Predictors of surgical margin status in breast-conserving surgery within a breast screening program

Surgical outcomes and prognosis of HER2+ invasive breast cancer patients with a DCIS component treated with breast-conserving surgery after neoadjuvant systemic therapy

INTRODUCTION

In up to 72 % of HER2+ invasive breast cancer (IBC), a ductal carcinoma in situ (DCIS) component is present. The presence of DCIS is associated with increased positive surgical margins after breast-conserving surgery (BCS). The aim of this study was to assess surgical margins, recurrence and survival in a nationwide cohort of HER2+ IBC with versus without a DCIS component, treated with neoadjuvant systemic therapy (NST) and BCS.

MATERIALS AND METHODS

Women diagnosed with HER2+ IBC treated with NST and BCS, between 2010 and 2019, were selected from the Netherlands Cancer Registry and linked to the Dutch Nationwide Pathology Databank. Kaplan-Meier and Cox regression analyses were performed to determine locoregional recurrence rate (LRR) and overall survival (OS) and associated clinicopathological variables. Surgical outcomes and prognosis were compared between IBC only and IBC+DCIS.

RESULTS

A total of 3056 patients were included: 1832 with IBC and 1224 with IBC+DCIS. Patients with IBC+DCIS had significantly more often positive surgical margins compared to IBC (12.8 % versus 4.9 %, p < 0.001). Five-year LRR was significantly higher in patients with IBC+DCIS compared to IBC (6.8 % versus 3.6 %, p < 0.001), but the presence of DCIS itself was not significantly associated with LRR after adjusting for confounders in multivariable analysis. Five-year OS did not differ between IBC+DCIS and IBC (94.9 % versus 95.7 %, p = 0.293).

CONCLUSION

The presence of DCIS is associated with higher rates of positive surgical margins, but not with LRR and lower OS when adjusted for confounders. Further research is necessary to adequately select IBC+DCIS patients for BCS after NST.

Clinicopathological Predictors of Positive Resection Margins in Breast-Conserving Surgery

BACKGROUND

Ductal carcinoma in situ (DCIS) is associated with risk of positive resection margins following breast-conserving surgery (BCS) and subsequent reoperation. Prior reports grossly underestimate the risk of margin positivity with IBC containing a DCIS component (IBC + DCIS) due to patient-level rather than margin-level analysis.

OBJECTIVE

The aim of this study was to delineate the relative risk of IBC + DCIS compared with pure IBC (without a DCIS component) on margin positivity through detailed margin-level interrogation.

METHODS

A single institution, retrospective, observational cohort study was conducted in which pathology databases were evaluated to identify patients who underwent BCS over 5 years (2014-2019). Margin-level interrogation included granular detail into the extent, pathological subtype and grade of disease at each resection margin. Predictors of a positive margin were computed using multivariate regression analysis.

RESULTS

Clinicopathological details were examined from 5454 margins from 909 women. The relative risk of a positive margin with IBC + DCIS versus pure IBC was 8.76 (95% confidence interval [CI] 6.64-11.56) applying UK Association of Breast Surgery guidelines, and 8.44 (95% CI 6.57-10.84) applying the Society of Surgical Oncology/American Society for Radiation Oncology guidelines. Independent predictors of margin positivity included younger patient age (0.033, 95% CI 0.006-0.060), lower specimen weight (0.045, 95% CI 0.020-0.069), multifocality (0.256, 95% CI 0.137-0.376), lymphovascular invasion (0.138, 95% CI 0.068-0.208) and comedonecrosis (0.113, 95% CI 0.040-0.185).

CONCLUSIONS

Compared with pure IBC, the relative risk of a positive margin with IBC + DCIS is approximately ninefold, significantly higher than prior estimates. This margin-level methodology is believed to represent the impact of DCIS more accurately on margin positivity in IBC.

Does cavity margin shaving reduce residual tumor and re-excision rates? A systematic review

PURPOSE

Cavity shaving (CS) is a surgical technique used in the treatment of breast cancer (BC). It may reduce margin positivity in histologic assessment and consequently reduces re- excision rates in breast conserving surgery (BCS). The evidence for this assumption is described in the present review.

METHODS

A systematic review of relevant literature in English from January 1999 to April 2019 was conducted. The analysis included studies on CS and its effects on re-excision rates and margin positivity. We searched PubMed databases for relevant publications. In total, 22 studies were included in the present review.

RESULTS

The benefit from CS on re-excision rates and histologic margin positivity was variable. Out of 22 studies, 17 reported a reduction in both re-excision rates and histologic margin positivity in margin shaved patients. Four studies could not find a significant reduction of second surgeries and residual tumor rates. One study suggested that CS after BCS was superior to single BCS only in subgroup analysis in IDC tumors.

CONCLUSION

CS is a surgical technique that was shown to reduce re-excision and margin positivity rates in most of the studies. Furthermore, it can be a useful tool to assess specimen margins and detect multifocality.

Immediate or delayed oncoplastic surgery after breast conserving surgery at the Netherlands Cancer Institute: a cohort study of 251 cases

PURPOSE

Oncoplastic surgery (OPS) after breast conserving surgery is preferably performed during the same operation. Offering delayed OPS instead of mastectomy to patients with a high risk of tumor-positive margins allows breast conservation with the option of margin re-excision during OPS, without having to dismantle the reconstruction. We aimed to evaluate surgical outcomes after immediate and delayed OPS.

METHODS

We included early-stage breast cancer patients who underwent OPS at the Netherlands Cancer Institute between 2016 and 2019. Patients were selected for delayed OPS after multidisciplinary consultation if the risk of tumor-positive margins with immediate OPS was considered significant (> 30%). Groups were compared on baseline characteristics and short-term surgical outcomes.

RESULTS

Of 242 patients with 251 OPS, 130 (52%) OPS had neoadjuvant chemotherapy. Immediate OPS was performed in 176 (70%) cases and delayed OPS in 76 (30%). Selection for delayed OPS was associated with tumor size (OR 1.03, 95% CI 1.01-1.04), ILC (OR 2.61, 95% CI 1.10-6.20), DCIS (OR 3.45, 95% CI 1.42-8.34) and bra size (OR 0.76, 95% CI 0.62-0.94). Delayed and immediate OPS differed in tissue weight (54 vs. 67 g, p = 0.034), tissue replacement (51% vs. 26%, p < .001) and tumor-positive margins (66% vs. 18%, p < .001). Re-excision was performed in 48 (63%) delayed OPS and in 11 (6%) immediate OPS. Groups did not differ in complications (21% vs. 18%, p = 0.333). Breast conservation after immediate and delayed OPS was 98% and 93%, respectively.

CONCLUSION

Performing delayed OPS in selected cases facilitated simultaneous margin re-excision without increasing complications, and resulted in an excellent breast conservation rate.

Effects of preoperative magnetic resonance image on survival rates and surgical planning in breast cancer conservative surgery: randomized controlled trial (BREAST-MRI trial)

BACKGROUND

Breast magnetic resonance imaging (MRI) has high sensitivity in detecting invasive neoplasms. Controversy remains about its impact on the preoperative staging of breast cancer surgery. This study evaluated survival and surgical outcomes of preoperative MRI in conservative breast cancer surgery.

METHODS

A phase III, randomized, open-label, single-center trial including female breast cancer participants, stage 0-III disease, and eligible for breast-conserving surgery. We compared the role of including MRI in preoperative evaluation versus radiologic exam routine with mammography and ultrasound in breast cancer conservative candidates. The primary outcome was local relapse-free survival (LRFS), and secondary outcomes were overall survival (OS), mastectomy rate, and reoperation rate.

RESULTS

524 were randomized to preoperative MRI group (n = 257) or control group (n = 267). The survival analysis showed a 5.9-years LRFS of 99.2% in MRI group versus 98.9% in control group (HR = 0.72; 95% CI 0.12-4.28; p = 0.7) and an OS of 95.3% in the MRI group versus 96.3% in the control group (HR = 1.37 95% CI 0.59-3.19; p = 0.8). Surgical management changed in 21 ipsilateral breasts in the MRI group; 21 (8.3%) had mastectomies versus one in the control group. No difference was found in reoperation rates, 22 (8.7%) in the MRI group versus 23 (8.7%) in the control group (RR = 1.002; 95% CI 0.57-1.75; p = 0.85).

CONCLUSION

Preoperative MRI increased the mastectomy rates by 8%. The use of preoperative MRI did not influence local relapse-free survival, overall survival, or reoperation rates.

Can Radiotherapy After Breast-Conserving Surgery be Omitted in Elderly Patients with Early-Stage, Hormone-Receptor Negative Breast Cancer? A Population-Based Study and Proposed Nomogram

INTRODUCTION

We aimed to evaluate whether radiotherapy (RT) after breast-conserving surgery (BCS) can be omitted in elderly patients with early-stage, hormone receptor-negative breast cancer.

