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Boeer B, Obermoser J, Marx M, Schönfisch B, Grube M, Röhm C, Helms G, Fugunt R, Hartkopf AD, Brucker SY, Hahn M. Ultrasound-guided breast-conserving surgery compared to conventional breast-conserving surgery. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024. [PMID: 38901438 DOI: 10.1055/a-2290-1543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
PURPOSE The goal of breast-conserving surgery is to achieve negative tumor margins, since insufficient marginal distance is associated with more local and distant recurrences. This study investigates whether IOUS (intraoperative ultrasound) can reduce the re-resection rate compared to standard breast surgery, regardless of tumor biology and focality. MATERIALS AND METHODS The present study is a monocentric, prospective, randomized, and non-blinded parallel group study conducted between 7/2015 and 2/2018. Patients with sonographically visible breast cancer were randomized into two study arms: 1) breast-conserving surgery with IOUS; 2) conventional arm. RESULTS 364 patients were included in the study and underwent surgery. Tumor biology, size, and focality were equally distributed in both groups (p = 0.497). The study arms did not differ significantly in the proportion of preoperative wire markings (p= 0.084), specimen weight (p = 0.225), surgery duration (p = 0.849), and the proportion of shavings taken intraoperatively (p = 0.903). Positive margins were present in 16.6% of the cases in the IOUS arm and in 20.8% in the conventional arm (p = 0.347). Re-operation was necessary after intraoperative shavings in 14.4% of cases in the US arm and in 21.3% in the conventional arm (p = 0.100). CONCLUSION Although the present study showed a clear difference in the rate of positive tumor margins with IOUS compared to conventional breast surgery without IOUS, this was not statistically significant in contrast to the current literature. This could be due to the high expertise of the breast surgeons, the precise wire marking, or the fact that the IOUS technique was not standardized.
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Affiliation(s)
- Bettina Boeer
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Jennifer Obermoser
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Mario Marx
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
- ELBLANDKLINIKUM Radebeul, Radebeul, Germany
| | - Birgitt Schönfisch
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Marcel Grube
- Diakonie-Klinikum Schwäbisch Hall, Schwäbisch Hall, Germany
| | - Carmen Röhm
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Gisela Helms
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Regina Fugunt
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Andreas D Hartkopf
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Sara Y Brucker
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
| | - Markus Hahn
- Department of Women's Health, University Hospital Tübingen, Tübingen, Germany
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Zhang M, Zhang J, Gao Y, Han Z, Guo C. Three-dimensional surgical margin positioning technique versus palpation-guided method for breast-conserving surgery: Feasibility, advantages, and quality of life. Asian J Surg 2024; 47:2606-2612. [PMID: 38548542 DOI: 10.1016/j.asjsur.2024.03.087] [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: 11/20/2023] [Revised: 02/10/2024] [Accepted: 03/06/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND The accurate evaluation of surgical margins holds crucial importance in determining the success of breast-conserving surgery (BCS). The aim of this study was to introduce a novel technique for the positioning of surgical margins in BCS while highlighting its advantages. METHODS This study included a cohort of breast cancer patients who underwent BCS. The patients were categorized into two groups: one group underwent BCS with the traditional palpation-guided method, and the other with the 3D-MPT technique. The study assessed and compared the feasibility, advantages, and outcomes in terms of quality of life between the two groups. RESULTS A total of 80 patients were successfully enrolled in the study. No significant differences in clinicopathological features were observed between the two groups. The 3D-MPT technique was found to be feasible and offered several advantages over the palpation-guided method. The utilization of guide wires by experienced radiologists to position the margins before surgery enabled precise and swift specimen removal, resulting in the conservation of valuable time and a reduction in the need for re-excision. Furthermore, the 3D-MPT technique exhibited the potential to enhance cosmetic outcomes and elevate patient satisfaction, particularly in cases with uncertain tumor boundaries detectable by palpation. CONCLUSION The 3D-MPT technique proves to be an effective and safe approach for reducing tumor positivity rates in initial surgical margins, thereby improving the quality of life for patients undergoing breast-conserving surgery in comparison to the conventional method.
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Affiliation(s)
- Mingliang Zhang
- Department of Surgical Oncology, The First Affiliated Hospital of Bengbu Medical University, No. 287 Changhuai Road, Bengbu 233003, China.
| | - Jingkang Zhang
- Department of Surgical Oncology, The First Affiliated Hospital of Bengbu Medical University, No. 287 Changhuai Road, Bengbu 233003, China
| | - Yue Gao
- Department of Surgical Oncology, The First Affiliated Hospital of Bengbu Medical University, No. 287 Changhuai Road, Bengbu 233003, China
| | - Zhuoqi Han
- Department of Surgical Oncology, The First Affiliated Hospital of Bengbu Medical University, No. 287 Changhuai Road, Bengbu 233003, China
| | - Chenxu Guo
- Department of Surgical Oncology, The First Affiliated Hospital of Bengbu Medical University, No. 287 Changhuai Road, Bengbu 233003, China
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Garza KY, King ME, Nagi C, DeHoog RJ, Zhang J, Sans M, Krieger A, Feider CL, Bensussan AV, Keating MF, Lin JQ, Sun MW, Tibshirani R, Pirko C, Brahmbhatt KA, Al-Fartosi AR, Thompson AM, Bonefas E, Suliburk J, Carter SA, Eberlin LS. Intraoperative Evaluation of Breast Tissues During Breast Cancer Operations Using the MasSpec Pen. JAMA Netw Open 2024; 7:e242684. [PMID: 38517441 PMCID: PMC10960202 DOI: 10.1001/jamanetworkopen.2024.2684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/30/2023] [Indexed: 03/23/2024] Open
Abstract
Importance Surgery with complete tumor resection remains the main treatment option for patients with breast cancer. Yet, current technologies are limited in providing accurate assessment of breast tissue in vivo, warranting development of new technologies for surgical guidance. Objective To evaluate the performance of the MasSpec Pen for accurate intraoperative assessment of breast tissues and surgical margins based on metabolic and lipid information. Design, Setting, and Participants In this diagnostic study conducted between February 23, 2017, and August 19, 2021, the mass spectrometry-based device was used to analyze healthy breast and invasive ductal carcinoma (IDC) banked tissue samples from adult patients undergoing breast surgery for ductal carcinomas or nonmalignant conditions. Fresh-frozen tissue samples and touch imprints were analyzed in a laboratory. Intraoperative in vivo and ex vivo breast tissue analyses were performed by surgical staff in operating rooms (ORs) within 2 different hospitals at the Texas Medical Center. Molecular data were used to build statistical classifiers. Main Outcomes and Measures Prediction results of tissue analyses from classification models were compared with gross assessment, frozen section analysis, and/or final postoperative pathology to assess accuracy. Results All data acquired from the 143 banked tissue samples, including 79 healthy breast and 64 IDC tissues, were included in the statistical analysis. Data presented rich molecular profiles of healthy and IDC banked tissue samples, with significant changes in relative abundances observed for several metabolic species. Statistical classifiers yielded accuracies of 95.6%, 95.5%, and 90.6% for training, validation, and independent test sets, respectively. A total of 25 participants enrolled in the clinical, intraoperative study; all were female, and the median age was 58 years (IQR, 44-66 years). Intraoperative testing of the technology was successfully performed by surgical staff during 25 breast operations. Of 273 intraoperative analyses performed during 25 surgical cases, 147 analyses from 22 cases were subjected to statistical classification. Testing of the classifiers on 147 intraoperative mass spectra yielded 95.9% agreement with postoperative pathology results. Conclusions and Relevance The findings of this diagnostic study suggest that the mass spectrometry-based system could be clinically valuable to surgeons and patients by enabling fast molecular-based intraoperative assessment of in vivo and ex vivo breast tissue samples and surgical margins.
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Affiliation(s)
- Kyana Y. Garza
- Department of Chemistry, The University of Texas at Austin
| | - Mary E. King
- Department of Chemistry, The University of Texas at Austin
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Chandandeep Nagi
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas
| | - Rachel J. DeHoog
- Department of Chemistry, The University of Texas at Austin
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Jialing Zhang
- Department of Chemistry, The University of Texas at Austin
| | - Marta Sans
- Department of Chemistry, The University of Texas at Austin
| | - Anna Krieger
- Department of Chemistry, The University of Texas at Austin
| | | | | | - Michael F. Keating
- Department of Chemistry, The University of Texas at Austin
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - John Q. Lin
- Department of Chemistry, The University of Texas at Austin
| | - Min Woo Sun
- Department of Biomedical Data Science, Stanford University, Stanford, California
| | - Robert Tibshirani
- Department of Biomedical Data Science, Stanford University, Stanford, California
| | - Christopher Pirko
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Kirtan A. Brahmbhatt
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ahmed R. Al-Fartosi
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Alastair M. Thompson
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Elizabeth Bonefas
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - James Suliburk
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Stacey A. Carter
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Livia S. Eberlin
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Żydowicz WM, Skokowski J, Marano L, Polom K. Current Trends and Beyond Conventional Approaches: Advancements in Breast Cancer Surgery through Three-Dimensional Imaging, Virtual Reality, Augmented Reality, and the Emerging Metaverse. J Clin Med 2024; 13:915. [PMID: 38337610 PMCID: PMC10856583 DOI: 10.3390/jcm13030915] [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: 01/11/2024] [Revised: 01/25/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024] Open
Abstract
Breast cancer stands as the most prevalent cancer globally, necessitating comprehensive care. A multidisciplinary approach proves crucial for precise diagnosis and treatment, ultimately leading to effective disease management. While surgical interventions continue to evolve and remain integral for curative treatment, imaging assumes a fundamental role in breast cancer detection. Advanced imaging techniques not only facilitate improved diagnosis but also contribute significantly to the overall enhancement of breast cancer management. This review article aims to provide an overview of innovative technologies such as virtual reality, augmented reality, and three-dimensional imaging, utilized in the medical field to elevate the diagnosis and treatment of breast cancer. Additionally, the article delves into an emerging technology known as the metaverse, still under development. Through the analysis of impactful research and comparison of their findings, this study offers valuable insights into the advantages of each innovative technique. The goal is to provide physicians, surgeons, and radiologists with information on how to enhance breast cancer management.
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Affiliation(s)
- Weronika Magdalena Żydowicz
- Department of General Surgery and Surgical Oncology, “Saint Wojciech” Hospital, “Nicolaus Copernicus” Health Center, Jana Pawła II 50, 80-462 Gdańsk, Poland; (W.M.Ż.); (J.S.)
| | - Jaroslaw Skokowski
- Department of General Surgery and Surgical Oncology, “Saint Wojciech” Hospital, “Nicolaus Copernicus” Health Center, Jana Pawła II 50, 80-462 Gdańsk, Poland; (W.M.Ż.); (J.S.)
- Department of Medicine, Academy of Applied Medical and Social Sciences, Akademia Medycznych I Spolecznych Nauk Stosowanych (AMiSNS), 2 Lotnicza Street, 82-300 Elbląg, Poland;
| | - Luigi Marano
- Department of General Surgery and Surgical Oncology, “Saint Wojciech” Hospital, “Nicolaus Copernicus” Health Center, Jana Pawła II 50, 80-462 Gdańsk, Poland; (W.M.Ż.); (J.S.)
