy for real-time, intraoperative margin assessment. Expert Rev Med Devices 2021; 18:1057-1068. [PMID: 34657525 DOI: 10.1080/17434440.2021.1992273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION For early-stage breast cancer, breast-conserving surgery (BCS) plus radiation is standard-of-care. Nationwide, >20% of BCS patients require re-excision for positive margins, resulting in delayed adjuvant therapy, increased complications, emotional and financial stress for patients, and additional cost to the healthcare system. Although several methods may be employed to mitigate positive margins, no technique can fully address the need. MarginProbe® is an adjunctive tool for real-time intraoperative margin assessment and is shown to reduce positive margins by >50%. AREAS COVERED Discussion of the impact of re-excision following BCS, a review of currently available methods for intraoperative margin management, followed by a technology and literature review of the MarginProbe® Radiofrequency Spectroscopy System. EXPERT OPINION Re-excision significantly impacts patients, providers and payers. Limitations in the ability to assess margins at time of surgery warrant more advanced methods of residual disease detection. MarginProbe facilitates the most efficient pathway for breast cancer patients through the surgical phase of treatment. The device is well-suited for adoption as the healthcare focus shifts from volume to value and supports the three pillars of the US Department of Health and Human Services' 'Triple-Aim' strategy: improve population health, improve patient experience of care, and reduce per-capita costs.
Collapse
Affiliation(s)
- Vincent J Reid
- Director of Surgical Oncology, Medical Director, Hall-Perrine Cancer Center, Cedar Rapids, IA - Clinical Associate Professor of Surgery at the University of Iowa Hospitals and Clinics, USA
| | - Jeffrey S Falk
- Department of Surgery, Ascension St. John Hospital and Medical Center, Detroit, MI - Clinical Associate Professor of Surgery, Wayne State University College of Medicine, St. George's University College of Medicine, USA
| | - Alice M Police
- Director of Breast Surgery, Northwell Health, Western Region, New York, USA
| | - Calvin A Ridgeway
- Medical Director of Breast Care Center, Lovelace Women's Hospital, NM, USA
| | - Lisa L Cadena
- Director, Training and Medical Education, Dilon Technologies, Newport News, VA, USA
| | - Stephen P Povoski
- Professor of Surgery, Division of Surgical Oncology, Department of Surgery, The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
8
|
Simpson D, Allan J, McFall B. Radiological Underestimation of Tumor Size Influences the Success Rate of Re-Excision after Breast-conserving Surgery. Eur J Breast Health 2021; 17:363-370. [PMID: 34651116 DOI: 10.4274/ejbh.galenos.2021.2021-4-7] [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: 04/14/2021] [Accepted: 07/04/2021] [Indexed: 12/01/2022]
Abstract
Objective Failure to achieve adequate margins after breast-conserving surgery often leads to re-excision, either by repeat breast-conserving surgery (BCS) or by mastectomy. Despite the high frequency of this problem, the success rate of achieving adequate margins by repeat BCS is not well documented. The objective of this study was to determine the success rate of repeat BCS and identify the factors influencing that rate. Materials and Methods A retrospective review was performed of all women undergoing repeat BCS for inadequate margins after initial BCS in our breast unit between 2013 and 2019. Univariate and multivariate analyses were carried out to identify the factors influencing how often adequate margins were achieved after repeat BCS. Results One hundred fifty-four patients underwent repeat BCS after initially inadequate margins, of which adequate margins were achieved in 82%. Patients with successful repeat BCS had smaller tumors, had less underestimation of tumor size on imaging, and were less likely to have had cavity shaves taken at their initial BCS. A tumor size more than 50% larger than predicted by imaging was independently associated with failure of repeat BCS in multivariate analysis (odds ratio: 3.6, 95% CI: 1.41-9.20, p = 0.007). Underestimation of tumor size by imaging was commoner and more extensive in patients with larger tumors and those with ductal carcinoma in situ. Conclusion Re-excision by cavity shaves has a high success rate and should be offered to all patients who are deemed suitable for the procedure. Patients whose tumors are more than 50% larger than predicted by imaging should be counseled about the higher risk of failure.