METHODS

Patients aged 65 years and older with T1-2N0-1, hormone receptor-negative breast cancer in 2010-2015 were extracted from the Surveillance, Epidemiology, and End Results program. Propensity score matching was used to balance the baseline of different groups. Survival analysis was performed using Kaplan-Meier plot and log-rank test. Independent risk factors were identified by multivariate Cox analysis. A nomogram predicting breast cancer-specific survival (BCSS) and a risk stratification model were constructed and validated.

RESULTS

A total of 4465 patients were included and 27.7% (1237/4465) patients did not receive postoperative RT. RT was significantly associated with improved overall survival (OS) (HR = 0.552 P < 0.001) and BCSS (HR = 0.559, P < 0.001) in the matched cohort. The same results were found after adjusting independent risk factors by multivariate analysis. On the basis of the nomogram predicting BCSS of patients without RT by incorporating independent risk factors (age, race, HER2 status, T stage, and N stage), we built a risk stratification model which indicated that RT improved OS (HR = 0.511, P < 0.001) and BCSS (HR = 0.517, P < 0.001) in the high-risk group (total score > 150), but not in the low-risk group (total score ≤ 120). The C-index and all calibration curves demonstrated sufficient accuracies and good predictive capabilities.

CONCLUSIONS

RT is indeed beneficial for the whole cohort in this study. However, it may be omitted in the low-risk subgroup without significantly sacrificing survival. For patients in the high-risk group, RT following BCS remained beneficial. This study highlights the need for prospective randomized trials to study RT de-escalation strategies.

Bracketing with Multiple Radioactive Seeds to Achieve Negative Margins in Breast Conservation Surgery: Multiple Seeds in Breast Surgery

INTRODUCTION

Breast conservation surgery (BCS) is the treatment of choice for unifocal, early-stage breast cancer. The ability to offer BCS to a wider subset of patients, including those with multifocal/multicentric cancer as well as extensive ductal carcinoma in situ, has emerged over time, especially in those undergoing joint oncoplastic reconstruction and those treated with neoadjuvant therapy. However, localization techniques using multiple radioactive seeds for bracketing in this patient subset have not been validated.

MATERIALS AND METHODS

A single-institution retrospective review was conducted of all patients with breast cancer who underwent BCS, guided by multiple bracketed iodine I 125 radioactive seeds between January 2014 and April 2017.

RESULTS

Bracketing of breast cancer using 2 or more radioactive seeds was performed in 157 breasts in 156 patients. Negative margins were achieved in 124 of 157 (79%) breasts, including 33 cases (21%) that underwent targeted margin reexcision at the time of surgery after intraoperative, multidisciplinary margin assessment. Thirty-three cases (21%) resulted in close or positive margins, of which 11 (7%) and 10 (6.4%) underwent completion mastectomy or repeat lumpectomy, respectively. Twelve patients (7.6%) did not undergo reexcision. En bloc resection was successful in 134 of 157 (85.4%) lumpectomies. Eighty-nine percent of the procedures were coupled with oncoplastic reconstruction.

CONCLUSION

Bracketing techniques using multiple radioactive seeds expands the indications for breast conservation therapy in patients who would have traditionally required mastectomy. Intraoperative margin assessment improves surgical and pathologic success. Larger defects created by multifocal resection are optimally managed in concert with oncoplastic reconstruction to minimize asymmetries and aesthetic defects.

Predictive value of ductal carcinoma in situ with invasive breast cancer in core needle biopsies for final pathologic size of intraductal elements

Preoperative evaluations of the size of ductal carcinoma in situ (DCIS) extension in invasive breast cancer (IBC) are problematic and markers of the actual size of DCIS remain elusive. This study aimed to quantify DCIS on core needle biopsy (CNB) and investigated its association with degree of DCIS extension on paired resection specimens, instead of with presence or absence of an extensive intraductal component or margin status as in earlier studies. This series examined 150 IBCs diagnosed from paired CNB and resection specimens. The DCIS/invasion ratio was calculated using the sum of each element size from CNB. In resection specimens, cases in which the greatest dimension of DCIS extension was longer than the greatest dimension of invasive size were defined as extended DCIS (Ext-DCIS). DCIS/invasion ratio level correlated positively with the degree of Ext-DCIS (P = 0.003). Using receiver operating characteristic curve analysis, setting cases with the subgroup of DCIS extension with greatest dimension > 2.5 times that of the invasive size in the resection specimen (Ext-DCIS > 2.5) as the positive class provided the best discrimination ability for DCIS/invasion ratio (0.375). In multivariate analysis, DCIS/invasion ratio > 0.375 was significantly associated with Ext-DCIS > 2.5 (P = 0.033). In conclusion, DCIS/invasion ratio > 0.375 in CNB was identified as a predictor of Ext-DCIS > 2.5 in resection specimens, suggesting that an approach combining DCIS/invasion ratio from CNB with preoperative staging may better predict the extent of DCIS and facilitate better surgical planning.

Tumor margins that lead to reoperation in breast cancer: A retrospective register study of 4,489 patients

Background and Objectives

Optimal margins for ductal carcinoma in situ (DCIS) remain controversial in breast‐conserving surgery (BCS) and mastectomy. We examine the association of positive margins, reoperations, DCIS and age.

Methods

A retrospective study of histopathological reports (4489 patients). Margin positivity was defined as ink on tumor for invasive carcinoma. For DCIS, we applied 2 mm anterior and side margin thresholds, and ink on tumor in the posterior margin.

Results

The incidence of positive side margins was 20% in BCS and 5% in mastectomies (p < 0.001). Of these patients, 68% and 14% underwent a reoperation (p < 0.001). After a positive side margin in BCS, the reoperation rates according to age groups were 74% (<49), 69% (50–64), 68% (65–79), and 42% (80+) (p = 0.013). Of BCS patients with invasive carcinoma in the side margin, 73% were reoperated on. A reoperation was performed in 70% of patients with a close (≤1 mm) DCIS side margin, compared to 43% with a wider (1.1–2 mm) margin (p = 0.002). The reoperation rates were 55% in invasive carcinoma with close DCIS, 66% in close extensive intraductal component (EIC), and 83% in close pure DCIS (p < 0.001).

Conclusions

Individual assessment as opposed to rigid adherence to guidelines was used in the decision on reoperation.

The Challenging Image-Guided Preoperative Breast Localization: A Modality-Based Approach

Breast conservation surgery (BCS) is the standard of care for treating patients with early-stage breast cancer and those with locally advanced breast cancer who achieve an excellent response to neoadjuvant chemotherapy. The radiologist is responsible for accurately localizing nonpalpable lesions to facilitate successful BCS. In this article, we present a practical modality-based guide on approaching challenging preoperative localizations, incorporating illustrative examples of challenging localizations performed under sonographic, mammographic, and MRI guidance, as well as under multiple modalities. Aspects of preprocedure planning, modality selection, patient communication, as well as procedural and positional techniques are highlighted. Clip and device migration is also considered. Further, an overview is provided of the most widely used wire localization (WL) and non-wire localization (NWL) devices in the United States. Accurate preoperative localization of breast lesions is essential to achieve successful surgical outcomes. Certain modality-based techniques can be adopted to successfully complete challenging cases.

Rates of margin positive resection with breast conservation for invasive breast cancer using the NCDB

Background

Previous studies suggest the rate of positive surgical margin (PSM) after lumpectomy for breast cancer is approximately 20 %. The risk of PSM at time of resection is often a source of fear for patients, driving some to elect to undergo mastectomy. This study describes rates and predictors of positive margins for invasive breast cancers in the National Cancer Database (NCDB).

Materials and methods

From 2004 to 2013, patients with non-metastatic invasive breast cancers who underwent breast conservation surgery were identified from the NCDB. Patients’ demographic, clinical, and facility of treatment characteristics were collected and compared. Per SSO-ASTRO-ASCO criteria, margin negative is defined as no gross or microscopic disease (i.e. no tumor on ink). Bivariate tests and multivariate logistic regression were conducted to identify independent predictors of patients with PSM at the time of resection.

Results

A total of 707,798 patients were identified with non-metastatic invasive breast tumors who underwent lumpectomy. Rate of PSM across the entire cohort was 5.02 %. Over time, the rate of PSM decreased significantly from 6.54 % in 2004 to 3.91 % in 2013 (p < 0.001). Pure lobular histology predicted for the highest rate of PSM compared with IDC (8.63 vs 4.55 %; p < 0.001). In adjusted analysis, high grade, non-ductal histology and HER2 amplification were significantly associated with PSM with breast conservation while estrogen and progesterone status were not.

Conclusion

This study demonstrates a 5 % risk of PSM at time of breast conservation surgery using a large, modern national database. Patients with invasive lobular and mixed histology have a nearly two-fold risk of PSM compared to invasive ductal cancers. These results provide important data points to help appropriately counsel patients regarding the risk of PSM.

•

Using the National Cancer Database (NCDB), trends in positive surgical margin (PSM) at time of lumpectomy for early stage invasive breast cancer are decreasing over time.