- Department of Medicine, Academy of Applied Medical and Social Sciences, Akademia Medycznych I Spolecznych Nauk Stosowanych (AMiSNS), 2 Lotnicza Street, 82-300 Elbląg, Poland;
| | - Karol Polom
- Department of Medicine, Academy of Applied Medical and Social Sciences, Akademia Medycznych I Spolecznych Nauk Stosowanych (AMiSNS), 2 Lotnicza Street, 82-300 Elbląg, Poland;
- Department of Gastrointestinal Surgical Oncology, Greater Poland Cancer Centre, Garbary 15, 61-866 Poznan, Poland
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Barbora A, Karri S, Firer MA, Minnes R. Multifractal analysis of cellular ATR-FTIR spectrum as a method for identifying and quantifying cancer cell metastatic levels. Sci Rep 2023; 13:18935. [PMID: 37919384 PMCID: PMC10622493 DOI: 10.1038/s41598-023-46014-1] [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: 05/18/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023] Open
Abstract
Cancer is a leading cause of mortality today. Sooner a cancer is detected, the more effective is the treatment. Histopathological diagnosis continues to be the gold standard worldwide for cancer diagnosis, but the methods used are invasive, time-consuming, insensitive, and still rely to some degree on the subjective judgment of pathologists. Recent research demonstrated that Attenuated Total Reflection-Fourier Transform Infrared (ATR-FTIR) spectroscopy can be used to determine the metastatic potential of cancer cells by evaluating their membrane hydration. In the current study, we demonstrate that the conversion of ATR-FTIR spectra using multifractal transformation generates a unique number for each cell line's metastatic potential. Applying this technique to murine and human cancer cells revealed a correlation between the metastatic capacity of cancer cells within the same lineage and higher multifractal value. The multifractal spectrum value was found to be independent of the cell concentration used in the assay and unique to the tested lineage. Healthy cells exhibited a smaller multifractal spectrum value than cancer cells. Further, the technique demonstrated the ability to detect cancer progression by being sensitive to the proportional change between healthy and cancerous cells in the sample. This enables precise determination of cancer metastasis and disease progression independent of cell concentration by comparing the measured spectroscopy derived multifractal spectrum value. This quick and simple technique devoid of observer bias can transform cancer diagnosis to a great extent improving public health prognosis worldwide.
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Affiliation(s)
- Ayan Barbora
- Department of Physics, Ariel University, 40700, Ariel, Israel
| | - Sirish Karri
- Department of Chemical Engineering, Ariel University, 40700, Ariel, Israel
| | - Michael A Firer
- Department of Chemical Engineering, Ariel University, 40700, Ariel, Israel
- Adelson School of Medicine, Ariel University, 40700, Ariel, Israel
- Ariel Center for Applied Cancer Research, Ariel University, 40700, Ariel, Israel
| | - Refael Minnes
- Department of Physics, Ariel University, 40700, Ariel, Israel.
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Ferrucci M, Milardi F, Passeri D, Mpungu LF, Francavilla A, Cagol M, Saibene T, Michieletto S, Toffanin M, Del Bianco P, Grossi U, Marchet A. Intraoperative Ultrasound-Guided Conserving Surgery for Breast Cancer: No More Time for Blind Surgery. Ann Surg Oncol 2023; 30:6201-6214. [PMID: 37606837 DOI: 10.1245/s10434-023-13900-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/23/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Breast-conserving surgery (BCS) still remains a blind surgery despite all available tumor localization methods. Intraoperative ultrasound (IOUS) allows real-time visualization during all resection phases. METHODS This was a prospective observational cohort study conducted at the Veneto Institute of Oncology between January 2021 and June 2022. Patients with ductal carcinoma in situ, T1-2 invasive cancer, or post-neoadjuvant tumors, suitable for BCS, were recruited. All breast cancer lesion types were included, i.e. solid palpable, solid non-palpable, non-solid non-palpable, and post-neoadjuvant treatment residual lesions. Eligible participants were randomly assigned to either IOUS or traditional surgery (TS) in a 1:1 ratio. The main outcomes were surgical margin involvement, reoperation rate, closest margin width, main specimen and cavity shaving margin volumes, excess healthy tissue removal, and calculated resection ratio (CRR). RESULTS Overall, 160 patients were enrolled: 80 patients were allocated to the TS group and 80 to the IOUS group. IOUS significantly reduced specimen volumes (16.8 cm3 [10.5-28.9] vs. 24.3 cm3 [15.0-41.3]; p = 0.015), with wider closest resection margin width (2.0 mm [1.0-4.0] vs. 1.0 mm [0.5-2.0] after TS; p < 0.001). Tumor volume to specimen volume ratio was significantly higher after IOUS (4.7% [2.5-9.1] vs. 2.9% [0.8-5.2]; p < 0.001). IOUS yielded significantly better CRR (84.5% [46-120.8] vs. 114% [81.8-193.2] after TS; p < 0.001), lower involved margin rate (2.5 vs. 15%; p = 0.009) and reduced re-excision rate (2.5 vs. 12.5%; p = 0.032). CONCLUSIONS IOUS allows real-time resection margin visualization and continuous control during BCS. It showed clear superiority over TS in both oncological and surgical outcomes for all breast cancer lesion types. These results disfavor the paradigm of blind breast surgery.
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Affiliation(s)
- Massimo Ferrucci
- Breast Surgery Unit, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy.
| | - Francesco Milardi
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Daniele Passeri
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | | | - Andrea Francavilla
- Unit of Biostatistics, Epidemiology and Public Health, Department of CardiacThoracic Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Matteo Cagol
- Breast Surgery Unit, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
| | - Tania Saibene
- Breast Surgery Unit, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
| | - Silvia Michieletto
- Breast Surgery Unit, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
| | - Mariacristina Toffanin
- Breast Surgery Unit, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
| | - Paola Del Bianco
- Clinical Trials and Biostatistics, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
| | - Ugo Grossi
- General Surgery, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Alberto Marchet
- Breast Surgery Unit, Veneto Institute of Oncology IOV, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Padua, Italy
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Zhao R, Zhang J, Gao J. Blood flow on ultrasound imaging is a predictor of lump margin status in breast-conserving patients: a retrospective matching study. Eur J Med Res 2023; 28:357. [PMID: 37730626 PMCID: PMC10510181 DOI: 10.1186/s40001-023-01356-4] [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: 01/27/2023] [Accepted: 09/10/2023] [Indexed: 09/22/2023] Open
Abstract
PURPOSE This study investigated the relationship between breast ultrasound features and lump margin status in breast-conserving patients. METHODS A single-institution database and medical records system were searched to identify patients who had undergone breast-conserving surgery between 2015 and 2022. Patients were divided into case and control groups based on their postoperative margin status, and different matching methods [case-control matching (CCM) and propensity score matching (PSM)] were used to match the cases and controls at a ratio of 1:1. RESULTS Before matching, patients with positive margins were more likely to have a tumor with increased blood flow (OR = 2.90, 95% CI 1.83-4.61, p < 0.001) and microcalcifications (OR = 2.22, 95% CI 1.44-3.42, p < 0.001). Among the 83 pairs of CCM subjects, patients with positive margins were prone to increased blood flow (p = 0.007) and crab sign (p = 0.040). In addition, there was a significant difference in blood flow (p = 0.030) among PSM subjects. After adjusting for the unbalanced factors, the same results were obtained. CONCLUSIONS Ultrasound blood flow significantly predicts the status of breast-conserving margins, but further studies are required to verify our findings.
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Affiliation(s)
- Rong Zhao
- General Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
| | - Jianyong Zhang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Jinnan Gao
- General Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China.
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China.
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Fosko NK, Gribkova Y, Krupa K, Bs KJ, Moore D, Chen C, Potdevin L, Kumar S, Eladoumikdachi F, Kowzun MJ. The Use of Intraoperative Ultrasound During Breast Conserving Surgery. Clin Breast Cancer 2023; 23:54-59. [PMID: 36319507 DOI: 10.1016/j.clbc.2022.10.003] [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: 07/18/2022] [Accepted: 10/07/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The purpose of this study is to evaluate the utilization of intraoperative ultrasound (IOUS) for tumor localization in breast-conserving surgery and to examine its impact on margin positivity and re-excision rates. Additionally, the study seeks to identify factors contributing to surgeon utilization of IOUS. METHODS A retrospective chart review was conducted of patients with preoperative diagnosis of breast cancer undergoing breast-conserving surgery by breast surgeons at multiple centers within a single healthcare system. Characteristics such as lesion size, palpability, histology, receptor status, and use of neoadjuvant chemotherapy were recorded. Re-excision rates were determined based on localization technique and surgeons' status of breast ultrasound certification. RESULTS A total of 671 cases were performed, with 322 meeting study inclusion. 57 cases utilized IOUS, 250 utilized preoperative wire-guided localization (WGL), 10 used both methods and 5 cases used neither method. There was no significant difference in re-excision rates between IOUS and WGL or among the four surgeons. Ultrasound-certified surgeons were more likely to utilize IOUS, and re-excision rates trended higher for WGL, which may be clinically significant. CONCLUSION Increasing familiarity with and utilization of IOUS during breast-conserving surgery may be clinically advantageous over traditional localization techniques. Ultrasound certification may lead to increased use of IOUS among surgeons.
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Affiliation(s)
- Nicole K Fosko
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Kelly Krupa
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Kavita Jain Bs
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Dirk Moore
- Rutgers School of Public Health, New Brunswick, New Jersey
| | - Chunxia Chen
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Lindsay Potdevin
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Shicha Kumar
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | | | - Maria J Kowzun
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
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The Beneficial Impact of Intraoperative Ultrasound on Resection Margin Status during Breast Conserving Surgery. Int J Surg Oncol 2022; 2022:2268821. [DOI: 10.1155/2022/2268821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 11/05/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Abstract
Background. Surgical resection with clear surgical cut margins is the mainstay of managing malignant breast neoplasms. Multiple techniques have been suggested to enhance resection status during breast-conserving surgery (BCS), including intraoperative ultrasonography (IOUS). Herein, we conducted the current investigation to reveal the benefit of IOUS on the achievement of R0 resection. Patients and Methods. This retrospective investigation included 140 patients who underwent BCS. They were divided into two groups: the IOUS group (40 cases) and the control group (100 cases). Our primary objective was to determine the free resection margin status (R0). Results. Both study groups expressed statistically comparable demographic and clinical data. Additionally, histopathological examination revealed no significant difference between the two groups regarding the tumor type, stage, or grade. Nonetheless, the R0 resection margin was more frequently encountered in association with IOUS application (97.5% compared to 79% in the control group), and that difference was statistically significant (
). Conclusion. The application of IOUS has a significant beneficial impact on the outcomes of BCS. It is associated with a marked decline in positive resection margins, and its application should be encouraged in the breast oncological practice.