Collapse
Affiliation(s)
- Duncan Simpson
- Breast Unit, Antrim Area Hospital, Bush Road, Antrim, Northern Ireland, United Kingdom
| | - Jennifer Allan
- Breast Unit, Antrim Area Hospital, Bush Road, Antrim, Northern Ireland, United Kingdom
| | - Brendan McFall
- Breast Unit, Antrim Area Hospital, Bush Road, Antrim, Northern Ireland, United Kingdom
| |
Collapse
|
9
|
Richey WL, Heiselman JS, Luo M, Meszoely IM, Miga MI. Impact of deformation on a supine-positioned image-guided breast surgery approach. Int J Comput Assist Radiol Surg 2021; 16:2055-2066. [PMID: 34382176 DOI: 10.1007/s11548-021-02452-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 07/06/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To reduce reoperation rates for image-guided breast-conserving surgery, the enhanced sensitivity of magnetic resonance (MR) supine imaging may be leveraged. However, accurate tissue correspondence between images and their physical counterpart in the surgical presentation is challenging due to breast deformations (e.g., from patient/arm position changes, and operating room table rotation differences). In this study, standard rigid registration methods are employed and tissue deformation is characterized. METHODS On n = 10 healthy breasts, surface displacements were measured by comparing intraoperative fiducial locations as the arm was moved from conventional MR scanning positions (arm-down and arm-up) to the laterally extended surgical configuration. Supine MR images in the arm-down and arm-up positions were registered to mock intraoperative presentations. RESULTS Breast displacements from a supine MR imaging configuration to a mock surgical presentation were 28.9 ± 9.2 mm with shifts occurring primarily in the inferior/superior direction. With respect to supine MR to surgical alignment, the average fiducial, target, and maximum target registration errors were 9.0 ± 1.7 mm, 9.3 ± 1.7 mm, and 20.0 ± 7.6 mm, respectively. Even when maintaining similar arm positions in the MR image and mock surgery, the respective averages were 6.0 ± 1.0 mm, 6.5 ± 1.1 mm, and 12.5 ± 2.8 mm. CONCLUSION From supine MR positioning to surgical presentation, the breast undergoes large displacements (9.9-70.1 mm). The data also suggest that significant nonrigid deformations (9.3 ± 1.7 mm with 20.0 mm average maximum) exist that need to be considered in image guidance and modeling applications.
Collapse
Affiliation(s)
- Winona L Richey
- Department of Biomedical Engineering, Vanderbilt University, 1225 Stevenson Center Ln, Nashville, 37235, USA.
- Vanderbilt Institute for Surgery and Engineering, 1161 21st Ave. S, Nashville, 37204, USA.
- Vanderbilt University, 1225 Stevenson Center Ln, Stevenson Center 5824, Nashville, TN, 37240, USA.
