1
|
Vanni G, Pellicciaro M, Materazzo M, Marsella V, Usai V, Noce A, Buonomo OC. Impact of cavity shave margins in patients with ductal carcinoma in situ undergoing conserving breast surgery. Front Oncol 2024; 14:1403069. [PMID: 38817901 PMCID: PMC11137221 DOI: 10.3389/fonc.2024.1403069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 04/29/2024] [Indexed: 06/01/2024] Open
Abstract
Aim The main challenge during breast-conserving surgery (BCS) is to obtain clear margins, especially in patients with ductal carcinoma in situ (DCIS) due to the absence of well-defined nodules. Many surgical approaches have been used in an attempt to reduce the positive margin rate. The aim of this retrospective study is to compare the cavity shave margin technique with standard surgery and the intraoperative evaluation of surgical margins. Methods This is a single-center retrospective study analyzing margin status, need for re-excision, and surgical time in a cohort of 227 patients who underwent surgery from September 2016 to September 2022. Results In patients subjected to cavity shaving, we reported a significant reduction in positive margins of 17.1% versus 28.7% (p-value = 0.042). Also, a difference in terms of surgical re-excision was reported as p-value = 0.039 (12.4% versus 23.8%, respectively, for the cavity shave and control group). In the multivariate analysis, intraoperative evaluation of the margins was a risk factor for margins re-excision (Wald = 4.315, p = 0.038, OR: 2.331 [95% CI: 1.049-5.180]). Surgical time was lower in patients subjected to cavity shaves (p = 0.024), and the relative mean time was 68.4 min ± 37.1 min in the cavity shave group versus 93.9 min ± 40.6 min in the control group. Conclusion The cavity shave margin technique in conserving breast surgery results in a reduction in positive margin rate, surgical re-excision, and operative time.
Collapse
Affiliation(s)
- Gianluca Vanni
- Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, Rome, Italy
| | - Marco Pellicciaro
- Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, Rome, Italy
- PhD Program in Applied Medical-Surgical Sciences, Department of Surgical Science, Tor Vergata University, Rome, Italy
| | - Marco Materazzo
- Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, Rome, Italy
- PhD Program in Applied Medical-Surgical Sciences, Department of Surgical Science, Tor Vergata University, Rome, Italy
| | - Valentina Marsella
- Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, Rome, Italy
| | - Valeria Usai
- PhD Program in Applied Medical-Surgical Sciences, Department of Surgical Science, Tor Vergata University, Rome, Italy
| | - Annalisa Noce
- UOSD Nephrology and Dialysis, Policlinico Tor Vergata, Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Oreste Claudio Buonomo
- University of Basilicata, Potenza, Italy
- Breast Unit, Policlinico Tor Vergata, Rome, Italy
| |
Collapse
|
2
|
Patterson R, Guest M, Shenouda M, Pareek V, Galloway K, Bucher O, Hebbard P, Nashed M. Predictors of residual disease after breast conservation surgery for ductal carcinoma in situ: A retrospective study. J Cancer Res Ther 2024; 20:844-849. [PMID: 39023593 DOI: 10.4103/jcrt.jcrt_2657_22] [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: 12/20/2022] [Accepted: 01/12/2023] [Indexed: 07/20/2024]
Abstract
BACKGROUND Breast-conserving therapy is the standard of care for ductal carcinoma in situ (DCIS). Debate on what constitutes a satisfactory margin persists. This study aimed to identify predictors of residual disease at re-excision. METHODS This is a population-based retrospective cohort study of women with DCIS who underwent a lumpectomy between 2007 and 2017 in Manitoba, with close (≤2 mm) or positive margins that led to re-excision. RESULTS The DCIS re-excision rate was 29.3% for 1001 patients. 63.2% of patients were found to have residual disease on re-excision. On univariable analysis, the size, margin status, number of positive margins, type of second surgery, and Van Nuys Prognostic Index score were associated with residual disease on re-excision. The size of DCIS and the number of positive margins remained statistically significant on multivariable analysis. CONCLUSIONS Re-excision should be rationalized by considering the predictors of residual disease in conjunction with other factors.