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10
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Zhao R, Xing J, Gao J. Development and Validation of a Prediction Model for Positive Margins in Breast-Conserving Surgery. Front Oncol 2022; 12:875665. [PMID: 35646633 PMCID: PMC9133412 DOI: 10.3389/fonc.2022.875665] [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: 02/14/2022] [Accepted: 04/12/2022] [Indexed: 11/21/2022] Open
Abstract
Background The chances of second surgery due to positive margins in patients receiving breast-conversing surgery (BCS) were about 20-40%. This study aims to develop and validate a nomogram to predict the status of breast-conserving margins. Methods The database identified patients with core needle biopsy-proven ductal carcinoma in situ (DCIS) or invasive breast carcinoma who underwent BCS in Shanxi Bethune Hospital between January 1, 2015 and December 31, 2021 (n = 573). The patients were divided into two models: (1) The first model consists of 398 patients who underwent BCS between 2015 and 2019; (2) The validation model consists of 175 patients who underwent BCS between 2020 and 2021. The development of the nomogram was based on the findings of multivariate logistic regression analysis. Discrimination was assessed by computing the C-index. The Hosmer-Lemeshow goodness-of-fit test was used to validate the calibration performance. Results The final multivariate regression model was developed as a nomogram, including blood flow signals (OR = 2.88, p = 0.001), grade (OR = 2.46, p = 0.002), microcalcifications (OR = 2.39, p = 0.003), tumor size in ultrasound (OR = 2.12, p = 0.011) and cerbB-2 status (OR = 1.99, p = 0.042). C-indices were calculated of 0.71 (95% CI: 0.64-0.78) and 0.68 (95% CI: 0.59-0.78) for the modeling and the validation group, respectively. The calibration of the model was considered adequate in the validation group (p > 0.05). Conclusion We developed a nomogram that enables the estimation of the preoperative risk of positive BCS margins. Our nomogram provides a valuable tool for identifying high-risk patients who might have to undergo a wider excision.
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Affiliation(s)
- Rong Zhao
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Jun Xing
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Jinnan Gao
- Department of Breast Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
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11
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Recent Advances in Intraoperative Lumpectomy Margin Assessment for Breast Cancer. CURRENT BREAST CANCER REPORTS 2022. [DOI: 10.1007/s12609-022-00451-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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12
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Kumar D, Singh C, Chintamani. A randomized study comparing intraoperative Ultrasound and Palpatory method in patients with breast cancer. JOURNAL OF RADIATION AND CANCER RESEARCH 2022. [DOI: 10.4103/jrcr.jrcr_49_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Choe AI, Ismail R, Mack J, Walter V, Yang AL, Dodge DG. Review of Variables Associated With Positive Surgical Margins Using Scout Reflector Localizations for Breast Conservation Therapy. Clin Breast Cancer 2021; 22:e232-e238. [PMID: 34348869 DOI: 10.1016/j.clbc.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: 06/04/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate factors contributing to positive surgical margins associated with reflector guidance for patients undergoing breast conserving therapy for malignancy. MATERIALS AND METHODS A retrospective IRB-approved review of our institutional database was performed for malignant breast lesions preoperatively localized from January 1, 2018 to December 31, 2020. The following data was recorded using electronic medical records: lesion type and grade, lesion location, reflector and wire placement modality, use of intraoperative ultrasound, margin status, patient age, family history, BMI, and final pathology. Statistical analysis was performed with univariate summary statistics and logistic regression. P < .05 was significant. RESULTS A total of 606 image-guided pre-surgical localizations were performed for lumpectomies of breast malignancies. A total of 352 of 606 (58%) wire localizations and 254 of 606 (42%) SCOUT reflector localizations were performed. Sixty out of 352 (17%) of wire-localized patients had positive surgical margins, whereas forty-eight out of 254 (19%) of reflector-localized patients had positive surgical margins. (OR = 1.12, P value: .59). For reflector guided cases, the use of intraoperative ultrasound (IOUS) was associated with decreased positive margin status (OR = 0 .28, 95% CI = [0.14, 0.58]) while in situ disease was associated with increased positive margin status (OR = 1.99, 95% CI = [1.05, 3.75]). No association between modality used for localization (mammography vs. ultrasound) and positive margin status was observed (OR = 0.63, 95% CI = [0.33, 1.19]). No association between positive margins and age, family history, tumor location and BMI was observed. CONCLUSION For reflector guided surgeries, the use of IOUS was associated with decreased positive margins, by contrast the presence of ductal carcinoma in situ was associated with increased positive margins. There was no statistically significant difference in surgical outcomes for reflector-guided localization compared to wire localizations of the breast.
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Affiliation(s)
- Angela I Choe
- Penn State Health Milton S Hershey Medical Center, Hershey, PA.
| | | | - Julie Mack
- Penn State Health Milton S Hershey Medical Center, Hershey, PA
| | - Vonn Walter
- Penn State Health Milton S Hershey Medical Center, Hershey, PA
| | | | - Daleela G Dodge
- Penn State Health Milton S Hershey Medical Center, Hershey, PA
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14
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Kumar N, Tandon M, Chintamani C. Intraoperative Specimen Ultrasonography: Is It a Reliable Tool for Margin Assessment Following Breast Conservation Surgery for Breast Carcinoma? Cureus 2021; 13:e15806. [PMID: 34178555 PMCID: PMC8221645 DOI: 10.7759/cureus.15806] [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] [Accepted: 06/21/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Assessment of margins after breast conservation surgery is an essential part of management in breast cancer and is important in prognostication of the patient. Various intra-operative techniques like frozen section and imprint cytology are in use to ensure negative margins but have their limitations in the fact that 3D evaluation is not feasible. These lead to false negatives and also are operator dependent. In order to obviate these shortcomings, various centers are using specimen imaging (specimen mammogram and ultrasonography). AIMS AND OBJECTIVES 1) To evaluate the accuracy of specimen ultrasonography in assessing the margins following breast conservation surgery (BCS). 2) To compare the accuracy of intra-operative specimen ultra-sonography with frozen section for assessment of excision margins following BCS. MATERIALS AND METHODS Sixty-two biopsy-proven patients with breast cancer who underwent BCS were included in this prospective study at a tertiary cancer care center. The oriented specimens were evaluated by specimen ultrasonography and later by frozen section. The final histopathology served as the gold standard. RESULTS Specimen ultrasonography is found to be superior to frozen section in providing detailed assessment of margins in patients undergoing breast conservation. Specimen ultrasonography was also able to detect additional lesions which might be missed on frozen section, especially the in-situ carcinoma.
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Affiliation(s)
- Niranjan Kumar
- Department of Surgery, Tata Main Hospital, Jamshedpur, IND
| | - Megha Tandon
- Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, IND
| | - Chintamani Chintamani
- Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, IND
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15
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Cartagena LC, McGuire K, Zot P, Pillappa R, Idowu M, Robila V. Breast-Conserving Surgeries With and Without Cavity Shave Margins Have Different Re-excision Rates and Associated Overall Cost: Institutional and Patient-Driven Decisions for Its Utilization. Clin Breast Cancer 2021; 21:e594-e601. [PMID: 33814286 DOI: 10.1016/j.clbc.2021.03.003] [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] [Received: 11/06/2020] [Revised: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Reducing the rate of margin positivity and reoperations remains a paramount goal in breast-conserving surgery (BCS). This study assesses the effectiveness of standard partial mastectomy with cavity shave margins (CSM) compared with partial mastectomy with selective margin resection (SPM), with regard to outcomes of the initial surgeries, re-excisions, and overall costs. PATIENTS AND METHODS This is a retrospective review of 122 eligible breast cancer patients who underwent BCS at one institution. The CSM and SPM groups each included 61 patients, matched for presurgical diagnoses and clinical stage. Data including margin status, rates and reason for re-excision, associated operation times, and costs were analyzed. RESULTS Patients undergoing CSM had less than half the rate of positive margins (PMs) (10% vs. 23%; P = .03) and re-excisions (8% vs. 23%; P = .02) compared with SPM. In the former group, the margin involvement was focal, and re-excisions were performed almost exclusively for PMs. For SPM, the majority (92%) of PMs were on the main lumpectomy specimen rather than the selective margins, and re-excisions included, in addition to PMs, extensive or multifocal negative but close margins. Reduced breast tissue volumes were removed with CSM, particularly for patients undergoing a single surgery (47 vs. 165 cm3; P < .001). The initial surgery with CSM is on average 27% more costly than that for SPM (P < .001), due to the increased pathology costs which are partially offset by the increased re-excision rates in SPM. CONCLUSION Circumferential cavity shaving, associated with consistent lower PMs, tissue volumes excised, and re-excision rates, is appropriate for routine implementation as a method offering superior surgical outcomes.
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Affiliation(s)
| | - Kandace McGuire
- Department of Surgery, Virginia Commonwealth University, Richmond, VA
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Lee J, Park HY, Kim WW, Park CS, Ji Y, Kim HJ, Kim WH, Park JY, Park NJY, Chae YS, Lee SJ, Jung JH. Clinical efficacy of intraoperative ultrasound for margin assessment in breast-conserving surgery. Breast J 2020; 26:2308-2311. [PMID: 33140879 DOI: 10.1111/tbj.14063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/06/2020] [Accepted: 09/09/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Jeeyeon Lee
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ho Yong Park
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Wan Wook Kim
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Chan Sub Park
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yungeun Ji
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hye Jung Kim
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Won Hwa Kim
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ji-Young Park
- Department of Pathology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Nora Jee-Young Park
- Department of Pathology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yee Soo Chae
- Department of Oncology/Hematology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Soo Jung Lee
- Department of Oncology/Hematology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jin Hyang Jung
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
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17
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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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18
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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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Newton A, Predina J, Mison M, Runge J, Bradley C, Stefanovski D, Singhal S, Holt D. Intraoperative near-infrared imaging can identify canine mammary tumors, a spontaneously occurring, large animal model of human breast cancer. PLoS One 2020; 15:e0234791. [PMID: 32555698 PMCID: PMC7299356 DOI: 10.1371/journal.pone.0234791] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/02/2020] [Indexed: 01/05/2023] Open
Abstract
Introduction Current methods of intraoperative margin assessment in breast conserving surgery are impractical, unreliable, or time consuming. We hypothesized that intraoperative near-infrared (NIR) imaging with an FDA-approved NIR optical contrast agent could identify canine mammary tumors, a spontaneous large animal model of human breast cancer, during surgery. Methods Dogs with mammary tumors underwent a standard of care lumpectomy or mastectomy with wide surgical margins 20 hours after indocyanine green administration (3 mg/kg IV). During surgery, NIR imaging was performed on tumors and wound margins in situ and tumors and lymph nodes ex vivo. Following resection, the wound bed was examined for residual fluorescence. Fluorescence intensity was determined by signal-to-background ratio (SBR). All tumors, areas of residual fluorescence, and lymph nodes underwent histopathologic analysis. Results There were 41 mammary tumors in 16 female dogs. Twenty tumors were malignant and 21 were benign. Twenty-eight tumors were fluorescent (mean SBR 1.5±0.2). Sensitivity of fluorescence for all malignant tumors was 80% (16/20) and 93.3% (14/15) for malignant tumors > 2 cm. Specificity for malignancy was low (< 2cm = 55%; > 2cm = 30%). Tumors > 2 cm were more likely to be fluorescent (OR 6.05, 95% CI 1.50–24.44, P = 0.011) but not more likely to be malignant (OR 3.09, 95% CI 0.86–11.14, P = 0.085) than tumors ≤ 2 cm. Four out of seven inguinal lymph nodes excised in the mastectomy specimen fluoresced. All four drained malignant tumors; however only 2/4 contained metastatic disease. Conclusion Systemic ICG accumulates reliably in malignant canine mammary tumors > 2 cm. Although no tumor margins fluoresced, a wider margin of normal tissue is removed in canine mastectomy, making direct comparisons with breast conserving surgery difficult. Targeted NIR imaging agents are likely required to improve detection of smaller tumors and improve the specificity of NIR imaging for residual disease and metastatic lymph node detection.