| | - Jon S Heiselman
- Department of Biomedical Engineering, Vanderbilt University, 1225 Stevenson Center Ln, Nashville, 37235, USA
- Vanderbilt Institute for Surgery and Engineering, 1161 21st Ave. S, Nashville, 37204, USA
| | - Ma Luo
- Department of Biomedical Engineering, Vanderbilt University, 1225 Stevenson Center Ln, Nashville, 37235, USA
- Vanderbilt Institute for Surgery and Engineering, 1161 21st Ave. S, Nashville, 37204, USA
| | - Ingrid M Meszoely
- Vanderbilt Institute for Surgery and Engineering, 1161 21st Ave. S, Nashville, 37204, USA
- Division of Surgical Oncology, Vanderbilt University Medical Center, 719 Thompson Ln Suite 22100, Nashville, 37232, USA
| | - Michael I Miga
- Department of Biomedical Engineering, Vanderbilt University, 1225 Stevenson Center Ln, Nashville, 37235, USA
- Vanderbilt Institute for Surgery and Engineering, 1161 21st Ave. S, Nashville, 37204, USA
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Medical Center North, 1161 21st Ave. S, Nashville, 37232, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA
| |
Collapse
|
10
|
Vartholomatos G, Ηarissis Η, Andreou M, Tatsi V, Pappa L, Kamina S, Βatistatou A, Markopoulos GS, Alexiou GA. Rapid Assessment of Resection Margins During Breast Conserving Surgery Using Intraoperative Flow Cytometry. Clin Breast Cancer 2021; 21:e602-e610. [PMID: 33820744 DOI: 10.1016/j.clbc.2021.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/28/2021] [Accepted: 03/03/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Positive margins are the most important factor for recurrence of the disease after breast-conserving surgery. Several methods have been developed throughout the years to evaluate the margin status during surgery in an attempt to assist the surgeon in excising the whole tumor at once, a goal that has not yet been accomplished. PATIENTS AND METHODS In our study, we compared intraoperative flow cytometry (iFC) with cytology and pathology in order to evaluate 606 samples of margins and tumors corresponding to 99 patients with invasive ductal carcinoma of no special type and invasive lobular carcinoma obtained from breast-conserving surgeries. RESULTS Using the pathology as the gold standard, flow cytometry had 93.3% sensitivity, 92.4% specificity, and 92.5% accuracy. Cytology had 82.3% sensitivity, 94.6% specificity, and 94.2% accuracy. CONCLUSIONS Our data support the suggestion that iFC is a novel, reliable technique that allows rapid evaluation of the excision margins of lumpectomies, thus improving the precision of breast-conserving surgery. Among the advantages of iFC are that it does not rely on the expertise of a pathologist or cytologist, it is low cost, and it has no additional psychological effect on patients, because no re-operation is needed.
Collapse
Affiliation(s)
- George Vartholomatos
- Haematology Laboratory-Unit of Molecular Biology, University Hospital of Ioannina, Ioannina, Greece; Neurosurgical Institute, University of Ioannina School of Medicine, Ioannina, Greece
| | | | - Maria Andreou
- Haematology Laboratory-Unit of Molecular Biology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Lamprini Pappa
- Department of Cytology, University Hospital of Ioannina, Ioannina, Greece
| | - Sevasti Kamina
- Department of Pathology, University Hospital of Ioannina, Ioannina, Greece
| | - Anna Βatistatou
- Department of Pathology, University Hospital of Ioannina, Ioannina, Greece
| | | | - George A Alexiou
- Neurosurgical Institute, University of Ioannina School of Medicine, Ioannina, Greece; Department of Neurosurgery, University Hospital of Ioannina, Ioannina, Greece.
| |
Collapse
|
11
|
Kuhl CK, Lehman C, Bedrosian I. Imaging in Locoregional Management of Breast Cancer. J Clin Oncol 2020; 38:2351-2361. [PMID: 32442068 PMCID: PMC7343437 DOI: 10.1200/jco.19.03257] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Christiane K Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital Aachen, RWTH, Aachen, Germany
| | - Constance Lehman
- Breast Imaging Section, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, Division of Surgery, University of Texas MD Anderson Cancer, Center, Houston, TX
| |
Collapse
|
12
|
Silva E, Tan M. ASO Author Reflections: Why the Surgeon, Who is the Person Most Influential in the Management of Breast Cancer, Must Have a Multidisciplinary Mindset. Ann Surg Oncol 2019; 27:739-740. [PMID: 31811436 DOI: 10.1245/s10434-019-08053-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Edibaldo Silva
- Surgical Oncology, University of Nebraska Medical Center, Omaha, USA.