•

Observed rates of PSM in this analysis are approximately 5 % for the entire cohort.

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Predictors of PSM are lobular histology, increasing T and N stage, grade, and Her2+ histology.

Lack of definitive presurgical pathological diagnosis is associated with inadequate surgical margins in breast-conserving surgery

PURPOSE

To determine the impact of definitive presurgical diagnosis on surgical margins in breast-conserving surgery (BCS) for primary carcinomas; clinicopathological features were also analyzed.

METHODS

This retrospective study included women who underwent BCS for primary carcinomas in 2016 and 2017. Definitive presurgical diagnosis was defined as having a presurgical core needle biopsy (CNB) and not being upstaged between biopsy and surgery. Biopsy data and imaging findings including breast density were retrieved. Inadequate surgical margins (IM) were defined per latest ASCO and ASTRO guidelines. Univariable and multivariable analyses were performed.

RESULTS

360 women (median age, 66) met inclusion criteria with 1 having 2 cancers. 82.5% (298/361) were invasive cancers while 17.5% (63/361) were ductal carcinoma in situ (DCIS). Most biopsies were US-guided (284/346, 82.0%), followed by mammographic (60/346, 17.3%), and MRI-guided (2/346, 0.6%). US and mammographic CNB yielded median samples of 2 and 4, respectively, with a 14G needle. 15 patients (4.2%) lacked presurgical CNB. The IM rate was 30.0%. In multivariable analysis, large invasive cancers (>20 mm), dense breasts, and DCIS were associated with IM (p = 0.029, p = 0.010, and p = 0.013, respectively). Most importantly, lack of definitive presurgical diagnosis was a risk factor for IM (OR, 2.35; 95% CI: 1.23-4.51, p = 0.010). In contrast, neither patient age (<50) nor aggressive features (e.g., LVI) were associated with IM.

CONCLUSION

Lack of a definitive presurgical diagnosis was associated with a two-fold increase of IM in BCS; other risk factors were dense breasts, large invasive cancers, and DCIS.

The Impact of Preoperative Breast MRI on Surgical Margin Status in Breast Cancer Patients Recalled at Biennial Screening Mammography: An Observational Cohort Study

Background

This study aimed to examine the association between preoperative magnetic resonance imaging (MRI) and surgical margin involvement, as well as to determine the factors associated with positive resection margins in screen-detected breast cancer patients undergoing breast-conserving surgery (BCS).

Methods

Breast cancer patients eligible for BCS and diagnosed after biennial screening mammography in the south of The Netherlands (2008–2017) were retrospectively included. Missing values were imputed and multivariable regression analyses were performed to analyze whether preoperative MRI was related to margin involvement after BCS, as well as to examine what factors were associated with positive resection margins, defined as more than focally (>4 mm) involved.

Results

Overall, 2483 patients with invasive breast cancer were enrolled, of whom 123 (5.0%) had more than focally involved resection margins. In multivariable regression analyses, preoperative MRI was associated with a reduced risk of positive resection margins after BCS (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.33–0.96). Lobular histology (adjusted OR 2.86, 95% CI 1.68–4.87), large tumor size (per millimeter increase, adjusted OR 1.05, 95% CI 1.03–1.07), high (>75%) mammographic density (adjusted OR 3.61, 95% CI 1.07–12.12), and the presence of microcalcifications (adjusted OR 4.45, 95% CI 2.69–7.37) and architectural distortions (adjusted OR 1.85, 95% CI 1.01–3.40) were independently associated with positive resection margins after BCS.

Conclusions

Preoperative MRI was associated with lower risk of positive resection margins in patients with invasive breast cancer eligible for BCS using multivariable analysis. Furthermore, specific mammographic characteristics and tumor characteristics were independently associated with positive resection margins after BCS.

Thermal Ablation as an Alternative for Surgical Resection of Small (≤ 2 cm) Breast Cancers: A Meta-Analysis

Women with early-stage breast cancer have an excellent prognosis with current therapy, but could presumably be treated less invasively, without the need for surgery. The primary goal of this meta-analysis was to examine whether thermal ablation is an effective method to treat early-stage breast cancer. Studies reporting on complete ablation rate after thermal ablation as a treatment of small breast cancers (≤ 2 cm) were included. Methodologic quality of included studies was assessed using MINORS criteria. Complete ablation rates are given as proportions, and meta-regression and subgroup analyses were performed. The overall complete ablation rate in 1266 patients was 86% and was highest after radiofrequency ablation (RFA) (92%). Local recurrence rates varied from 0% to 3%, with a median follow-up of 15 to 61 months. Overall, complication rates were low (5%-18% across techniques) and were highest after high-intensity focused ultrasound ablation and lowest after cryoablation. Cosmetic outcome was good to excellent in at least 85% of patients but was reported infrequently and long-term results of cosmetic outcome after thermal ablation and radiotherapy are still lacking. Thermal ablation techniques treating early-stage breast cancer (≤ 2 cm) are safe and effective based on complete ablation rate and short-term local recurrence rates. Especially, RFA, microwave ablation, and cryoablation are promising techniques as an alternative to surgical resection without jeopardizing current treatment effectiveness or safety. Owing to great heterogeneity in the included studies, a formal recommendation on the best technique is not possible. These findings warrant the design of large randomized controlled trials comparing thermal ablation and breast-conserving surgery in the treatment of T1 breast cancer.

Adequacy of invasive and in situ breast carcinoma margins in radioactive seed and wire-guided localization lumpectomies

Image-guided preoperative localizations help surgeons to completely resect nonpalpable breast cancers. The objective of this study is to compare the adequacy of specimen margins for both invasive breast cancer (IBC) and ductal carcinoma in situ (DCIS) after radioactive seed localization (RSL) vs wire-guided localization (WGL). We retrospectively reviewed 600 cases at a single Canadian academic center from January 2014 to September 2017, comparing surgical margins, re-excisions and reoperations, localization accuracy and major complications (migration, accidental deployment, vasovagal reaction), as well as operative duration between RSL and WGL cases. IBC margins were positive in 7% of RSL and 6% of WGL cases (P = .57). Tumor size (P = .039) and association with DCIS (P = .036) predicted positive margins in invasive carcinoma. DCIS margins were positive in 6% and 8%, and close (≤2 mm) in 37% and 36% of cases (P = .45) for RSL and RSL cases respectively. The presence of extensive intraductal component predicted positive DCIS margins (P < .0001). There was no significant difference between intraoperative re-excisions (P = .54), localization accuracy (P = .34), and operation duration (P = .81). Reoperation for lumpectomies and mastectomies was marginally higher for WGL than RSL (P = .049). There were 11 (4%) WGL and no RSL complications (P = .03). Overall, positive margins for IBC, close or positive margins for DCIS, intraoperative re-excision, localization accuracy, and operation duration were similar between RSL and WGL. The reoperation rate was higher in WGL than RSL, which may reflect practice changes over time. RSL was safer than WGL with lower complication rates.

Preoperative Magnetic Resonance Imaging Features Associated with Positive Resection Margins in Patients with Invasive Lobular Carcinoma

Objective

To investigate preoperative magnetic resonance imaging (MRI) findings associated with resection margin status in patients with invasive lobular carcinoma (ILC) who underwent breast-conserving surgery.

Materials and Methods

One hundred and one patients with ILC who underwent preoperative MRI were included. MRI (tumor size, multifocality, type of enhancing lesion, distribution of non-mass enhancement [NME], and degree of background parenchymal enhancement) and clinicopathological features (age, pathologic tumor size, presence of ductal carcinoma in situ [DCIS] or lobular carcinoma in situ, presence of lymph node metastases, and estrogen receptor/progesterone receptor/human epidermal growth factor receptor type 2 status) were analyzed. A positive resection margin was defined as the presence of invasive cancer or DCIS at the inked surface. Logistic regression analysis was performed to determine pre- and postoperative variables associated with positive resection margins.

Results

Among the 101 patients, 21 (20.8%) showed positive resection margins. In the univariable analysis, NME, multifocality, axillary lymph node metastasis, and pathologic tumor size were associated with positive resection margins. With respect to preoperative MRI findings, multifocality (odds ratio [OR] = 3.977, p = 0.009) and NME (OR = 2.741, p = 0.063) were associated with positive resection margins in the multivariable analysis, although NME showed borderline significance.

Conclusion

In patients with ILC, multifocality and the presence of NME on preoperative breast MRI were associated with positive resection margins.

Is specimen radiography still necessary in patients with non-palpable breast cancer undergoing breast-conserving surgery using radioactive I-125 seed localization?

AIM

To evaluate the diagnostic performance for margin assessment of specimen radiography (SR) in breast conserving surgery (BCS) using radioactive I¹²⁵-seed localization (RSL).

METHODS

The clinical, radiographic and histopathological data of women who underwent BCS after pre-operative RSL with intraoperative SR during nine consecutive years were analyzed. The histological margin and radiographic margin outcomes on SR were compared and results of intraoperative re-excisions were investigated.