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Affiliation(s)
- Andrew Newton
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Jarrod Predina
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Michael Mison
- Department of Clinical Sciences and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, United States of America
| | - Jeffrey Runge
- Department of Clinical Sciences and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, United States of America
| | - Charles Bradley
- Department of Pathobiology, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, United States of America
| | - Darko Stefanovski
- Department of Clinical Studies New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, Pennsylvania, United States of America
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - David Holt
- Department of Clinical Sciences and Advanced Medicine, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, United States of America
- * E-mail:
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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: 29] [Impact Index Per Article: 7.3] [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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21
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Krishna KL, Srinath BS, Santosh D, Velusamy S, Divyamala KP, Sariya Mohammadi J, Kurpad V, Kulkarni S, Yaji P, Goud S, Dhanireddy S, Ram J. A comparative study of perioperative techniques to attain negative margins and spare healthy breast tissue in breast conserving surgery. Breast Dis 2020; 39:127-135. [PMID: 32831188 DOI: 10.3233/bd-200443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND AND AIM Traditionally lumpectomy as a part of breast-conserving surgery (BCS) is performed by palpation-guided method leading to positive margins and large excision volumes. There is no evidence suggesting that wide margin excisions decrease intra-breast tumour recurrence. Various perioperative techniques are used for margin assessment. We aimed to compare three commonly used techniques, i.e., ultrasound-guided surgery, palpation-guided surgery and cavity shaving for attaining negative margins and estimating the extent of healthy breast tissue resection. METHOD A prospective comparative study was performed on 90 patients who underwent breast conservation surgery for early breast cancer between August 2018 and June 2019. Tumour excision with a minimum of 1 cm margin was done either using ultrasound, palpation or cavity shaving. Histopathological evaluation was done to assess the margin status and excess amount of resected normal breast tissue. Calculated resection ratio (CRR) defining the excess amount of the resected breast tissue was achieved by dividing the total resection volume (TRV) by optimal resection volume (ORV). The time taken for excision was also recorded. RESULTS Histopathology of all 90 patients (30 in each group) revealed a negative resection margin in 93.3% of 30 patients in palpation-guided surgery group and 100% in both ultrasound-guided surgery and cavity shaving groups. Two patients (6.7%) from the cavity shaving group had positive margins on initial lumpectomy but shave margins were negative. TRV was significantly less in the ultrasound-guided surgery group compared to the palpation-guided surgery group and cavity shaving group (76.9 cm3, 94.7 cm3 and 126.3 cm3 respectively; p < 0.0051). CRR was 1.2 in ultrasound group compared to 1.9 in palpation group and 2.1 in cavity shave group which was also statistically significant (p < 0.0001).Excision time was significantly less (p < 0.001) in palpation-guided surgery group (13.8 min) compared to cavity shaving group (15.1 min) and ultrasound-guided group (19.4 min). CONCLUSION Ultrasound-guided surgery is more accurate in attaining negative margins with the removal of least amount of healthy breast tissue compared to palpation-guided surgery and cavity shaving.
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Affiliation(s)
- Kanyadhara Lohita Krishna
- Department of Surgical Oncology, Sri Shankara Cancer Hospital and Research Centre, Basavangudi, Bangalore, Karnataka, India
| | - B S Srinath
- Department of Surgical Oncology, Sri Shankara Cancer Hospital and Research Centre, Basavangudi, Bangalore, Karnataka, India
| | - Divya Santosh
- Department of Breast Radiology, Sri Shankara Cancer Hospital and Research Centre, Basavangudi, Bangalore, Karnataka, India
| | - Shanthi Velusamy
- Department of Pathology, Sri Shankara Cancer Hospital and Research Centre, Basavangudi, Bangalore, Karnataka, India
| | - K P Divyamala
- Department of Pathology, Sri Shankara Cancer Hospital and Research Centre, Basavangudi, Bangalore, Karnataka, India
| | - J Sariya Mohammadi
- Department of Surgical Oncology, Sri Shankara Cancer Hospital and Research Centre, Basavangudi, Bangalore, Karnataka, India
| | - Vishnu Kurpad
- Department of Surgical Oncology, Sri Shankara Cancer Hospital and Research Centre, Basavangudi, Bangalore, Karnataka, India
| | - Sanjeev Kulkarni
- Department of Surgical Oncology, Sri Shankara Cancer Hospital and Research Centre, Basavangudi, Bangalore, Karnataka, India
| | - Prabhat Yaji
- Department of Surgical Oncology, Sri Shankara Cancer Hospital and Research Centre, Basavangudi, Bangalore, Karnataka, India
| | - Sandeep Goud
- Department of Surgical Oncology, Sri Shankara Cancer Hospital and Research Centre, Basavangudi, Bangalore, Karnataka, India
| | - Subhashini Dhanireddy
- Department of Surgical Oncology, Sri Shankara Cancer Hospital and Research Centre, Basavangudi, Bangalore, Karnataka, India
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22
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Use of Intraoperative Ultrasound During Breast Conservation Surgery (BCS) for Palpable Breast Cancer: an Extremely Effective Approach with Improved Oncological Outcome. Indian J Surg Oncol 2019; 10:600-607. [PMID: 31857750 DOI: 10.1007/s13193-019-00934-5] [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: 12/19/2018] [Accepted: 05/02/2019] [Indexed: 10/26/2022] Open
Abstract
For clinically low-volume breast cancer patients subjected to BCS, there is a concern regarding achieving microscopically negative margins and avoiding inadvertent resection of excessive volume of breast tissue. In this study, we utilized intraoperative ultrasound to guide resection in patients subjected to BCS. This was compared with palpation-guided resection. A total of 80 patients of invasive breast carcinoma (T1-2, N0-1, M0) (39 patients in USG-guided BCS (group A) and 41 patients in palpation-guided BCS (group B)) were enrolled. In group A, intraoperative localization was performed using a multifrequency 10-MHz linear array ultrasound probe and tumors were excised under USG guidance. In group B, tumor excision was guided by the palpation skills of the surgeon with the aim of achieving grossly negative margin circumferentially. Specimen volume was measured using water displacement technique. One out of 39 patients (2.56%) in group A and 5 out of 41(12.19%) in group B had positive margin in histopathology report. Mean of specimen volume in groups A and B was 42.67 and 57.97 ml respectively (P = 0.011). Mean of excess volume removed in study group was 4.19 ml and in control group, it was 24.11 ml (P = < 0.01). Mean of calculated resection ratio in study group was 1.1 and in control group was 1.73 (P = 0.01). Use of intraoperative ultrasound during BCS may help in improving margin clearance, reducing additional procedures, and preserving the normal breast parenchyma. The safety, ease, and effectivity of this technique may result in its wider application in future.
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Jamaris S, Akpolat-Basci L, Stephanou M, Wetzig S, Cubuk Y, Gerharz J, Bittner AK, See MH, Liedtke C, Kolberg HC. Re-Excision Rates in Breast-Conserving Surgery for Invasive Breast Cancer after Neoadjuvant Chemotherapy with and without the Use of a Radiopaque Tissue Transfer and X-ray System. Breast Care (Basel) 2019; 14:302-307. [PMID: 31798390 DOI: 10.1159/000493017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Significant re-excision rates in breast-conserving surgery (BCS) after neoadjuvant systemic chemotherapy may result from difficulties in defining the surgical target particularly in cases with excellent treatment response. Devices allowing an exact topographic localisation of the lesion in the resected tissue could reduce re-excision rates by optimising the intraoperative detection of involved margins. Methods 80 patients with invasive breast cancer receiving BCS after neoadjuvant chemotherapy were included in this non-randomized case-control study. 40 patients with specimen radiography performed in a standard approach (control group) were compared to 40 patients with use of a radiopaque tissue transfer system (study group). Results 19/80 (23.75%) patients required re-excision because of involved margins; among those, 14/40 (35%) were in the control group and 5/40 (12.5%) in the study group. The association between the use of the radiopaque tissue transfer system and the lower re-excision rate was statistically significant (p = 0.023). Conclusion Our analysis provides a rationale for the routine use of a radiopaque tissue transfer system for specimen radiography in BCS after neoadjuvant chemotherapy for invasive breast cancer in order to reduce re-excision rates.
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Affiliation(s)
- Suniza Jamaris
- Department of Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Leyla Akpolat-Basci
- Klinik für Gynäkologie und Senologie, Evangelisches Krankenhaus Wesel, Wesel, Germany
| | - Miltiades Stephanou
- Klinik für Gynäkologie und Geburtshilfe, Marienhospital Bottrop, Bottrop, Germany
| | - Sarah Wetzig
- Klinik für Gynäkologie und Geburtshilfe, Marienhospital Bottrop, Bottrop, Germany
| | - Yueksel Cubuk
- Klinik für Radiologie, Marienhospital Bottrop, Bottrop, Germany
| | | | - Ann-Kathrin Bittner
- Klinik für Gynäkologie und Geburtshilfe, Universitätsklinikum Essen, Essen, Germany
| | - Mee Hoong See
- Department of Surgery, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Cornelia Liedtke
- Klinik für Gynäkologie mit Brustzentrum, Charité - Universitätsmedizin Berlin, Berlin, Germany
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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.
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Affiliation(s)
- Edibaldo Silva
- Surgical Oncology, University of Nebraska Medical Center, Omaha, USA.
| | - Mona Tan
- MammoCare, Breast Surgery, Singapore, Singapore
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Vispute T, Seenu V, Parshad R, Hari S, Thulkar S, Mathur S. Comparison of resection margins and cosmetic outcome following intraoperative ultrasound-guided excision versus conventional palpation-guided breast conservation surgery in breast cancer: A randomized controlled trial. Indian J Cancer 2019; 55:361-365. [PMID: 30829271 DOI: 10.4103/ijc.ijc_2_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Use of intraoperative ultrasound (IOUS) has been shown to help achieve satisfactory cosmesis and negative margins in breast conserving surgery (BCS). This study has been done to compare the oncological and cosmetic outcomes following BCS using conventional palpatory method and IOUS. MATERIALS AND METHODS This is a prospective randomized controlled trial conducted at a tertiary care teaching and research institute in India. Patients with early operable breast cancer willing for BCS were included. Tumors were excised with 1 cm margin. In palpatory group, tumor was palpated and 1 cm margin was taken with a measuring scale while in the second group, IOUS was used to mark the margins. Histopathological evaluation was done to assess margins and cosmesis was assessed by patient, resident doctor, and nurse independently. RESULTS Sixty patients were included, 32 in the ultrasonography-guided and 28 in palpation-guided wide local excision. The mean age of patients was 48.78 years. In both groups, mean tumor size was 3.18 cm. Margin thickness and positivity was higher in palpatory group (though P > 0.05). Most patients were satisfied with cosmesis. There was no significant difference in complications and specimen volume in both groups. Presence of ductal carcinoma in situ component and expression of Her2neu by tumor cells had a significant impact on margin positivity. CONCLUSIONS Intraoperative use of ultrasound offers a real-time assessment of margin status and may reduce the margin positivity rate compared to conventional palpation-guided method.