| | - Mona Tan
- MammoCare, Breast Surgery, Singapore, Singapore
| |
Collapse
|
13
|
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
|
14
|
Silva E, Tan M. The Impact of Margin Status on Breast Conservation Rates. Ann Surg Oncol 2019; 26:3931-3938. [PMID: 31482391 DOI: 10.1245/s10434-019-07641-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Contemporary data indicate that breast conservation treatment (BCT) results in superior survival outcomes compared with mastectomy. However, positive margins after lumpectomy have implications for local control, and re-excisions are recommended to achieve negative margins. The need for reoperations after an initial attempt at BCT is associated with higher chance of conversion to mastectomy. Achieving negative margins at the first therapeutic surgical procedure is therefore critical to optimise BCT rates and survival outcomes. METHODS A compilation of scientific reports on BCT, margin status, rates of reoperation, and the impact on BCT rates was reviewed. Re-excision rates after initial lumpectomy is variable to a staggering degree and reported to be between 0 and 100%. High reoperation rates (ROR) are associated with higher likelihood of conversion to mastectomy, which may not confer favourable treatment outcomes. Although widely agreed that decreasing ROR is a desirable objective, there is controversy regarding the need for its urgent implementation as a quality metric. Critics of this cite challenges related to how this can be achieved and its attendant ramifications. On the other hand, without the appropriate incentive for quality improvement of surgical treatment of breast cancer, patients may be subject to poorer overall outcomes. DISCUSSION Techniques and approaches are discussed in this article to enable a reduction in positive margin status, and therefore ROR. The rationale for achieving ROR of 10-20% are explicated, as well as the impact this would have on BCT rates, which translates to better survival outcomes for women with breast cancer.
Collapse
Affiliation(s)
- Edibaldo Silva
- Surgical Oncology, University of Nebraska Medical Center, Omaha, USA.
| | - Mona Tan
- MammoCare, Breast Surgery, Singapore, Singapore
| |
Collapse
|
15
|
Faermann R, Weidenfeld J, Chepelev L, Kendal W, Verma R, Scott-Moncrieff A, Peddle S, Doherty G, Lau J, Ramsay T, Arnaout A, Lamb L, Watters JM, Seely JM. Outcomes after Surgery for Early Stage Breast Cancer in Women Staged With Preoperative Breast Magnetic Resonance Imaging According to Breast Tissue Density. JOURNAL OF BREAST IMAGING 2019; 1:115-121. [PMID: 38424925 DOI: 10.1093/jbi/wbz018] [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: 01/11/2019] [Indexed: 03/02/2024]
Abstract
PURPOSE To determine surgical outcomes and breast cancer disease-free survival outcomes of women with early stage breast cancer with and without use of preoperative breast MRI according to breast tissue density. METHODS Women with early stage breast cancer diagnosed from 2004 to 2009 were classified into 2 groups: 1) those with dense and heterogeneously dense breasts (DB); 2) those with nondense breasts (NDB) (scattered fibroglandular and fatty replaced tissue). The 2 groups were reviewed to determine who underwent preoperative MRI. Breast tissue density was determined with mammography according to ACR BI-RADS. Patients were compared according to tumor size, grade, stage, and treatment. Survival analysis was performed using Kaplan-Meier estimates. RESULTS In total, 261 patients with mean follow-up of 85 months (25-133) were included: 156 DB and 105 NDB. Disease-free survival outcomes were better in the DB group in patients with MRI than in those without MRI: patients with MRI had significantly fewer local recurrences (P < 0.016) and metachronous contralateral breast cancers (P < 0.001), but this was not the case in the NDB group. Mastectomies were higher in the DB group with preoperative MRI than in those without MRI (P < 0.01), as it was in the NDB group (P > 0.05). CONCLUSIONS Preoperative breast MRI was associated with reduced local recurrence and metachronous contralateral cancers in the DB group, but not in the NDB group; however, the DB patients with MRI had higher mastectomy rates.