RESULTS

A consecutive series of 448 women with invasive carcinoma (n = 211), ductal carcinoma in situ (DCIS) (n = 79) and a combination of DCIS and invasive carcinoma (n = 158) were included. The median minimal margins for the radiological masses and microcalcifications measured on SR were 14 mm and 11 mm, respectively. Based on a radiological cut-off SR margin value of 1 mm, the overall sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were 21.0%, 95.0%, 26.0%, and 94.0%, respectively. The area under the receiver-operating curve was 0.73. Intraoperative re-excisions based on SR were performed in 31 (6.9%) patients; histopathological examination of the additional excised tissue revealed DCIS or invasive carcinoma in 6 (19.4%) patients. Hence, SR was beneficial for 6/448 patients (1.3%), and unnecessary intraoperative re-excisions were performed in 20/448 patients (4.5%). The number need to treat is 75; this implies that per 75-SR one resection with involved margins is prevented.

CONCLUSION

SR has a moderate diagnostic performance for margin involvement using RSL. A more accurate intraoperative margin assessment tool is warranted.

Occurrence of Residual Cancer Within Re-excisions After Subcutaneous Mastectomy of Invasive Breast Cancer and Ductal Carcinoma In Situ - A Retrospective Analysis

BACKGROUND/AIM

Surgical margin status remains an important determinant for recurrence of invasive breast cancer and ductal carcinoma in situ. We compared the number of positive margins in initial histology with rates of residual tumor in re-excision specimens. Furthermore, we analysed cost-effectiveness of re-excisions.

PATIENTS AND METHODS

101 patients treated with secondary surgery were included. The first group underwent breast conserving surgery and secondary mastectomy. The second group was primarily treated with subcutaneous mastectomy followed by secondary surgery.

RESULTS

Within the first group, 22.7% did not show residual tumor in the re-excision specimen. Of the second group, 54.3% had no residual tumor. Consequentially 45.7% needed a re-excision to achieve R0 status. Cost-effectiveness was determined as secondary endpoint. If a patient needs a secondary mastectomy the hospital gains 602,65€ in comparison to a primary breast conserving operation.

CONCLUSION

In every second patient who had first received a subcutaneous mastectomy, no tumor could be detected in the secondary operation despite a previous R1 status.

Preoperative Predictive Factors of Positive Margin Status After Breast Conserving Therapy (BCT) with Intraoperative Radiation Therapy (IORT): A Retrospective Study of 400 Patients

INTRODUCTION

Single-fraction intraoperative radiation therapy (IORT) has emerged as a therapeutic option in patients undergoing breast conserving therapy (BCT) for early stage breast cancer, often eliminating the need for postoperative external beam radiation therapy. However, if a positive margin is encountered after BCT, the patient will ultimately require external beam radiation therapy. The purpose of this study was to identify preoperative factors from patient demographics, preoperative workup, or biopsy results that may be predictive of postoperative margin status.

MATERIALS AND METHODS

A retrospective chart review was performed on 396 patients who underwent BCT with IORT. Logistic regression models were utilized for statistical analysis.

RESULTS

The majority of studied variables were similar; however, differences were noted for high-grade tumors, in situ status, and progesterone receptor-negative (PR^-) tumors. Grade 3 tumors were significantly associated with positive margin status when compared with Grade 1 (odds ratio, 2.30; P = .036). PR^- status tumors were found to be approximately 2 times more likely to have a positive margin (P = .028). Patients with in situ (stage 0) status tumors were 1.986 times more likely to have positive margins when compared with those with an invasive tumor (P = .030).

CONCLUSIONS

Higher grade PR^- tumors are at increased risk of having a positive margin, which should be taken into consideration when considering treatment with IORT.

Solving the preoperative breast MRI conundrum: design and protocol of the MIPA study

Despite its high diagnostic performance, the use of breast MRI in the preoperative setting is controversial. It has the potential for personalized surgical management in breast cancer patients, but two of three randomized controlled trials did not show results in favor of its introduction for assessing the disease extent before surgery. Meta-analyses showed a higher mastectomy rate in women undergoing preoperative MRI compared to those who do not. Nevertheless, preoperative breast MRI is increasingly used and a survey from the American Society of Breast Surgeons showed that 41% of respondents ask for it in daily practice. In this context, a large-scale observational multicenter international prospective analysis (MIPA study) was proposed under the guidance of the European Network for the Assessment of Imaging in Medicine (EuroAIM). The aims were (1) to prospectively and systematically collect data on consecutive women with a newly diagnosed breast cancer, not candidates for neoadjuvant therapy, who are offered or not offered breast MRI before surgery according to local practice; (2) to compare these two groups in terms of surgical and clinical endpoints, adjusting for covariates. The underlying hypotheses are that MRI does not cause additional mastectomies compared to conventional imaging, while reducing the reoperation rate in all or in subgroups of patients. Ninety-six centers applied to a web-based call; 36 were initially selected based on volume and quality standards; 27 were active for enrollment. On November 2018, the target of 7000 enrolled patients was reached. The MIPA study is presently at the analytic phase. Key Points • Breast MRI has a high diagnostic performance but its utility in the preoperative setting is controversial. • A large-scale observational multicenter prospective study was launched to compare women receiving with those not receiving preoperative MRI. • Twenty-seven centers enrolled more than 7000 patients. The study is presently at the analytic phase.

Preoperative breast cancer staging with multi-modality imaging and surgical outcomes

PURPOSE

To compare the rates of mastectomy and re-operation after breast-conserving surgery (BCS) among patients who had different pre-operative multi-modality imaging, hence identifying significant predictors of mastectomy and re-operations within each group.

METHOD

Retrospective study of consecutive patients with primary breast cancer treated January 2010 - December 2016, divided in 3 groups, undergoing pre-operative local staging respectively with conventional imaging modalities only (2D mammography, ultrasound (US)), conventional imaging and tomosynthesis (DBT) and/or MRI. The primary outcome was identification of significant predictors of surgical outcomes, within each group. Study variables examined in univariate analysis were age, lesion dimension, breast density, multifocality, tumor size, histology, and if associated with outcomes they were included in binary logistic regression analysis.

RESULTS

Amongst 1547 patients, patient and tumor characteristics differed across the three groups, as did mastectomy rates which were 18 % (102/562) for 2D + US, 36 % (154/428) for 2D + DBT + US, 45 % (250/557) for 2D+/-DBT + US + MRI(p < 0.001). Variables strongly associated with mastectomy were larger lesions and multifocality (as was multi-modality group). Re-operation rate showed an opposite trend: 12.2 % (56/459) for 2D + US, 8 % (22/272) for 2D + DBT + US, 6.5 % (20/306) for 2D+/-DBT + US + MRI. Re-operation rate for 2D+/-DBT + US + MRI was lower than for 2D + US (p = 0.01) but similar to 2D + DBT + US (p = 0.58). Patients who had 2D + US and re-operations had significantly larger lesions, more underestimation, higher proportion of invasive carcinoma with in-situ component than those who did not require re-operation.

CONCLUSIONS

Patients who had larger tumors and multifocal disease were more frequently staged by adding DBT and/or MRI to conventional imaging (mammography and US) which was associated with more extensive surgical treatment but lower reoperation rates.

The prognostic significance of co-existence ductal carcinoma in situ in invasive ductal breast cancer: a large population-based study and a matched case-control analysis

Background

To evaluate the prognostic significance of co-existence ductal carcinoma in situ (DCIS) in invasive ductal breast cancer (IDC) compared with pure IDC.

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was searched to identify unilateral IDC cases between 2004 and 2015, which were grouped into pure IDC and IDC with DCIS component (IDC-DCIS). Comparisons of the distribution of clinical-pathological characteristics the two groups were performed using Pearson's chi-square. Breast cancer-specific survival (BCSS) and overall survival (OS) were estimated using the Kaplan-Meier method and compared across RS groups using the log-rank statistic. Cox models were fitted to assess the factors independently associated with survival. A 1:1 matched case-control analysis was conducted with each clinical-pathological characteristic matched completely.

Results

A total of 98,097 pure IDC cases (39.6%) and 149,477 IDC-DCIS cases (60.4%) were enrolled. IDC-DCIS patients were presented with less aggressive characteristics such as lower proportion of histologic grade III (34.2% vs. 42.2%, P<0.001), ER negative (16.8% vs. 26.1%, P<0.001) and PR negative (26.5% vs. 35.7%, P<0.001) disease and higher proportion of T1 cases (68.7% vs. 58.2%, P<0.001) compared with pure IDC patients. Co-existence DCIS was an independent prognostic factor for BCSS and OS in the whole cohort. According to the multivariate analysis, it was an independent favorable prognostic factor among ER positive cases, but an independent negative prognostic factor among ER negative cases based on the matched cohort.

Conclusions

Co-existence DCIS showed quite different prognostic significance among ER positive and negative disease.