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Affiliation(s)
- Tejas Vispute
- Department of Surgical Oncology, BRA-IRCH; Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
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- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - V Seenu
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Rajinder Parshad
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Smriti Hari
- Department of Radio Diagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Thulkar
- Department of Radio Diagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Sandeep Mathur
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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Value of intra-operative ultrasound in localization of palpable or non-palpable breast tumors during breast conserving surgery. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2018. [DOI: 10.1016/j.ejrnm.2018.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Carlino G, Rinaldi P, Giuliani M, Rella R, Bufi E, Padovano F, Ciardi C, Romani M, Belli P, Manfredi R. Ultrasound-guided preoperative localization of breast lesions: a good choice. J Ultrasound 2018; 22:85-94. [PMID: 30367356 DOI: 10.1007/s40477-018-0335-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 10/11/2018] [Indexed: 12/31/2022] Open
Abstract
PURPOSE The aim of the study was to verify whether ultrasound (US)-guided preoperative localization of breast lesions is an adequate technique for correct and safe surgical resection and to contribute positively and effectively to this topic in the literature with our results. METHODS From June 2016 to November 2016, 155 patients with both benign and malignant breast lesions were selected from our institute to undergo US localization before surgery. The lesions included were: sonographically visible and nonpalpable lesions; palpable lesions for which a surgeon had requested US localization to better evaluate the site and extension; sonographically visible, multifocal breast lesions, both palpable and nonpalpable. US localization was performed using standard linear transducers (Siemens 18 L6, 5.5-8 MHz, 5.6 cm, ACUSON S2000 System, Siemens Medical Solutions). The radiologist used a skin pen to mark the site of the lesion, and the reported lesion's depth and distance from the nipple and pectoral muscle were recorded. The lesions were completely excised by a team of breast surgeons, and the surgical specimens were sent to the Radiology Department for radiological evaluation and to the Pathology Department for histological assessment. RESULTS In 155 patients who underwent to preoperative US localization, 188 lesions were found, and the location of each lesion was marked with a skin pen. A total of 181 lesions were confirmed by the final histopathologic exam (96.28%); 132 of them (72.92%) were malignant, and 124 of these (93.93%) showed free margins. CONCLUSIONS US-guided preoperative localization of sonographically visible breast lesions is a simple and nontraumatic procedure with high specificity and is a useful tool for obtaining accurate surgical margins.
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Affiliation(s)
- Giorgio Carlino
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Pierluigi Rinaldi
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Michela Giuliani
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Rossella Rella
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Enida Bufi
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Federico Padovano
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Chiara Ciardi
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Maurizio Romani
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Paolo Belli
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Riccardo Manfredi
- Department of Radiology, Fondazione Policlinico A. Gemelli IRCCS - Università Cattolica Sacro Cuore, Largo Agostino Gemelli 8, 00168, Rome, Italy
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Intraoperative ultrasound in breast cancer surgery-from localization of non-palpable tumors to objectively measurable excision. World J Surg Oncol 2018; 16:184. [PMID: 30205823 PMCID: PMC6134720 DOI: 10.1186/s12957-018-1488-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 09/05/2018] [Indexed: 01/08/2023] Open
Abstract
Background The utilization of intraoperative ultrasound (IOUS) in breast cancer surgery is a relatively new concept in surgical oncology. Over the last few decades, the field of breast cancer surgery has been striving for a more rational approach, directing its efforts towards removing the tumor entirely yet sparing tissue and structures not infiltrated by tumor cells. Further progress in objectivity and optimization of breast cancer excision is possible if we make the tumor and surrounding tissue visible and measurable in real time, during the course of the operation; IOUS seems to be the optimal solution to this complex requirement. IOUS was introduced into clinical practice as a device for visualization of non-palpable tumors, and compared to wire-guided localization (WGL), IOUS was always at least a viable, or much better alternative, in terms of both precision in identification and resection and for patients’ and surgeons’ comfort. In recent years, intraoperative ultrasound has been used in the surgery of palpable tumors to optimize resection procedures and overcome the disadvantages of classic palpation guided surgery. Objective The aim of this review is to show the role of IOUS in contemporary breast cancer surgery and its changes over time. Methods A PubMed database comprehensive search was conducted to identify all relevant articles according to assigned key words. Conclusion Over time, the use of IOUS has been transformed from being the means of localizing non-palpable lesions to an instrument yielding a reduced number of positive resection margins, with a smaller volume of healthy breast tissue excided around tumor, by making the excision of the tumor optimal and objectively measurable.
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Vieni S, Graceffa G, Priola R, Fricano M, Latteri S, Latteri MA, Cipolla C. Ultrasound-Guided Breast-Conservative Surgery Decreases the Rate of Reoperations for Palpable Breast Cancer. Am Surg 2018. [DOI: 10.1177/000313481808400663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study is to verify whether the performance of ultrasound-guided quadrantectomy (USGQ) versus palpation-guided quadrantectomy (PGQ) can reduce the incidence of positive margins and if it can change the attitude of the surgeon. A retrospective study was conducted on 842 patients underwent quadrantectomy for breast cancer, 332 of them underwent USGQ, whereas 550 underwent PGQ. The histological type of the tumors and the margin status obtained with the histological examination were compared. The histological examination of the surgical specimen showed involvement of the margins in 24/842 patients (2.85%), 22 (2.61%) of them belonged to the PGQ group, and two to the USGQ group (P = 0.0011). The highest rate of microscopically positive margins was, statistically significant, for carcinoma in situ, when compared with patients with invasive carcinoma (0.0001). USGQ technique showed several advantages compared with PGQ. In fact, the former notes a lower positive margin rate and, consequently, a lower rate of reintervention. In addition, it may change the surgeon's attitude by causing him to remove another slice of margin to ensure more histological negativity. It should be the gold standard technique for breast-conservative surgery of palpable tumors.
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Affiliation(s)
- Salvatore Vieni
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Giuseppa Graceffa
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Roberta Priola
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Martina Fricano
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Stefania Latteri
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Mario A. Latteri
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
| | - Calogero Cipolla
- From the Department of Surgical Oncological and Oral Sciences, Division of General and Oncological Surgery, University of Palermo, Palermo, Italy
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Wilson KE, Bachawal SV, Willmann JK. Intraoperative Resection Guidance with Photoacoustic and Fluorescence Molecular Imaging Using an Anti-B7-H3 Antibody-Indocyanine Green Dual Contrast Agent. Clin Cancer Res 2018; 24:3572-3582. [PMID: 29712688 DOI: 10.1158/1078-0432.ccr-18-0417] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/21/2018] [Accepted: 04/23/2018] [Indexed: 01/12/2023]
Abstract
Purpose: Breast cancer often requires surgical treatment including breast-conserving surgical resection. However, with current postsurgical histologic margin analysis, one quarter of breast cancer patients undergo reexcision to achieve negative margins corresponding to decreased local recurrence and better outcomes. Therefore, a method with high resolution and specificity for intraoperative margin assessment is needed.Experimental Design: First, quantitative immunofluorescence staining of B7-H3 expression was assessed in four pathologic stages of breast cancer progression of the MMTV-PyMT transgenic murine model. Next, an antibody-dye contrast agent, B7-H3-ICG, was injected into mice prior to surgical resection of breast cancer. Anatomic ultrasound, spectroscopic photoacoustic (sPA), and fluorescence imaging were used to guide resection of mammary glands suspected of containing cancer. Resected tissues were processed for H&E staining and pathologic assessment and compared with sPA and fluorescence imaging signals.Results: Tissue containing DCIS (46.0 ± 4.8 a.u.) or invasive carcinoma (91.7 ± 21.4 a.u.) showed significantly higher (P < 0.05) B7-H3 expression than normal and hyperplastic tissues (1.3 ± 0.8 a.u.). During image-guided surgical resection, tissue pieces assessed as normal or hyperplastic (n = 17) showed lower average sPA (3.17 ± 0.48 a.u.) and fluorescence signal [6.83E07 ± 2.00E06 (p/s)/(μW/cm²)] than DCIS and invasive carcinoma tissue (n = 63) with an average sPA signal of 23.98 ± 4.88 a.u. and an average fluorescence signal of 7.56E07 ± 1.44E06 (p/s)/(μW/cm²) with AUCs of 0.93 [95% confidence interval (CI), 0.87-0.99] and 0.71 (95% CI, 0.57-0.85), respectively.Conclusions: It was demonstrated that sPA and fluorescence molecular imaging combined with B7-H3-ICG agent can assess the disease status of tissues with high diagnostic accuracy, intraoperatively, with high resolution, sensitivity, and specificity. Clin Cancer Res; 24(15); 3572-82. ©2018 AACR.
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Affiliation(s)
- Katheryne E Wilson
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, School of Medicine, Stanford, California.
| | - Sunitha V Bachawal
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, School of Medicine, Stanford, California
| | - Jürgen K Willmann
- Department of Radiology, Molecular Imaging Program at Stanford, Stanford University, School of Medicine, Stanford, California
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Krekel NMA, Haloua MH, Volders JH, Meijer S, van den Tol MP. Response to “The CUBE Technique: Continuous Ultrasound-Guided Breast Excision,” Published in August 2014 by Tummel et al. Amsterdam, 28th January 2015. Ann Surg Oncol 2017; 24:578. [DOI: 10.1245/s10434-017-6161-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Indexed: 11/18/2022]
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Barth RJ, Krishnaswamy V, Paulsen KD, Rooney TB, Wells WA, Rizzo E, Angeles CV, Marotti JD, Zuurbier RA, Black CC. A Patient-Specific 3D-Printed Form Accurately Transfers Supine MRI-Derived Tumor Localization Information to Guide Breast-Conserving Surgery. Ann Surg Oncol 2017; 24:2950-2956. [PMID: 28766199 PMCID: PMC6015768 DOI: 10.1245/s10434-017-5979-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Wire-localized excision of nonpalpable breast cancer is imprecise, resulting in positive margins 25-30% of the time. METHODS Patients underwent preoperative supine magnetic resonance imaging (MRI). A radiologist outlined the tumor edges on consecutive images, creating a three-dimensional (3D) view of its location. Using 3D printing, a bra-like plastic form (the Breast Cancer Locator [BCL]) was fabricated, with features that allowed a surgeon to (1) mark the edges of the tumor on the breast surface; (2) inject blue dye into the breast 1 cm from the tumor edges; and (3) place a wire in the tumor at the time of surgery. RESULTS Nineteen patients with palpable cancers underwent partial mastectomy after placement of surgical cues using patient-specific BCLs. The cues were in place in <5 min and no adverse events occurred. The BCL accurately localized 18/19 cancers. In the 18 accurately localized cases, all 68 blue-dye injections were outside of the tumor edges. Median distance from the blue-dye center to the pathologic tumor edge was 1.4 cm, while distance from the blue dye to the tumor edge was <5 mm in 4% of injections, 0.5-2.0 cm in 72% of injections, and >2 cm in 24% of injections. Median distance from the tumor center to the BCL-localized wire and to the clip placed at the time of diagnosis was similar (0.49 vs. 0.73 cm) on specimen mammograms. CONCLUSIONS Information on breast cancer location and shape derived from a supine MRI can be transferred safely and accurately to patients in the operating room using a 3D-printed form.