Collapse
Affiliation(s)
- Renata Faermann
- Ottawa Hospital, Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Jonathan Weidenfeld
- Ottawa Hospital, Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Leonid Chepelev
- Ottawa Hospital, Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Wayne Kendal
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Ottawa Hospital, Department of Radiation Oncology, University of Ottawa, Ottawa, ON, Canada
| | - Raman Verma
- Ottawa Hospital, Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Andrew Scott-Moncrieff
- Ottawa Hospital, Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Susan Peddle
- Ottawa Hospital, Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Geoff Doherty
- Ottawa Hospital, Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Jackie Lau
- Ottawa Hospital, Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Epidemiology, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Angel Arnaout
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Ottawa Hospital, Department of Surgery, Ottawa, ON, Canada
| | - Leslie Lamb
- Ottawa Hospital, Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | | | - Jean M Seely
- Ottawa Hospital, Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
16
|
Metcalfe LN, Zysk AM, Yemul KS, Jacobs LK, Oker EE, Underwood HR, Thompson AM. Beyond the Margins-Economic Costs and Complications Associated With Repeated Breast-Conserving Surgeries. JAMA Surg 2019; 152:1084-1086. [PMID: 28768303 DOI: 10.1001/jamasurg.2017.2661] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
| | - Adam M Zysk
- Diagnostic Photonics, Inc., Chicago, Illinois
| | | | - Lisa K Jacobs
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Elif E Oker
- Health Care Services Corporation, Chicago, Illinois
| | | | | |
Collapse
|
17
|
Mubuuke AG. Knowledge, attitudes and practice of breast sonography among females at a rural health facility in Uganda. JOURNAL OF GLOBAL HEALTH REPORTS 2019. [DOI: 10.29392/joghr.3.e2019024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
|
18
|
Havel L, Naik H, Ramirez L, Morrow M, Landercasper J. Impact of the SSO-ASTRO Margin Guideline on Rates of Re-excision After Lumpectomy for Breast Cancer: A Meta-analysis. Ann Surg Oncol 2019; 26:1238-1244. [DOI: 10.1245/s10434-019-07247-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Indexed: 12/12/2022]
|
19
|
McEvoy MP, Landercasper J, Naik HR, Feldman S. Update of the American Society of Breast Surgeons Toolbox to address the lumpectomy reoperation epidemic. Gland Surg 2018; 7:536-553. [PMID: 30687627 DOI: 10.21037/gs.2018.11.03] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2015, the American Society of Breast Surgeons (ASBrS) convened a multidisciplinary consensus conference, the Collaborative Attempt to Lower Lumpectomy Reoperation Rates (CALLER). The CALLER conference endorsed a "toolbox" of multiple processes of care for which there was evidence that they were associated with fewer reoperations. We present an update of the toolbox taking into consideration the latest advances in decreasing re excision rates. In this review, we performed a comprehensive review of the literature from 2015-2018 using search terms for each tool. The original ten tools were updated with the latest evidence from the literature and our strength of recommendation. We added an additional section looking at new tools and techniques that may provide more accurate intraoperative assessment of margins. The updates on the CALLER Toolbox for lumpectomy will help guide surgeons to various resources to aid in the removal of breast cancer, while being aware of cosmesis and decreasing re excision rates.
Collapse
Affiliation(s)
- Maureen P McEvoy
- Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, USA
| | - Jeffrey Landercasper
- Gundersen Health System, Norma J. Vinger Center for Breast Cancer, La Crosse, WI, USA
| | - Himani R Naik
- Gundersen Health System, Norma J. Vinger Center for Breast Cancer, La Crosse, WI, USA
| | - Sheldon Feldman
- Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, USA
| |
Collapse
|
20
|
Valero MG, Mallory MA, Losk K, Tukenmez M, Hwang J, Camuso K, Bunnell C, King T, Golshan M. Surgeon Variability and Factors Predicting for Reoperation Following Breast-Conserving Surgery. Ann Surg Oncol 2018; 25:2573-2578. [PMID: 29786129 DOI: 10.1245/s10434-018-6526-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Reoperation after breast-conserving surgery (BCS) is common and has been partially associated with the lack of consensus on margin definition. We sought to investigate factors associated with reoperations and variation in reoperation rates across breast surgeons at our cancer center. METHODS Retrospective analyses of patients with clinical stage I-II breast cancer who underwent BCS between January and December 2014 were conducted prior to the recommendation of 'no ink on tumor' margin. Patient demographics and tumor and surgical data were extracted from medical records. A multivariate regression model was used to identify factors associated with reoperation. RESULTS Overall, 490 patients with stage I (n = 408) and stage II (n = 89) breast cancer underwent BCS; seven patients had bilateral breast cancer and underwent bilateral BCS procedures. Median invasive tumor size was 1.1 cm, reoperation rate was 22.9% (n = 114) and varied among surgeons (range 15-40%), and, in 100 (88%) patients, the second procedure was re-excision, followed by unilateral mastectomy (n = 7, 6%) and bilateral mastectomy (n = 7, 6%). Intraoperative margin techniques (global cavity or targeted shaves) were utilized in 50.1% of cases, while no specific margin technique was utilized in 49.9% of cases. Median total specimen size was 65.8 cm3 (range 24.5-156.0). In the adjusted model, patients with multifocal disease were more likely to undergo reoperation [odds ratio (OR) 5.78, 95% confidence interval (CI) 2.17-15.42]. In addition, two surgeons were found to have significantly higher reoperation rates (OR 6.41, 95% CI 1.94-21.22; OR 3.41, 95% CI 1.07-10.85). CONCLUSIONS Examination of BCS demonstrated variability in reoperation rates and margin practices among our breast surgeons. Future trials should look at surgeon-specific factors that may predict for reoperations.