Preoperative breast MRI features associated with positive or close margins in breast-conserving surgery

PURPOSE

To determine preoperative magnetic resonance imaging (MRI) features associated with positive or close margins in patients with breast cancer who underwent breast-conserving surgery (BCS).

MATERIALS AND METHODS

A retrospective review identified 249 patients with invasive ductal carcinoma (IDC) who underwent preoperative MRI and BCS as a primary procedure between 2008 and 2010. The MR images were reviewed for descriptions of findings with no new interpretations made. Margins were defined as positive (tumor touching the inked specimen margin), close (<2 mm tumor-free margin), or negative (≥2 mm tumor-free margin). Multivariate logistic regression analysis was performed to evaluate imaging and clinical factors predictive of positive or close margins.

RESULTS

Of the 249 patients, 83 (33.3%) had positive or close margins and 166 (66.7%) had negative margins on the initial BCS specimen. Multivariate analysis showed that multifocal disease (odds ratio, 4.8; 95% CI, 1.9-12.2; p =  0.001), nonmass enhancement lesion (odds ratio, 3.0; 95% CI, 1.5-6.2, p =  0.003), greater background parenchymal enhancement (odds ratio, 2.5; 95% CI, 1.1-5.6; p =  0.023), larger lesion size (odds ratio, 1.3; 95% CI, 1.0-1.7, p =  0.032), and presence of ductal carcinoma in situ on needle biopsy (odds ratio, 2.4; 95% CI, 1.3-4.6; p = 0.008) were independent predictors of positive or close margins.

CONCLUSIONS

Multifocal disease, nonmass enhancement lesion, or greater background parenchymal enhancement on preoperative breast MRI were significantly associated with positive or close margins. Identifying these MRI features before surgery can be helpful to reduce the reoperation rate in BCS.

Radio-guided and clip-guided preoperative localization for malignant microcalcifications offer similar performances in breast-conserving surgery

Obtaining a tailored breast resection is challenging in microcalcifications detected on screening mammography, and an accurate localization is required. The aim of this study was to compare the efficacy of radio-guided localization (ROLL) versus ultrasound localization of a titanium clip with collagen (TCC) in terms of clear margins, re-intervention rates, excess of resected breast tissue, and operative times in pure malignant microcalcifications detected on screening mammography. Two hundred and twenty-one consecutive patients with malignant microcalcifications detected on screening mammography from a tertiary breast unit were reviewed: 177 patients were localized by TCC and 44 patients by stereotactic ROLL. A propensity score-matched analysis was performed, followed by a logistic regression model, to avoid selection bias. Adequacy of resection was expressed as the calculated resection ratio considering lesion size. No differences were found in clear margins with ROLL versus TCC (77.3% vs 81.8%, adjusted OR 2, P = 0.27). Re-operation rates were similar, being 11.3% with ROLL and 7.4% with TCC (P = 0.627). Mean resection volume was 46.2 cm³ with ROLL versus 54.2 cm³ with TCC (P = 0.222). Adjusted mean calculated resection ratio was 1.8 with ROLL and 2.1 with TCC (P = 0.38). Surgery time was longer with TCC compared to ROLL (69.6 vs 52.7 minutes, P < 0.0001). ROLL and TCC are equally effective to excise malignant microcalcifications with clear margins, providing similar re-intervention rates and resection volumes.

MRI predictors of tumor-positive margins after breast-conserving surgery

PURPOSE

The purpose of this study is to identify predictors of tumor-positive surgical margins after breast-conserving surgery on dynamic contrast-enhanced (DCE) MRI.

MATERIALS AND METHODS

We conducted a retrospective study of consecutive women who underwent DCE MRI before breast-conserving surgery from 2005 to 2014. Patient demographics, indication for surgery, MRI findings, biopsy pathology results, and surgical outcomes were reviewed. The unpaired t-test and chi-square test were used to compare the positive and negative margins groups.

RESULTS

554 women (mean age, 56; range, 26-90) underwent DCE MRI before 575 breast-conserving surgeries for invasive carcinoma (n = 473) or ductal carcinoma in situ (DCIS) (n = 102). Positive margins requiring re-excision occurred in 19.7% (93/473) of surgeries for invasive carcinoma and 31.4% (32/102) of surgeries for DCIS. For invasive carcinoma surgeries, positive margins were more common when MRI demonstrated the finding of non-mass enhancement (NME) rather than the finding of enhancing mass (33.8% [22/65] versus 16.9% [61/360], p < 0.01). Tumor size on MRI was significantly larger in the positive margins group (2.5 cm versus 1.9 cm, p < 0.001). Positive margins were more common with invasive lobular rather than invasive ductal histology at core biopsy (38.3% [18/47] versus 16.0% [56/350], p < 0.001). For DCIS surgeries, there were no significant differences in positive margin rates related to MRI features.

CONCLUSION

For invasive carcinoma surgeries, positive margins are associated with NME on MRI, larger tumor size on MRI, and lobular histology at core biopsy. These findings may be used to predict which patients are at risk for positive margins after breast-conserving surgery.

Oncoplastic Breast Reconstruction in Breast Conservation Surgery: Improving the Oncological and Aesthetic Outcomes

Breast conservation surgery (BCS) is now the standard of care for patients with early breast cancer. The main contraindications for BCS besides the presence of multicentricity and diffuse microcalcifications are inadequate tumour size to breast size ratio. With the advent of oncoplastic techniques, the indications of BCS may be further extended to patient with larger tumour size and or small volume breast. We prospectively assessed 42 patients undergoing oncoplastic breast conservation surgery for cosmetic and oncologic outcomes. Cosmetic outcome assessment was done by comparison of operated breast to contralateral breast by an independent surgeon, nurse and patient's attendant at 6 months post-surgery. Risk factors for compromised oncologic outcomes included grades II/III tumours and non-ductal histology. Intraoperative margin assessment with frozen section analysis proved to be important in order to achieve negative surgical margins on final histopathology. By univariate analysis, tumours located in central quadrant and medial half of the breast had similar cosmetic outcomes comparable to tumours located in other quadrants. Majority of our patients (90%) had overall good to excellent cosmetic outcomes on Harvard scale. Oncoplastic breast conservation surgery techniques allow for larger parenchymal resections without compromising oncologic and cosmetic results. It further allows extension of BCS to patients otherwise denied for the same based on earlier recommendations for mastectomy. Oncoplastic techniques and intraoperative margin assessment with frozen section are vital in attaining adequate margins and also decrease chance of local recurrence and revision surgery for positive margins.

Optical palpation for the visualization of tumor in human breast tissue

Accurate and effective removal of tumor in one operation is an important goal of breast-conserving surgery. However, it is not always achieved. Surgeons often utilize manual palpation to assess the surgical margin and/or the breast cavity. Manual palpation, however, is subjective and has relatively low resolution. Here, we investigate a tactile imaging technique, optical palpation, for the visualization of tumor. Optical palpation generates maps of the stress at the surface of tissue under static preload compression. Stress is evaluated by measuring the deformation of a contacting thin compliant layer with known mechanical properties using optical coherence tomography. In this study, optical palpation is performed on 34 freshly excised human breast specimens. Wide field-of-view (up to ~46 × 46 mm) stress images, optical palpograms, are presented from four representative specimens, demonstrating the capability of optical palpation to visualize tumor. Median stress reported for adipose tissue, 4 kPa, and benign dense tissue, 8 kPa, is significantly lower than for invasive tumor, 60 kPa. In addition, we demonstrate that optical palpation provides contrast consistent with a related optical technique, quantitative micro-elastography. This study demonstrates that optical palpation holds promise for visualization of tumor in breast-conserving surgery.

Clinical feasibility of optical coherence micro-elastography for imaging tumor margins in breast-conserving surgery

It has been demonstrated that optical coherence micro-elastography (OCME) provides additional contrast of tumor compared to optical coherence tomography (OCT) alone. Previous studies, however, have predominantly been performed on mastectomy specimens. Such specimens typically differ substantially in composition and geometry from the more clinically relevant wide-local excision (WLE) specimens excised during breast-conserving surgery. As a result, it remains unclear if the mechanical contrast observed is maintained in WLE specimens. In this manuscript, we begin to address this issue by performing a feasibility study of OCME on 17 freshly excised, intact WLE specimens. In addition, we present two developments required to sustain the progression of OCME towards intraoperative deployment. First, to enable the rapid visualization of en face images required for intraoperative assessment, we describe an automated segmentation algorithm to fuse en face micro-elastograms with OCT images to provide dual contrast images. Secondly, to validate contrast in micro-elastograms, we present a method that enables co-registration of en face images with histology of WLE specimens, sectioned in the orthogonal plane, without any modification to the standard clinical workflow. We present a summary of the observations across the 17 specimens imaged in addition to representative micro-elastograms and OCT images demonstrating contrast in a number of tumor margins, including those involved by invasive ductal carcinoma, mucinous carcinoma, and solid-papillary carcinoma. The results presented here demonstrate the potential of OCME for imaging tumor margins.