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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
- Female
- Follow-Up Studies
- Humans
- Imaging, Three-Dimensional/methods
- Magnetic Resonance Imaging/methods
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Invasiveness
- Neoplasm Staging
- Supine Position
- Surgery, Computer-Assisted/methods
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Affiliation(s)
- Richard J Barth
- Section of General Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | | | - Keith D Paulsen
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - Timothy B Rooney
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Wendy A Wells
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Elizabeth Rizzo
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Christina V Angeles
- Section of General Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jonathan D Marotti
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Rebecca A Zuurbier
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Candice C Black
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Karadeniz Cakmak G, Emre AU, Tascilar O, Bahadir B, Ozkan S. Surgeon performed continuous intraoperative ultrasound guidance decreases re-excisions and mastectomy rates in breast cancer. Breast 2017; 33:23-28. [DOI: 10.1016/j.breast.2017.02.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/11/2016] [Accepted: 02/22/2017] [Indexed: 01/14/2023] Open
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Carmon M, Olsha O, Gekhtman D, Nikitin I, Cohen Y, Messing M, Lioubashevsky N, Abu Dalo R, Hadar T, Golomb E. Detectability of Hygroscopic Clips Used in Breast Cancer Surgery. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:401-408. [PMID: 28039936 DOI: 10.7863/ultra.16.02053] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/25/2016] [Indexed: 06/06/2023]
Abstract
Sonographically detectable clips were introduced over the last decade. We retrospectively studied the rate and duration of sonographically detectable clip detectability in patients with breast cancer who had sonographically detectable clips inserted over a 2-year period. Nine of 26 patients had neoadjuvant chemotherapy, with all clips remaining detectable 140 to 187 days after insertion. Six of the 9 had intraoperative sonographic localization, with 1 reoperation (17%). Eleven additional patients with nonpalpable tumors and sonographically detectable clips had intraoperative sonographic localization with 1 reoperation (9%). In 1 patient, a sonographically detectable clip enabled intraoperative identification of a suspicious lymph node. There were no complications or clip migration. Sonographically detectable clips are helpful in breast cancer surgery with and without neoadjuvant chemotherapy, remaining detectable for many months and often averting preoperative localization and scheduling difficulties.
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Affiliation(s)
- Moshe Carmon
- Breast Health Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Oded Olsha
- Breast Health Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - David Gekhtman
- Breast Imaging Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Irena Nikitin
- Breast Imaging Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Yamin Cohen
- Hala: the Rachel Nash Jerusalem Comprehensive Breast Clinic, Jerusalem, Israel
| | - Michael Messing
- Hala: the Rachel Nash Jerusalem Comprehensive Breast Clinic, Jerusalem, Israel
| | | | - Ribhi Abu Dalo
- Breast Health Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Tal Hadar
- Breast Health Unit, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
| | - Eliahu Golomb
- Department of Pathology, Shaare Zedek Medical Center, Hebrew University, Jerusalem, Israel
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Gray RJ, Pockaj BA, Garvey E, Blair S. Intraoperative Margin Management in Breast-Conserving Surgery: A Systematic Review of the Literature. Ann Surg Oncol 2017; 25:18-27. [PMID: 28058560 DOI: 10.1245/s10434-016-5756-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Breast surgeons have a wide variety of intraoperative techniques available to help achieve low rates for positive margins of excision, with variable levels of evidence. METHODS A systematic review of the medical literature from 1995 to July 2016 was conducted, with 434 abstracts identified and evaluated. The analysis included 106 papers focused on intraoperative management of breast cancer margins and contained actionable data. RESULTS Ultrasound-guided lumpectomy for palpable tumors, as an alternative to palpation guidance, can lower positive margin rates, but the effect when used as an alternative to wire localization (WL) for nonpalpable tumors is less certain. Localization techniques such as radioactive seed localization and radioguided occult lesion localization were found potentially to lower positive margin rates as alternatives to WL depending on baseline positive margin rates. Intraoperative pathologic methods including gross histology, frozen section analysis, and imprint cytology all have the potential to lower the rates of positive margins. Cavity-shave margins and the Marginprobe device both lower rates of positive margins, with some potential for negative cosmetic effects. Specimen radiography and multiple miscellaneous techniques did not affect positive margin rates or provided too little evidence for formation of a conclusion. CONCLUSIONS A systematic review of the literature showed evidence that several intraoperative techniques and actions can lower the rates of positive margins. These results are presented together with graded recommendations.
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Affiliation(s)
| | | | - Erin Garvey
- Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Sarah Blair
- UCSD Department of Surgery, UCSD Cancer Center, Encinitas, USA
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Volders JH, Haloua MH, Krekel NMA, Negenborn VL, Kolk RHE, Lopes Cardozo AMF, Bosch AM, de Widt-Levert LM, van der Veen H, Rijna H, Taets van Amerongen AHM, Jóźwiak K, Meijer S, van den Tol MP. Intraoperative ultrasound guidance in breast-conserving surgery shows superiority in oncological outcome, long-term cosmetic and patient-reported outcomes: Final outcomes of a randomized controlled trial (COBALT). Eur J Surg Oncol 2016; 43:649-657. [PMID: 27916314 DOI: 10.1016/j.ejso.2016.11.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/18/2016] [Accepted: 11/03/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The multicenter randomized controlled COBALT trial demonstrated that ultrasound-guided breast-conserving surgery (USS) results in a significant reduction of margin involvement (3.1% vs. 13%) and excision volumes compared to palpation-guided surgery (PGS). The aim of the present study was to determine long term oncological and patient-reported outcomes including quality of life (QoL), together with their progress over time. METHODS 134 patients with T1-T2 breast cancer were randomized to USS (N = 65) or PGS (N = 69). Cosmetic outcomes were assessed with the Breast Cancer Conservative Treatment cosmetic results (BCCT.core) software, panel-evaluation and patient self-evaluation on a 4-point Likert-scale. QoL was measured using the EORTC QLQ-C30/-BR23 questionnaire. RESULTS No locoregional recurrences were reported after mean follow-up of 41 months. Seven patients (5%) developed distant metastatic disease (USS 6.3%, PGS 4.4%, p = 0.466), of whom six died of disease (95.5% overall survival). USS achieved better cosmetic outcomes compared to PGS, with poor outcomes of 11% and 21% respectively, a result mainly attributable to mastectomies due to involved margins following PGS. There was no difference after 1 and 3 years in cosmetic outcome. Dissatisfied patients included those with larger excision volumes, additional local therapies and worse QoL. Patients with poor/fair cosmetic outcomes scored significantly lower on aspects of QoL, including breast-symptoms, body image and sexual enjoyment. CONCLUSION By significantly reducing positive margin status and lowering resection volumes, USS improves the rate of good cosmetic outcomes and increases patient-satisfaction. Considering the large impact of cosmetic outcome on QoL, USS has great potential to improve QoL following breast-conserving therapy.
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Affiliation(s)
- J H Volders
- Department of Surgery, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands.
| | - M H Haloua
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - N M A Krekel
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - V L Negenborn
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - R H E Kolk
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - A M F Lopes Cardozo
- Department of Surgery, Northwest Clinics, Wilhelminalaan 12, 1815JD Alkmaar, The Netherlands.
| | - A M Bosch
- Department of Surgery, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands.
| | - L M de Widt-Levert
- Department of Surgery, Waterland Hospital, Waterlandlaan 250, 1441 RN Purmerend, The Netherlands.
| | - H van der Veen
- Department of Surgery, Red Cross Hospital, Vondellaan 13, 1942 LE Beverwijk, The Netherlands.
| | - H Rijna
- Department of Surgery, Kennemergasthuis, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands.
| | - A H M Taets van Amerongen
- Department of Radiology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - K Jóźwiak
- Department of Epidemiology and Biostatistics, NKI-AVL, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
| | - S Meijer
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - M P van den Tol
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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Merrill AL, Buckley J, Tang R, Brachtel E, Rai U, Michaelson J, Ly A, Specht MC, Yagi Y, Smith BL. A Study of the Growth Patterns of Breast Carcinoma Using 3D Reconstruction: A Pilot Study. Breast J 2016; 23:83-89. [PMID: 27860134 DOI: 10.1111/tbj.12688] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Lumpectomy with microscopically clear margins is a safe and effective approach for surgical management of breast carcinoma. Margins are positive for tumor in 18-50% of lumpectomies, as it is not possible to accurately determine the shape or microscopic borders of a tumor preoperatively or intraoperatively. We examined the 3D microanatomy and growth patterns of common breast carcinoma subtypes to provide guidance for lumpectomy surgery. Prospective consent was obtained for the use of excess tissue from patients undergoing lumpectomy or mastectomy for breast carcinoma. Tissue blocks from nine breast carcinomas were serially sectioned. Hematoxylin and eosin-stained slides at 100 μm intervals were scanned using a Nanozoomer (Hamamatsu, Japan) microscopic-resolution scanner. Three-dimensional reconstructions of tumors were created from scanned images using Reconstruct, open-access software. Breast carcinoma subtypes demonstrated characteristic growth patterns within breast tissue, which may have implications for lumpectomy surgery. Invasive ductal carcinomas showed a spherical shape, with a spiculated surface representing tumor cells infiltrating into surrounding parenchyma. Ductal carcinoma in situ appeared to spread along the duct system, creating dilated, tortuous, tumor-filled ducts. The invasive lobular carcinomas examined had a haphazard, linear, infiltrative growth pattern, different from the shape seen in ductal carcinomas. Our preliminary work suggests that invasive ductal and invasive lobular carcinomas appear to have distinct growth patterns in three dimensions and ductal carcinoma in situ appears to grow in a linear fashion along the duct network. The microanatomy studies described have the potential to guide refinements in breast lumpectomy technique.
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Affiliation(s)
- Andrea L Merrill
- Division of Surgical Oncology, Center for Breast Cancers, Massachusetts General Hospital, Boston, Massachusetts
| | - Julliette Buckley
- Division of Surgical Oncology, Center for Breast Cancers, Massachusetts General Hospital, Boston, Massachusetts
| | - Rong Tang
- Division of Surgical Oncology, Center for Breast Cancers, Massachusetts General Hospital, Boston, Massachusetts
| | - Elena Brachtel
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Upahvan Rai
- Division of Surgical Oncology, Center for Breast Cancers, Massachusetts General Hospital, Boston, Massachusetts
| | - James Michaelson
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Amy Ly
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michelle C Specht
- Division of Surgical Oncology, Center for Breast Cancers, Massachusetts General Hospital, Boston, Massachusetts
| | - Yukako Yagi
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Barbara L Smith
- Division of Surgical Oncology, Center for Breast Cancers, Massachusetts General Hospital, Boston, Massachusetts
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Ultrasound-guided breast-conserving surgery for early-stage palpable and nonpalpable invasive breast cancer: decreased excision volume at unchanged tumor-free resection margin. Breast Cancer Res Treat 2016; 158:535-41. [PMID: 27444926 DOI: 10.1007/s10549-016-3914-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 07/14/2016] [Indexed: 01/08/2023]
Abstract
Ultrasound guidance (USG) during breast-conserving surgery improves tumor-free surgical resection margins. The objective of this study was to evaluate whether USG reduces resection volumes without compromising margin status. 134 patients with palpable or nonpalpable T1-2N0-1 invasive breast cancer were treated with USG and compared with a historical reference control group (CON) consisting of palpation-guided (PAG) or wire-guided localization (WIG) breast-conserving surgery. Primary outcomes were excess resection volume and clear margin status, and secondary outcome was re-excision rate. 66 patients underwent USG. In the CON group (n = 68), PAG was performed in 24 (35 %) and WIG in 44 (64 %) patients. Median excision volume [39 (IQR 20-66) vs 56 (38-94) cm(3); p = 0.001] and median calculated resection ratio [1.7 (1.0-2.9) vs 2.8 (1.4-4.6) (p = 0.005)] were significantly smaller in the USG than in the CON group. Median minimal distance to the resection margin [4 mm (IQR 2-5 mm) vs 2 mm (1-4 mm), p = 0.004] was significantly larger. Clear resection margins were achieved in 58 of the USG patients (88 %) and in 58 of the CON patients (86 %) (p = 0.91); this was true in patients with palpable as well as nonpalpable lesions. Reexcision was needed in 6.1 and 7.2 % respectively. Relative risk for re-excision in the USG group was 0.82 (95 % CI 0.23-2.93). In patients with palpable and nonpalpable breast cancers, USG allows for lower excision volume and reduced resection of healthy breast tissue, without increased re-excision rate.