Collapse
Affiliation(s)
- Monica G Valero
- Department of Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Melissa Anne Mallory
- Department of Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Katya Losk
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Mustafa Tukenmez
- Department of Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | | | - Kristen Camuso
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Craig Bunnell
- Harvard Medical School, Boston, MA, USA.,Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | - Tari King
- Department of Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Mehra Golshan
- Department of Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
21
|
Dunham AL, Ramirez LD, Vang CA, Linebarger JH, Landercasper J. Profiling Surgeon Performance for Breast Cancer Lumpectomy by Composite Measurement of Reoperations, Cosmetic Outcomes, and Patient Preferences. Ann Surg Oncol 2018; 25:1943-1952. [DOI: 10.1245/s10434-018-6479-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Indexed: 11/18/2022]
|
22
|
Chagpar AB, Tsangaris TN, Lannin DR. Do All Positive Margins in Breast Cancer Patients Undergoing a Partial Mastectomy Need to Be Resected? J Am Coll Surg 2018. [PMID: 29524664 DOI: 10.1016/j.jamcollsurg.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Positive margins have been reported in 20% to 40% of patients undergoing a partial mastectomy, often resulting in re-excision. How often the re-excision yields additional cancer and whether there are predictors of residual disease remain unknown. STUDY DESIGN Patients who had a positive margin (defined as tumor at ink for patients with invasive disease or within 1 mm for patients with ductal carcinoma in situ) in the SHAVE (A Randomized Controlled Trial of Routine Shave Margins Versus Standard Partial Mastectomy in Breast Cancer Patients) trial before randomization were evaluated to determine the rate of additional disease either in cavity shave margins or at re-excision. Details of the SHAVE trial can be found elsewhere. RESULTS Of the 235 patients in the trial, 82 (34.9%) had a positive margin before randomization; 58 of these patients underwent either cavity shave margins excision or a re-excision of the positive margin(s). Twenty-one (36.2%) patients had residual disease. On bivariate analysis, residual disease was associated with younger patient age (median 51 vs 62 years; p = 0.007), and the presence of high-grade ductal carcinoma in situ (57.1% vs 31.3% for grade 2 and 0% for grade 1; p = 0.025). The following factors were not associated with further disease: patient race; ethnicity; BMI; volume of resection; number of positive margins; extent of ductal carcinoma in situ; and extent, grade, and histologic subtype of invasive cancer. On multivariate analysis, only patient age younger than 60 years remained a significant predictor of residual disease (odds ratio 3.920; 95% CI 1.081 to 14.220; p = 0.038). CONCLUSIONS Positive margins are associated with further disease in more than one-third of patients and, aside from young age, there are no predictors of this. These findings support continued re-excision of positive margins, particularly in patients younger than 60 years of age.