Does intra-operative margin assessment improve margin status and re-excision rates? A population-based analysis of outcomes in breast-conserving surgery for ductal carcinoma in situ

BACKGROUND AND OBJECTIVES

Using a 2 mm margin criteria, we evaluated the effect of intra-operative margin assessment on margin status and re-excisions following breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS).

METHODS

We identified patients undergoing BCS for DCIS from a prospective, population-based database. Multivariable logistic regression was used to determine the effect of specimen mammography, ultrasound and macroscopic assessment by a pathologist on margins and re-excision rates.

RESULTS

In 588 patients, 52% (95% confidence interval [CI], 48%-56%) had positive margins (<2 mm), 39% (95% CI, 35%-43%) had a re-excision and 15% (95% CI, 12%-18%) had completion mastectomy. There were few re-excisions for margins ≥2 mm (2%). Adjusting for confounders, any margin assessment versus wire localization alone did not reduce positive margins (odds ratio [OR], 0.75; P = 0.202) or re-excisions (OR, 1.14; P = 0.564), however both outcomes varied by type of technique ( P < 0.001). Individually, only macroscopic assessment by pathologist reduced positive margins (OR, 0.54; P = 0.002) and re-excisions (OR, 0.61; P = 0.036).

CONCLUSIONS

Despite adherence to a 2 mm margin criteria, re-excision rates remain high following BCS for DCIS, with 39% converted to mastectomy when re-excision is required. Intra-operative margin assessment does not appear to reduce re-excisions; in particular, surgeons should be aware of the limitations of specimen mammography for margin assessment in DCIS.

The Feasibility of Breast-Conserving Surgery for Multiple Ipsilateral Breast Cancer: An Initial Report from ACOSOG Z11102 (Alliance) Trial

BACKGROUND

Historically, multiple ipsilateral breast cancer (MIBC) has been a contraindication to breast-conserving therapy (BCT). We report the feasibility of BCT in MIBC from the ACOSOG Z11102 trial [Alliance], a single arm noninferiority trial of BCT for women with two or three sites of malignancy in the ipsilateral breast.

METHODS

Women who enrolled preoperatively in ACOSOG Z11102 were evaluated for conversion to mastectomy and need for reoperation to obtain negative margins. Characteristics of women who successfully underwent BCT and those who converted to mastectomy were compared. Factors were examined for association with the need for margin reexcision.

RESULTS

Of 198 patients enrolled preoperatively, 190 (96%) had 2 foci of disease. Median size of the largest tumor focus was 1.5 (range 0.1-7.0) cm; 49 patients (24.8%) had positive nodes. There were 14 women who underwent mastectomy due to positive margins, resulting in a conversion to mastectomy rate of 7.1% (95% confidence interval [CI] 3.9-10.6%). Of 184 patients who successfully completed BCT, 134 completed this in a single operation. Multivariable logistic regression analysis did not identify any factors significantly associated with conversion to mastectomy or need for margin reexcision.

CONCLUSIONS

Breast conservation is feasible in MIBC with 67.6% of patients achieving a margin-negative excision in a single operation and 7.1% of patients requiring conversion to mastectomy due to positive margins. No characteristic was identified that significantly altered the risk of conversion to mastectomy or need for reexcision. CLINICALTRIALS.

GOV IDENTIFIER

NCT01556243.

Obtaining adequate surgical margin status in breast-conservation therapy: intraoperative ultrasound-guided resection versus specimen mammography

Background and aim

The purpose of breast-conserving surgery (BCS) for women with cancer is to perform an oncological radical procedure with disease-free margins at the final histological assessment and with the best aesthetic result possible. Intraoperative resected specimen ultrasound and intraoperative resected specimen mammography may reduce the rates of positive margins and reexcision among patients undergoing conserving therapy. Our objective is to compare the two methods with the histopathological results for a preset cut off and asses which parameters can influence the positive margin status.

Method

A prospective study was performed on 83 patients who underwent breast conservation surgery for early breast cancer (pT1-3a pN0-1 M0) between 2014 and 2016. After excision the specimen was oriented in the operating room by the surgeon. Metallic clips and threads were placed on margins: one clip and the long thread at 12 o’clock, two clips and the short threads at 9 o’clock. The next step was intraoperative ultrasound assessment of the specimen. For the margins under 2 mm we performed selective margin shaving, followed by mammography to identify and document the lesion and finally histopathological examination of the specimen with reporting the gross and microscopic margins. The positive margins required re-excision or boost of radiation at the posterior or anterior margins, depending on the case.

Results

We set a cut-off at 2 mm. The sensitivity and specificity of the intraoperative margin assessment via the ultrasound method were 90.91% (95% CI 70.84–98.88%) and 67.21% (95% CI 54–78.69%) respectively. The sensitivity and specificity of the intraoperative margin assessment via the mammographic procedure were 45.45% (95% CI 24.39–67.79%) and 85.25% (95% CI 73.83–93.02%) respectively. There was positive correlation between the histopathological and intraoperative ultrasound exam (p=0.018) and negative correlation between the histopathological exam and the post-operative mammographic exam (p=0.68). We found a positive correlation between the positive margin status and age (<40), preoperative chemotherapy, intraductal carcinoma, inflammatory process around the tumor, and the immunohistochemical triple negative profile.

Conclusions

According to our results, the intraoperative ultrasound of the breast specimen for a cutt-off at 2 mm can decrease the rates of margin positivity compared to the mammographic procedure and has the potential to diminish the number of subsequent undesired re-excisions.

Surgeon Variability and Factors Predicting for Reoperation Following Breast-Conserving Surgery

BACKGROUND

Reoperation after breast-conserving surgery (BCS) is common and has been partially associated with the lack of consensus on margin definition. We sought to investigate factors associated with reoperations and variation in reoperation rates across breast surgeons at our cancer center.

METHODS

Retrospective analyses of patients with clinical stage I-II breast cancer who underwent BCS between January and December 2014 were conducted prior to the recommendation of 'no ink on tumor' margin. Patient demographics and tumor and surgical data were extracted from medical records. A multivariate regression model was used to identify factors associated with reoperation.

RESULTS

Overall, 490 patients with stage I (n  = 408) and stage II (n  = 89) breast cancer underwent BCS; seven patients had bilateral breast cancer and underwent bilateral BCS procedures. Median invasive tumor size was 1.1 cm, reoperation rate was 22.9% (n  = 114) and varied among surgeons (range 15-40%), and, in 100 (88%) patients, the second procedure was re-excision, followed by unilateral mastectomy (n  = 7, 6%) and bilateral mastectomy (n  = 7, 6%). Intraoperative margin techniques (global cavity or targeted shaves) were utilized in 50.1% of cases, while no specific margin technique was utilized in 49.9% of cases. Median total specimen size was 65.8 cm³ (range 24.5-156.0). In the adjusted model, patients with multifocal disease were more likely to undergo reoperation [odds ratio (OR) 5.78, 95% confidence interval (CI) 2.17-15.42]. In addition, two surgeons were found to have significantly higher reoperation rates (OR 6.41, 95% CI 1.94-21.22; OR 3.41, 95% CI 1.07-10.85).

CONCLUSIONS

Examination of BCS demonstrated variability in reoperation rates and margin practices among our breast surgeons. Future trials should look at surgeon-specific factors that may predict for reoperations.

Factors influencing reoperation following breast-conserving surgery

BACKGROUND

Reoperation rates after breast-conserving surgery are highly variable and the best techniques for optimizing margin clearance are being evaluated. The aim was to identify the reoperation rate at our centre and identify influential factors, including a change in guidelines on margin recommendations and the introduction of in-theatre specimen X-ray.

METHODS

A retrospective review of medical records was undertaken to identify 562 patients who underwent breast conservation at The Royal Melbourne Hospital and Royal Women's Hospital between 2013 and 2015. All cases that underwent subsequent re-excision or total mastectomy were captured and factors influencing margin excision recorded.

RESULTS

Reoperation was undertaken in 19.5% of patients (110; 86 re-excisions and 24 total mastectomies). There was a reduction in reoperation rate from 25% to 17% (P = 0.01) with adoption of the margin guidelines in 2014, but no significant reduction with the introduction of in-theatre specimen X-ray in 2015 (21% versus 16%, P = 0.14). On multivariate analysis, factors that significantly influenced reoperation rates were the presence of multifocality on mammogram (odds ratio (OR): 5.3, 95% confidence interval (CI): 1.6-16.7, P < 0.01); lesion size on mammogram (OR: 2.2 per 10 mm, 95% CI: 1.4-3.6, P < 0.01); smaller excision specimen weight (OR: 0.5 per 25 g of resection, 95% CI: 0.3-0.8, P < 0.01); and pure ductal carcinoma in situ on final pathology (OR: 5.9, 95% CI: 1.9-16.7, P < 0.01).