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Laws A, Brar MS, Bouchard-Fortier A, Leong B, Quan ML. Intraoperative Margin Assessment in Wire-Localized Breast-Conserving Surgery for Invasive Cancer: A Population-Level Comparison of Techniques. Ann Surg Oncol 2016; 23:3290-6. [DOI: 10.1245/s10434-016-5401-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Indexed: 11/18/2022]
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Dixon JM, Newlands C, Dodds C, Thomas J, Williams LJ, Kunkler IH, Bing A, Macaskill EJ. Association between underestimation of tumour size by imaging and incomplete excision in breast-conserving surgery for breast cancer. Br J Surg 2016; 103:830-8. [DOI: 10.1002/bjs.10126] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/18/2015] [Accepted: 01/06/2016] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Completeness of excision is the most important factor influencing local recurrence after breast-conserving surgery (BCS). The aim of this case–control study was to determine factors influencing incomplete excision in patients undergoing BCS.
Methods
Women with invasive breast cancer treated by BCS between 1 June 2008 and 31 December 2009 were identified from a prospectively collected database in the Edinburgh Breast Unit. The maximum size of the tumour, measured microscopically, was compared with the size estimated before operation by mammography and ultrasound imaging. A multivariable analysis was performed to investigate factors associated with incomplete excision.
Results
The cohort comprised 311 women, of whom 193 (62·1 per cent) had a complete (CE group) and 118 (40·7 per cent) an incomplete (IE group) excision. Mammography underestimated tumour size in 75·0 per cent of the IE group compared with 40·7 per cent of the CE group (P < 0·001). Ultrasound imaging underestimated tumour size in 82·5 per cent of the IE group compared with 56·5 per cent of the CE group (P < 0·001). The risk of an incomplete excision was greater when mammography or ultrasonography underestimated pathological size: odds ratio (OR) 4·38 (95 per cent c.i. 2·59 to 7·41; P < 0·001) for mammography, and OR 3·64 (2·03 to 6·54; P < 0·001) for ultrasound imaging. For every 1-mm underestimation of size by mammography and ultrasonography, the relative odds of incomplete excision rose by 10 and 14 per cent respectively.
Conclusion
Underestimation of tumour size by current imaging techniques is a major factor associated with incomplete excision in women undergoing BCS.
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Affiliation(s)
- J M Dixon
- Edinburgh Breast Unit, University of Edinburgh, Edinburgh, UK
| | - C Newlands
- Edinburgh University Medical School, University of Edinburgh, Edinburgh, UK
| | - C Dodds
- South East Scotland Cancer Network, NHS Lothian, University of Edinburgh, Edinburgh, UK
| | - J Thomas
- Edinburgh Breast Unit, University of Edinburgh, Edinburgh, UK
| | - L J Williams
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - I H Kunkler
- Edinburgh Breast Unit, University of Edinburgh, Edinburgh, UK
| | - A Bing
- Edinburgh Breast Unit, University of Edinburgh, Edinburgh, UK
| | - E J Macaskill
- Department of Breast Surgery, Ninewells Hospital and Medical School, Dundee, UK
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Volders JH, Haloua MH, Krekel NMA, Meijer S, van den Tol PM. Current status of ultrasound-guided surgery in the treatment of breast cancer. World J Clin Oncol 2016; 7:44-53. [PMID: 26862490 PMCID: PMC4734937 DOI: 10.5306/wjco.v7.i1.44] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/02/2015] [Accepted: 10/27/2015] [Indexed: 02/06/2023] Open
Abstract
The primary goal of breast-conserving surgery (BCS) is to obtain tumour-free resection margins. Margins positive or focally positive for tumour cells are associated with a high risk of local recurrence, and in the case of tumour-positive margins, re-excision or even mastectomy are sometimes needed to achieve definite clear margins. Unfortunately, tumour-involved margins and re-excisions after lumpectomy are still reported in up to 40% of patients and additionally, unnecessary large excision volumes are described. A secondary goal of BCS is the cosmetic outcome and one of the main determinants of worse cosmetic outcome is a large excision volume. Up to 30% of unsatisfied cosmetic outcome is reported. Therefore, the search for better surgical techniques to improve margin status, excision volume and consequently, cosmetic outcome has continued. Nowadays, the most commonly used localization methods for BCS of non-palpable breast cancers are wire-guided localization (WGL) and radio-guided localization (RGL). WGL and RGL are invasive procedures that need to be performed pre-operatively with technical and scheduling difficulties. For palpable breast cancer, tumour excision is usually guided by tactile skills of the surgeon performing “blind” surgery. One of the surgical techniques pursuing the aims of radicality and small excision volumes includes intra-operative ultrasound (IOUS). The best evidence available demonstrates benefits of IOUS with a significantly high proportion of negative margins compared with other localization techniques in palpable and non-palpable breast cancer. Additionally, IOUS is non-invasive, easy to learn and can centralize the tumour in the excised specimen with low amount of healthy breast tissue being excised. This could lead to better cosmetic results of BCS. Despite the advantages of IOUS, only a small amount of surgeons are performing this technique. This review aims to highlight the position of ultrasound-guided surgery for malignant breast tumours in the search for better oncological and cosmetic outcomes.
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Rubio IT, Esgueva-Colmenarejo A, Espinosa-Bravo M, Salazar JP, Miranda I, Peg V. Intraoperative Ultrasound-Guided Lumpectomy Versus Mammographic Wire Localization for Breast Cancer Patients After Neoadjuvant Treatment. Ann Surg Oncol 2016; 23:38-43. [DOI: 10.1245/s10434-015-4935-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Haloua MH, Volders JH, Krekel NMA, Barbé E, Sietses C, Jóźwiak K, Meijer S, van den Tol MP. A nationwide pathology study on surgical margins and excision volumes after breast-conserving surgery: There is still much to be gained. Breast 2015; 25:14-21. [PMID: 26801411 DOI: 10.1016/j.breast.2015.11.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 10/23/2015] [Accepted: 11/14/2015] [Indexed: 01/08/2023] Open
Abstract
AIM OF THE STUDY The current study aims to assess margin status in relation to amount of healthy breast tissue resected in breast-conserving surgery (BCS) on a nationwide scale. METHODS Using PALGA (a nationwide network and registry of histology and cytopathology in the Netherlands), all patients who underwent BCS for primary invasive carcinoma in 2012-13 were selected (10,058 excerpts). 9276 pathology excerpts were analyzed for a range of criteria including oncological margin status and distance to closest margin, specimen weight/volume, greatest tumor diameter, and with or without localization method. Calculated resection ratios (CRR) were assessed to determine excess healthy breast tissue resection. RESULTS Margins for invasive carcinoma and in situ carcinoma combined were tumor-involved in 498 (5.4%) and focally involved in 1021 cases (11.0%) of cases. Unsatisfactory resections including (focally) involved margins and margins ≤ 1 mm were reported in 33.8% of patients. The median lumpectomy volume was 46 cc (range 1-807 cc; SD 49.18) and median CRR 2.32 (range 0.10-104.17; SD 3.23), indicating the excision of 2.3 the optimal resection volume. CONCLUSION The unacceptable rate of tumor-involved margins as well as margins ≤ 1 mm in one third of all patients is also achieved at the expense of healthy breast tissue resection, which may carry the drawback of high rates of cosmetic failure. These data clearly suggest the need for improvement in current breast conserving surgical procedures to decrease tumor-involved margin rates while reducing the amount of healthy breast tissue resected.
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Affiliation(s)
- M H Haloua
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - J H Volders
- Department of Surgical Oncology, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands
| | - N M A Krekel
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - E Barbé
- Department of Pathology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
| | - C Sietses
- Department of Surgical Oncology, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands
| | - K Jóźwiak
- Department of Epidemiology and Biostatistics, NKI-AVL, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - S Meijer
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - M P van den Tol
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
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Karanlik H, Ozgur I, Sahin D, Fayda M, Onder S, Yavuz E. Intraoperative ultrasound reduces the need for re-excision in breast-conserving surgery. World J Surg Oncol 2015; 13:321. [PMID: 26596699 PMCID: PMC4657358 DOI: 10.1186/s12957-015-0731-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 11/06/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate ultrasound-guided surgery for palpable breast cancer by comparing the standard palpation-guided surgery in terms of the extent of healthy breast tissue resection, the percentage of tumor-free margins, and cosmetic outcomes. METHODS This was a prospective, observational cohort study conducted from January 2009 to July 2011. Breast cancer patients, diagnosed via biopsy, were operated in guidance with either ultrasound or palpation. Patient demographics, tumor features, intraoperative findings, pathologic and cosmetic results, intraoperative-measured ultrasound margins, and pathology margins were compared. RESULTS Ultrasound (US)-guided lumpectomy was performed on 84 women and palpation-guided lumpectomy on 80 women. Patient demographics and tumor characteristics showed no differences. The rate of re-excision was 17 % for the palpation-guided surgery group, and 6 % for the US-guided group (p = 0.03). There was good correlation between the closest margins recorded by US and pathology margins (r = 0.76, p = 0.01). Volume of resection was significantly larger in the palpation-guided group despite the similar size of tumors (p = 0.048). Cosmetic outcome of surgery was equivalent between groups. CONCLUSIONS Intraoperative ultrasound guidance for excision of palpable breast cancers is feasible and gives results in terms of pathologic margins that are comparable with those achieved by standard palpation-guided excisions.