Collapse
Affiliation(s)
- Anees B Chagpar
- Department of Surgery, Yale University School of Medicine, New Haven, CT.
| | | | - Donald R Lannin
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
23
|
So A, De La Cruz LM, Williams AD, Bahng J, Liao G, McDonald ES, Fisher CS, Czerniecki BJ, Sataloff D, Tchou J. The impact of preoperative magnetic resonance imaging and lumpectomy cavity shavings on re-excision rate in pure ductal carcinoma in situ-A single institution's experience. J Surg Oncol 2017; 117:558-566. [PMID: 29127721 DOI: 10.1002/jso.24890] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 10/02/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES The impact of preoperative magnetic resonance imaging (pMRI) and cavity shave margins (CSM) on re-excision rate (RR) in DCIS is unclear. We investigated whether either modality was associated with RR in DCIS. METHODS This is a single-institution retrospective study of 295 women undergoing breast conservation surgery for pure DCIS (2010-2013). CSM were the systematic resection of 4-6 margins during lumpectomy whereas selective shave margins (SSM) were the selective resection of 1-3 margins. Patient demographics and clinical characteristics were abstracted. RR was analyzed according to the use of pMRI, SSM, or CSM with respect to three high-volume breast surgeons at our institution. RESULTS RR was not associated with the use of pMRI (P = 0.87). Any shave margins (P = 0.05), DCIS size (P < 0.001), and DCIS grade (P = 0.14) associated with a lower RR. Of our high-volume surgeons, RR was lower for Surgeon A (P = 0.02). Multivariate analyses showed larger DCIS (OR 1.35, P = 0.005) and practices specific to surgeons B (OR 3.23, P = 0.04) and C (OR 3.57, P = 0.04) increased re-excision odds. CONCLUSIONS SSM/CSM and pMRI use varied among surgeons. Our results suggested the routine use of CSM, not pMRI, could lower re-excision rate, which highlighted a quality improvement opportunity at our institution.
Collapse
Affiliation(s)
- Alycia So
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Austin D Williams
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph Bahng
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Geraldine Liao
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth S McDonald
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carla S Fisher
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Dahlia Sataloff
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Tchou
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
24
|
Cavity Shaving plus Lumpectomy versus Lumpectomy Alone for Patients with Breast Cancer Undergoing Breast-Conserving Surgery: A Systematic Review and Meta-Analysis. PLoS One 2017; 12:e0168705. [PMID: 28046058 PMCID: PMC5207394 DOI: 10.1371/journal.pone.0168705] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 12/04/2016] [Indexed: 12/11/2022] Open
Abstract
The margin status is a well-established prognostic predictor for patients undergoing breast-conserving surgery (BCS). Recent data suggested that cavity shaving in addition to lumpectomy might be a promising approach for improving the clinical outcomes. We aimed to compare the efficacy and safety between cavity shaving plus lumpectomy and lumpectomy alone with a systematic review and meta-analysis. We searched the PubMed, Embase, and Cochrane CENTRAL databases for studies comparing cavity shaving with lumpectomy before June 10, 2016. Both comparative studies and self-control studies were included. A random-effects model was used to estimate the odds ratios (ORs) for positive margin rate, reoperation rate, recurrence rate, and weighted mean difference (WMD) for excised tissue volume. Twenty-six studies were included in the meta-analysis. The cavity shaving group had a significantly lower positive margin rate than the BCS-alone group (16.4% vs. 31.9%; OR = 0.41, 95% CI 0.32-0.53, P < 0.05). Cavity shaving was associated with a significantly decreased rate of reoperation (OR = 0.42, 95% CI 0.30-0.59, P < 0.05). The overall locoregional rate was low for cavity shaving and BCS-alone (3% vs. 4%). Cavity shaving had no significant effect on the risk of locoregional recurrence (OR = 0.86, 95% CI 0.32-2.35; P = 0.78). The excised tissue volume did not differ substantially between cavity shaving and BCS alone (WMD = -23.88, 95% CI -55.20 to 7.44, P = 0.14). For patients undergoing BCS, additional cavity shaving was an effective method to decrease the positive margin rate and avoid reoperation. The addition of cavity shaving did not appear to have excessive excised tissue volume compared with partial mastectomy alone.
Collapse
|
25
|
|