CONCLUSION

Optimizing reoperation rates following breast-conserving surgery remains a surgical challenge, particularly in patients with in situ or multifocal disease. Adoption of international margin guidelines reduced reoperation rates at our centre; however, introduction of intraoperative specimen X-ray had no influence.

Predicting initial margin status in breast cancer patients during breast-conserving surgery

Background

We sought to develop and validate a model for prediction of initial margin status during breast-conserving surgery (BCS).

Methods

We included eligible breast cancer patients receiving BCS in Sun Yat-sen Memorial Hospital from January 2003 to December 2014. All patients received intraoperative frozen-section analysis for initial margin assessment. We used univariate and multivariate logistic regression analyses to screen for predictors. A nomogram was developed in the training cohort (n=1,193) from the south branch of the hospital and externally validated in the validation cohort (n=499) from the north branch. We used the area under the receiver-operating characteristic curve and Hosmer–Lemeshow tests to assess the discrimination and accuracy of the nomogram.

Results

The initial margin-positivity rates were 19.5% and 25.2% in the training and validation cohorts, respectively. Preoperative tumor size, preoperative lymph-node status, suspicion of multifocality, hormone-receptor status, and HER2 status were significantly associated with margin status. The model included these five variables. The discrimination and calibration of the model were considered acceptable in both cohorts.

Conclusion

The nomogram can predict the likelihood of having positive initial margins during BCS and may be useful for clinical decision-making in the surgical treatment of breast cancer patients.

Wide-field quantitative micro-elastography of human breast tissue

Currently, 20-30% of patients undergoing breast-conserving surgery require a second surgery due to insufficient surgical margins in the initial procedure. We have developed a wide-field quantitative micro-elastography system for the assessment of tumor margins. In this technique, we map tissue elasticity over a field-of-view of ~46 × 46 mm. We performed wide-field quantitative micro-elastography on thirteen specimens of freshly excised tissue acquired from patients undergoing a mastectomy. We present wide-field optical coherence tomography (OCT) images, qualitative (strain) micro-elastograms and quantitative (elasticity) micro-elastograms, acquired in 10 minutes. We demonstrate that wide-field quantitative micro-elastography can extend the range of tumors visible using OCT-based elastography by providing contrast not present in either OCT or qualitative micro-elastography and, in addition, can reduce imaging artifacts caused by a lack of contact between tissue and the imaging window. Also, we describe how the combined evaluation of OCT, qualitative micro-elastograms and quantitative micro-elastograms can improve the visualization of tumor.

A system for automatic monitoring of surgical instruments and dynamic, non-rigid surface deformations in breast cancer surgery

When negative tumor margins are achieved at the time of resection, breast conserving therapy (lumpectomy followed with radiation therapy) offers patients improved cosmetic outcomes and quality of life with equivalent survival outcomes to mastectomy. However, high reoperation rates ranging 10-59% continue to challenge adoption and suggest that improved intraoperative tumor localization is a pressing need. We propose to couple an optical tracker and stereo camera system for automated monitoring of surgical instruments and non-rigid breast surface deformations. A bracket was designed to rigidly pair an optical tracker with a stereo camera, optimizing overlap volume. Utilizing both devices allowed for precise instrument tracking of multiple objects with reliable, workflow friendly tracking of dynamic breast movements. Computer vision techniques were employed to automatically track fiducials, requiring one-time initialization with bounding boxes in stereo camera images. Point based rigid registration was performed between fiducial locations triangulated from stereo camera images and fiducial locations recorded with an optically tracked stylus. We measured fiducial registration error (FRE) and target registration error (TRE) with two different stereo camera devices using a phantom breast with five fiducials. Average FREs of 2.7 ± 0.4 mm and 2.4 ± 0.6 mm with each stereo-camera device demonstrate considerable promise for this approach in monitoring the surgical field. Automated tracking was shown to reduce error when compared to manually selected fiducial locations in stereo camera image-based localization. The proposed instrumentation framework demonstrated potential for the continuous measurement of surgical instruments in relation to the dynamic deformations of a breast during lumpectomy.

Focally positive margins in breast conserving surgery: Predictors, residual disease, and local recurrence

BACKGROUND

Re-excision after breast conserving surgery (BCS) for invasive breast cancer (IBC) can be omitted for focally positive margins in the Netherlands, but this guideline is not routinely followed. Focally positive and extensively positive margins have rarely been studied separately and compared to negative margins regarding clinicopathological predictors, residual disease incidence, and local recurrence.

METHODS

All females with BCS for Tis-T3, without neo-adjuvant chemotherapy between 2005 and 2014 at one university hospital were included. Clinicopathological and follow-up information was collected from electronic patient records. Index tumor samples from all patients with re-excision were reviewed by one pathologist. Margins were classified as negative (≥2 mm width), close (<2 mm width), focally positive (≤4 mm length of tumor touching inked margin), or extensively positive (>4 mm length).

RESULTS

From 499 patients included, 212 (43%) had negative, 161 (32%) had close, 59 (12%) had focally positive, and 67 (13%) had extensively positive margins. Increasingly involved margins were associated with lobular type, tumor size, and adjacent DCIS in IBC patients and lesion size in purely DCIS patients. In IBC patients, 17%, 49%, and 77% had re-excision after close, focally positive, and extensively positive margins and residual disease incidence was 55%, 50%, and 70% respectively. In purely DCIS patients, 26 (65%), 13 (87%), and 16 (94%) had re-excision after close, focally positive, and extensively positive margins and residual disease incidence was 39%, 46%, and 90% respectively.

CONCLUSION

Incidence of residual disease after focally positive margins was not different from close margins, but was significantly higher after extensively positive margins. We recommend quantifying extent of margin involvement in all pathology reports.

Impact of Preoperative Breast MR Imaging and MR-guided Surgery on Diagnosis and Surgical Outcome of Women with Invasive Breast Cancer with and without DCIS Component

Purpose To (a) compare the diagnostic accuracy of breast magnetic resonance (MR) imaging with that of conventional imaging (digital mammography and breast ultrasonography) in the identification of ductal carcinoma in situ (DCIS) components of biopsy-proven invasive breast cancer before surgery and (b) investigate the surgical outcome (positive margin rates and mastectomy rates) of women with breast cancer who underwent preoperative MR imaging combined with MR-guided needle biopsy and/or MR-guided lesion localization or bracketing where appropriate. Materials and Methods The authors performed a prospective two-center study of 593 consecutive patients with biopsy-proven invasive breast cancer who underwent breast MR imaging in addition to conventional imaging. MR-guided vacuum biopsy and MR-guided lesion bracketing were performed for DCIS components visible at MR imaging alone. The accuracy of breast MR imaging was compared with that of conventional imaging, and surgical outcomes (positive margin and mastectomy rates) were investigated. Results Surgical-pathologic assessment demonstrated DCIS components in 139 of the 593 women (23.4%). The sensitivity of MR imaging for the diagnosis of DCIS components pre-operatively (84.9%; 118 of 139) was significantly higher than that of conventional imaging (36.7%; 51 of 139) (P < .0001); more than half of DCIS components (51.1%; 71 of 139) were detected only with MR imaging. The sensitivity advantage of MR imaging over conventional imaging increased with increasing relative size of DCIS components, as follows: The sensitivity of MR imaging versus conventional imaging for small, marginal DCIS components was 56.8% (21 of 37) versus 29.7% (11 of 37); the sensitivity for extensive DCIS components was 91.7% (55 of 60) versus 41.7% (25 of 60); the sensitivity for large, predominant DCIS components was 100.0% (42 of 42) versus 35.7% (15 of 42). Moreover, the sensitivity advantage of MR imaging over conventional imaging increased with increasing nuclear grade of DCIS components, as follows: The sensitivity of MR imaging versus conventional imaging for low-grade DCIS components was 74.0% (20 of 27) versus 40.7% (11 of 27); the sensitivity for intermediate-grade DCIS components was 84.1% (53 of 63) versus 34.9% (22 of 63); the sensitivity for high-grade DCIS components was 91.8% (45 of 49) versus 36.7% (18 of 49) (P < .05-.001 for all). Positive margin rates were low overall (3.7% [95% Clopper Pearson confidence interval [CI]: 2.3%, 5.6%]) and did not differ significantly between the 139 women with DCIS components (5.0% [95% CI: 2.0%, 10.1%]) compared with the 454 women without such components (3.3% [95% CI: 1.9%, 5.4%]). The same was true for mastectomy rates (10.8% [95% CI: 6.2%, 17.2%] vs 8.1% [95% CI: 5.8%, 11.1%]). Conclusion Breast MR imaging improves depiction of DCIS components of invasive breast cancers before surgery and is associated with positive margin and mastectomy rates that are low irrespective of the presence or absence of DCIS components. ^© RSNA, 2017.

Frozen sections in patients undergoing breast conserving surgery at a single ambulatory surgical center: 5 year experience

OBJECTIVES

To evaluate outcomes of our breast frozen section (FS) practice in its first 5 years, including our specialized FS of margins (FSM) procedure for breast conserving therapy (BCT) patients.