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Affiliation(s)
- Hasan Karanlik
- Surgical Oncology Unit, Institute of Oncology, Istanbul University, Istanbul, Turkey.
| | - Ilker Ozgur
- Department of General Surgery, Acibadem International Hospital, Bakirkoy, Istanbul, Turkey
| | - Dilek Sahin
- Department of Radiology, Institute of Oncology, Istanbul University, Istanbul, Turkey
| | - Merdan Fayda
- Department of Radiation Oncology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Semen Onder
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ekrem Yavuz
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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Landercasper J, Attai D, Atisha D, Beitsch P, Bosserman L, Boughey J, Carter J, Edge S, Feldman S, Froman J, Greenberg C, Kaufman C, Morrow M, Pockaj B, Silverstein M, Solin L, Staley A, Vicini F, Wilke L, Yang W, Cody H. Toolbox to Reduce Lumpectomy Reoperations and Improve Cosmetic Outcome in Breast Cancer Patients: The American Society of Breast Surgeons Consensus Conference. Ann Surg Oncol 2015; 22:3174-83. [PMID: 26215198 PMCID: PMC4550635 DOI: 10.1245/s10434-015-4759-x] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Multiple recent reports have documented significant variability of reoperation rates after initial lumpectomy for breast cancer. To address this issue, a multidisciplinary consensus conference was convened during the American Society of Breast Surgeons 2015 annual meeting. METHODS The conference mission statement was to "reduce the national reoperation rate in patients undergoing breast conserving surgery for cancer, without increasing mastectomy rates or adversely affecting cosmetic outcome, thereby improving value of care." The goal was to develop a toolbox of recommendations to reduce the variability of reoperation rates and improve cosmetic outcomes. Conference participants included providers from multiple disciplines involved with breast cancer care, as well as a patient representative. Updated systematic reviews of the literature and invited presentations were sent to participants in advance. After topic presentations, voting occurred for choice of tools, level of evidence, and strength of recommendation. RESULTS The following tools were recommended with varied levels of evidence and strength of recommendation: compliance with the SSO-ASTRO Margin Guideline; needle biopsy for diagnosis before surgical excision of breast cancer; full-field digital diagnostic mammography with ultrasound as needed; use of oncoplastic techniques; image-guided lesion localization; specimen imaging for nonpalpable cancers; use of specialized techniques for intraoperative management, including excisional cavity shave biopsies and intraoperative pathology assessment; formal pre- and postoperative planning strategies; and patient-reported outcome measurement. CONCLUSIONS A practical approach to performance improvement was used by the American Society of Breast Surgeons to create a toolbox of options to reduce lumpectomy reoperations and improve cosmetic outcomes.
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Affiliation(s)
- Jeffrey Landercasper
- Gundersen Health System Norma J. Vinger Center for Breast Care, La Crosse, WI, USA,
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Ivanovic NS, Zdravkovic DD, Skuric Z, Kostic J, Colakovic N, Stojiljkovic M, Opric S, Stefanovic Radovic M, Soldatovic I, Sredic B, Granic M. Optimization of breast cancer excision by intraoperative ultrasound and marking needle - technique description and feasibility. World J Surg Oncol 2015; 13:153. [PMID: 25896818 PMCID: PMC4404261 DOI: 10.1186/s12957-015-0568-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 04/04/2015] [Indexed: 12/30/2022] Open
Abstract
Background We present a surgical technique and the preliminary results of breast cancer excision after insertion of a specially constructed marking needle into the tumor, controlled by intraoperative ultrasound. Resection margins were projected in six directions by ultrasound measurements, determined in relation to the needle, and resection was done in accordance with those measurements. The main objective was to obtain resection margins similar (equal) to those projected by intraoperative ultrasound (10 mm). Methods Detailed description of the technique is given. Thirty-two female patients undergoing breast-conserving surgery, up to 30 mm in diameter, for palpable and non-palpable invasive breast cancer, were operated on using this technique. Its feasibility was tested by analyzing the success (rate) of needle placement in the tumor, the measurements executed, and the performance of the excision. Results All stages of the technique were successfully performed to completion on all 32 patients. The procedure of needle placement and ultrasound measurement of distances took 11 min on average (between 6 and 20 min). The average distance of the tumor margin from the resection margin was 12.9 mm (2 to 30 mm, 95% confidence interval [11.9, 14.06]). There was one patient with a positive resection margin (3%). Conclusions The technique of excising palpable and non-palpable breast cancer by intraoperative ultrasound and an especially constructed marking needle is feasible and comfortable to perform. Preliminary results imply that resection volume can be rationalized, with the same or better oncological safety.
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Affiliation(s)
- Nebojsa S Ivanovic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia. .,Medical Faculty of Belgrade University, Dr Subotica 8, Belgrade, 11000, Serbia.
| | - Darko D Zdravkovic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia. .,Medical Faculty of Belgrade University, Dr Subotica 8, Belgrade, 11000, Serbia.
| | - Zlatko Skuric
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Jelena Kostic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Natasa Colakovic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Miodrag Stojiljkovic
- Department of Pathology, UMC Bezanijska kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Svetlana Opric
- Department of Pathology, UMC Bezanijska kosa, Autoput bb, Belgrade, 11000, Serbia.
| | | | - Ivan Soldatovic
- Department of Statistics, Medical faculty of Belgrade University, Dr Subotica 8, Belgrade, 11000, Serbia.
| | - Biljana Sredic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia.
| | - Miroslav Granic
- Department of Surgical Oncology, UMC Bezanijska Kosa, Autoput bb, Belgrade, 11000, Serbia. .,Medical Faculty of Belgrade University, Dr Subotica 8, Belgrade, 11000, Serbia.
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Optimization of breast cancer excision by intraoperative ultrasound and marking needle - technique description and feasibility. World J Surg Oncol 2015. [PMID: 25896818 DOI: 10.1186/s12957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We present a surgical technique and the preliminary results of breast cancer excision after insertion of a specially constructed marking needle into the tumor, controlled by intraoperative ultrasound. Resection margins were projected in six directions by ultrasound measurements, determined in relation to the needle, and resection was done in accordance with those measurements. The main objective was to obtain resection margins similar (equal) to those projected by intraoperative ultrasound (10 mm). METHODS Detailed description of the technique is given. Thirty-two female patients undergoing breast-conserving surgery, up to 30 mm in diameter, for palpable and non-palpable invasive breast cancer, were operated on using this technique. Its feasibility was tested by analyzing the success (rate) of needle placement in the tumor, the measurements executed, and the performance of the excision. RESULTS All stages of the technique were successfully performed to completion on all 32 patients. The procedure of needle placement and ultrasound measurement of distances took 11 min on average (between 6 and 20 min). The average distance of the tumor margin from the resection margin was 12.9 mm (2 to 30 mm, 95% confidence interval [11.9, 14.06]). There was one patient with a positive resection margin (3%). CONCLUSIONS The technique of excising palpable and non-palpable breast cancer by intraoperative ultrasound and an especially constructed marking needle is feasible and comfortable to perform. Preliminary results imply that resection volume can be rationalized, with the same or better oncological safety.
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Osako T, Nishimura R, Nishiyama Y, Okumura Y, Tashima R, Nakano M, Fujisue M, Toyozumi Y, Arima N. Efficacy of intraoperative entire-circumferential frozen section analysis of lumpectomy margins during breast-conserving surgery for breast cancer. Int J Clin Oncol 2015; 20:1093-101. [PMID: 25855313 DOI: 10.1007/s10147-015-0827-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 03/31/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Intraoperative frozen section analysis of the surgical margins during breast-conserving surgery (BCS) for breast cancer can reliably achieve clear surgical margins and prevent re-operations. The aim of this study was to assess intraoperative entire-circumferential frozen section analysis (IEFSA) of the lumpectomy margins during BCS. METHODS A total of 1029 patients who underwent BCS with IEFSA between June 2007 and July 2013 were available for assessment. The inner surfaces of the shaved lumpectomy margins were examined as frozen sections during BCS. The margins were defined as positive when the cancer cells were present within 5 mm from the edge of the outermost margins of the specimens. RESULTS Out of 1029 patients, 312 patients (30.3 %) had positive margins after the initial lumpectomy and underwent additional resections during BCS. Fourteen patients (1.4 %) underwent mastectomy following the results of additional resections during the first surgery. Of 1015 patients who completed BCS, 60 patients (5.9 %) were found to have positive margins in the final pathology. One patient (0.1 %) underwent re-operation after BCS while the residual diseases of the other 59 patients were judged to be minimal. Of the 312 patients who were judged to have positive margins after the initial lumpectomy with IEFSA, 53 patients (16.9 %) were found to have negative margins in the final pathology. At a median follow-up time of 54.1 months, one patient (0.1 %) had a recurrence of breast cancer in the preserved breast. CONCLUSION IEFSA is useful for preventing the need for re-operation and local recurrence after BCS.
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Affiliation(s)
- Tomofumi Osako
- Department of Breast and Endocrine Surgery, Kumamoto City Hospital, 1-1-60 Kotoh, Higashi-ku, Kumamoto, 862-8605, Japan.
| | - Reiki Nishimura
- Department of Breast and Endocrine Surgery, Kumamoto City Hospital, 1-1-60 Kotoh, Higashi-ku, Kumamoto, 862-8605, Japan
| | - Yasuyuki Nishiyama
- Department of Breast and Endocrine Surgery, Kumamoto City Hospital, 1-1-60 Kotoh, Higashi-ku, Kumamoto, 862-8605, Japan
| | - Yasuhiro Okumura
- Department of Breast and Endocrine Surgery, Kumamoto City Hospital, 1-1-60 Kotoh, Higashi-ku, Kumamoto, 862-8605, Japan
| | - Rumiko Tashima
- Department of Breast and Endocrine Surgery, Kumamoto City Hospital, 1-1-60 Kotoh, Higashi-ku, Kumamoto, 862-8605, Japan
| | - Masahiro Nakano
- Department of Breast and Endocrine Surgery, Kumamoto City Hospital, 1-1-60 Kotoh, Higashi-ku, Kumamoto, 862-8605, Japan
| | - Mamiko Fujisue
- Department of Breast and Endocrine Surgery, Kumamoto City Hospital, 1-1-60 Kotoh, Higashi-ku, Kumamoto, 862-8605, Japan
| | - Yasuo Toyozumi
- Department of Pathology, Kumamoto City Hospital, 1-1-60 Kotoh, Higashi-ku, Kumamoto, 862-8605, Japan
| | - Nobuyuki Arima
- Department of Pathology, Kumamoto City Hospital, 1-1-60 Kotoh, Higashi-ku, Kumamoto, 862-8605, Japan
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Ultrasonography Mapping Combined With Mammography Before Breast-Conserving Surgery for Primary Breast Cancer With Microcalcifications: A Novel Approach. Clin Breast Cancer 2014; 14:352-7. [DOI: 10.1016/j.clbc.2013.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 12/23/2013] [Accepted: 12/23/2013] [Indexed: 12/28/2022]
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Haloua MH, Krekel NMA, Meijer S, van den Tol MP. Ultrasound-guided surgery for palpable breast cancer: a historical perspective. BREAST CANCER MANAGEMENT 2014. [DOI: 10.2217/bmt.14.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Breast cancer surgery has changed dramatically from the en bloc removal of the breast to the less invasive breast-conserving surgery. The recent COBALT trial comparing ultrasound-guided surgery with palpation-guided surgery for palpable breast cancer showed less margin involvement and decreased excision volumes with ultrasonography, which resulted in less additional therapy and possibly improved cosmetic outcome. Other surgical techniques pursuing these same aims have been developed over the past two decades and are referred to as oncoplastic surgery. Unfortunately oncoplastic surgery lacks sufficient evidence to corroborate its widespread implementation and should thereby solely be applied to selected cases. This review aims to highlight the position of ultrasound-guided surgery from a perspective of breast-conserving surgery in the search for better oncological and cosmetic outcomes.
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Affiliation(s)
- MH Haloua
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - NMA Krekel
- Department of Plastic & Reconstructive Surgery, VU University Medical Center, De Boelelaan 1117, Room 7F-020, 1081 HV Amsterdam, The Netherlands
| | - S Meijer
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - MP van den Tol
- Department of Surgical Oncology, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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