METHODS

One thousand two hundred and forty eight patients undergoing 1303 breast FSM and/or sentinel lymph node (SLN) FS were included. Clinicopathologic features were assessed by chart review.

RESULTS

Use of SLN FS declined, from 43.5% of FS cases before to 19.2% of FS cases after 2012. FSM patients had a decline in overall reexcision to 12.3% in 2013-2014 (p = 0.063). There was also decline in reexcision for focally close margins (p < 0.0001) but no change in reexcision for extensively close margins. Reexcision was significantly associated with lobular subtype, multifocality and larger (≥T2) size. False negative FSM cases were most often influenced by extensively close or positive final (reexcised) margins sent for permanent section only (96/148; 64.9%).

CONCLUSIONS

Despite changing surgical practices, FSM remains a valuable service that reduces reexcision in BCT patients.

Optical coherence elastography - OCT at work in tissue biomechanics [Invited]

Optical coherence elastography (OCE), as the use of OCT to perform elastography has come to be known, began in 1998, around ten years after the rest of the field of elastography - the use of imaging to deduce mechanical properties of tissues. After a slow start, the maturation of OCT technology in the early to mid 2000s has underpinned a recent acceleration in the field. With more than 20 papers published in 2015, and more than 25 in 2016, OCE is growing fast, but still small compared to the companion fields of cell mechanics research methods, and medical elastography. In this review, we describe the early developments in OCE, and the factors that led to the current acceleration. Much of our attention is on the key recent advances, with a strong emphasis on future prospects, which are exceptionally bright.

Technical success, technique efficacy and complications of minimally-invasive imaging-guided percutaneous ablation procedures of breast cancer: A systematic review and meta-analysis

OBJECTIVES

To systematically review studies concerning imaging-guided minimally-invasive breast cancer treatments.

METHODS

An online database search was performed for English-language articles evaluating percutaneous breast cancer ablation. Pooled data and 95% confidence intervals (CIs) were calculated. Technical success, technique efficacy, minor and major complications were analysed, including ablation technique subgroup analysis and effect of tumour size on outcome.

RESULTS

Forty-five studies were analysed, including 1,156 patients and 1,168 lesions. Radiofrequency (n=577; 50%), microwaves (n=78; 7%), laser (n=227; 19%), cryoablation (n=156; 13%) and high-intensity focused ultrasound (HIFU, n=129; 11%) were used. Pooled technical success was 96% (95%CI 94-97%) [laser=98% (95-99%); HIFU=96% (90-98%); radiofrequency=96% (93-97%); cryoablation=95% (90-98%); microwave=93% (81-98%)]. Pooled technique efficacy was 75% (67-81%) [radiofrequency=82% (74-88); cryoablation=75% (51-90); laser=59% (35-79); HIFU=49% (26-74)]. Major complications pooled rate was 6% (4-8). Minor complications pooled rate was 8% (5-13%). Differences between techniques were not significant for technical success (p=0.449), major complications (p=0.181) or minor complications (p=0.762), but significant for technique efficacy (p=0.009). Tumour size did not impact on variables (p>0.142).

CONCLUSIONS

Imaging-guided percutaneous ablation techniques of breast cancer have a high rate of technical success, while technique efficacy remains suboptimal. Complication rates are relatively low.

KEY POINTS

• Imaging-guided ablation techniques for breast cancer are 96% technically successful. • Overall technique efficacy rate is 75% but largely inhomogeneous among studies. • Overall major and minor complication rates are low (6-8%).

Wide-field optical coherence micro-elastography for intraoperative assessment of human breast cancer margins

Incomplete excision of malignant tissue is a major issue in breast-conserving surgery, with typically 20 - 30% of cases requiring a second surgical procedure arising from postoperative detection of an involved margin. We report advances in the development of a new intraoperative tool, optical coherence micro-elastography, for the assessment of tumor margins on the micro-scale. We demonstrate an important step by conducting whole specimen imaging in intraoperative time frames with a wide-field scanning system acquiring mosaicked elastograms with overall dimensions of ~50 × 50 mm, large enough to image an entire face of most lumpectomy specimens. This capability is enabled by a wide-aperture annular actuator with an internal diameter of 65 mm. We demonstrate feasibility by presenting elastograms recorded from freshly excised human breast tissue, including from a mastectomy, lumpectomies and a cavity shaving.

Reoperations after primary breast conserving surgery in women with invasive breast cancer in Catalonia, Spain: a retrospective study

BACKGROUND

Although complete tumor resection is accepted as the best means to reduce recurrence, reoperations after lumpectomy are a common problem in breast cancer. The aim of this study was to assess the reoperation rates after primary breast conserving surgery in invasive breast cancer cases diagnosed in Catalonia, Spain, between 2005 and 2011 and to identify variations based on patient and tumour characteristics.

METHODS

Women with invasive incident breast cancer identified from the Patient's Hospital Discharge Database [174.0-174.9 codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) as the primary diagnosis] and receiving primary breast conserving surgery were included in the study and were followed up to 3 and 12 months by collecting information about repeat breast cancer surgery.

RESULTS

Reoperation rates after primary breast conserving surgery decreased from 13.0 % in 2005 to 11.7 % in 2011 at 3 months and from 14.2 % in 2005 to 12.9 % in 2011 at 12 months' follow-up. While breast conservation reoperations saw a slight, non-significant increase in the same period (from 5.7 to 7.3 % at 3 months, and from 6.0 to 7.5 % at 12 months), there was a significant decrease in radical reoperation (from 7.3 to 4.4 % at 3 months and from 8.2 to 5.4 % at 12 months). Overall, additional breast surgeries decreased among younger women.

CONCLUSIONS

Despite the rise of breast conserving surgery, reoperation rates following initial lumpectomy in Catalonia decreased by 10 % at 3 and 12 months' follow-up, remaining low and almost unchanged. Ultimately, there was also a significant decrease in mastectomies.

Predictors of Surgical Margin Following Breast-Conserving Surgery: A Large Population-Based Cohort Study

Background

The purpose of this retrospective, population-based, cohort study was to identify patient and tumor characteristics that are associated with a high risk of tumor-positive margins after breast-conserving surgery (BCS) to optimize preoperative counseling.

Methods

All patients with invasive breast cancer (IBC) reported according to the synoptic reporting module in the Dutch Pathology Registry between 2009 and 2015 were included (n = 42.048 cases). Data extraction included age, type of surgery, several tumor characteristics, and resection margin status according to the Dutch indications for re-excision (free, focally positive, or more than focally positive). Univariate and multivariate tests were used to determine the association between clinicopathological features and margin status, restricted to patients with BCS.

Results

Of 42,048 cases, a total of 25,315 cases (60.2 %) with IBC underwent BCS. Of these patients, 2578 patients (10.2 %) had focally positive resection margins and 1665 (6.6 %) had more than focally positive resection margins. By univariate analysis, the following features were significantly associated with involved margins: age < 60 years, multifocality, lobular subtype, tumor size >2 cm, intermediate- and high-grade, positive ER status, positive Her2 status, angio-invasion, and the presence/extent of a ductal carcinoma in situ (DCIS) component. In multivariate logistic regression, the variables with the strongest association with involved margins (OR > 2) were multifocality, lobular subtype, large tumor size, and the presence of DCIS.

Conclusions

Several clinicopathologic features are associated with involved resection margins after BCS for IBC. Assessment of these features preoperatively could be used to optimize preoperative counseling.

Intra-operative assessment of excised breast tumour margins using ClearEdge imaging device

INTRODUCTION

Breast conserving surgery (BCS) aims to remove a breast cancer completely and obtain clear margins. Complete excision is essential to reduce the risk of local recurrence. The ClearEdge™ (CE) imaging device examines margins of excised breast tissue intra-operatively. The aim of this study was to investigate the potential of the device in detecting margin involvement in patients having BCS.

METHODS

In Phase-1 58 patients underwent BCS and had 334 margins assessed by the device. In Phase-2 the device was used in 63 patients having BCS and 335 margins were assessed. Patients with margins considered close or involved by the CE device were re-excised.

RESULTS

The margin assessment accuracies in Phase-1 and Phase-2 compared to permanent section pathology were very similar: sensitivity (84.3% and 87.3%), specificity (81.9% and 75.6%), positive predictive value (67.2% and 63.6%), and negative predictive value (92.2% and 92.4%). The false positive rate (18.1% and 24.4%) and false negative rate (15.7% and 12.7%) were low in both phases. In Phase-2 re-excision rate was 37%, but in the 54 where the CE device was used appropriately the re-excision rate was 17%. Had all surgeons interpreted all images appropriately and re-excised margins detected as abnormal by the device in Phase-2 then the re-excision rate would have been 7%.

CONCLUSION

This study shows that the CE device has potential to reduce re-excision after BCS and further randomized studies of its value are warranted.