Collapse
MESH Headings
- Humans
- Female
- Retrospective Studies
- Neoplasm, Residual/pathology
- Breast Neoplasms/surgery
- Breast Neoplasms/pathology
- Mastectomy, Segmental/methods
- Middle Aged
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Aged
- Margins of Excision
- Prognosis
- Adult
- Reoperation/statistics & numerical data
- Aged, 80 and over
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/surgery
- Neoplasm Recurrence, Local/epidemiology
Collapse
Affiliation(s)
- Ryan Patterson
- Max Rady College of Medicine, University of Manitoba, McDermot Avenue, Winnipeg, Manitoba, Canada
| | - Mitchell Guest
- Max Rady College of Medicine, University of Manitoba, McDermot Avenue, Winnipeg, Manitoba, Canada
| | | | | | | | | | - Pamela Hebbard
- Max Rady College of Medicine, University of Manitoba, McDermot Avenue, Winnipeg, Manitoba, Canada
- Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Maged Nashed
- Max Rady College of Medicine, University of Manitoba, McDermot Avenue, Winnipeg, Manitoba, Canada
- Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
3
|
Jong LJS, Appelman JGC, Sterenborg HJCM, Ruers TJM, Dashtbozorg B. Spatial and Spectral Reconstruction of Breast Lumpectomy Hyperspectral Images. SENSORS (BASEL, SWITZERLAND) 2024; 24:1567. [PMID: 38475103 DOI: 10.3390/s24051567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024]
Abstract
(1) Background: Hyperspectral imaging has emerged as a promising margin assessment technique for breast-conserving surgery. However, to be implicated intraoperatively, it should be both fast and capable of yielding high-quality images to provide accurate guidance and decision-making throughout the surgery. As there exists a trade-off between image quality and data acquisition time, higher resolution images come at the cost of longer acquisition times and vice versa. (2) Methods: Therefore, in this study, we introduce a deep learning spatial-spectral reconstruction framework to obtain a high-resolution hyperspectral image from a low-resolution hyperspectral image combined with a high-resolution RGB image as input. (3) Results: Using the framework, we demonstrate the ability to perform a fast data acquisition during surgery while maintaining a high image quality, even in complex scenarios where challenges arise, such as blur due to motion artifacts, dead pixels on the camera sensor, noise from the sensor's reduced sensitivity at spectral extremities, and specular reflections caused by smooth surface areas of the tissue. (4) Conclusion: This gives the opportunity to facilitate an accurate margin assessment through intraoperative hyperspectral imaging.
Collapse
Affiliation(s)
- Lynn-Jade S Jong
- Image-Guided Surgery, Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
- Department of Nanobiophysics, Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - Jelmer G C Appelman
- Image-Guided Surgery, Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
- Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1111, 1081 HV Amsterdam, The Netherlands
| | - Henricus J C M Sterenborg
- Image-Guided Surgery, Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Theo J M Ruers
- Image-Guided Surgery, Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
- Department of Nanobiophysics, Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - Behdad Dashtbozorg
- Image-Guided Surgery, Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| |
Collapse
|
4
|
Gilmore R, Chen J, Dembinski R, Reissis Y, Milek D, Cadena L, Habibi M. Cost minimization in breast conserving surgery: a comparative study of radiofrequency spectroscopy and full cavity shave margins. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:66. [PMID: 37716980 PMCID: PMC10504787 DOI: 10.1186/s12962-023-00477-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 09/09/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND In an effort to minimize positive margins and subsequent re-excision after breast conserving surgery (BCS), many providers and facilities have implemented either a Full Cavity Shave (FCS) approach or adding the MarginProbe Radiofrequency Spectroscopy System. OBJECTIVE We sought to create a functioning Pro-Forma for use by facilities and payers to evaluate and compare the cost savings of implementing FCS or MarginProbe based on personalized variable inputs. METHODS A decision tree demonstrating three possible surgical pathways, BCS, BCS + FCS, and BCS + MarginProbe was developed with clinical inputs for re-excision rate, mastectomy as 2nd surgery, rate of reconstruction, and rate of 3rd surgery derived by a literature review. A surgical pathway cost formula was created using the decision tree and financial inputs derived by utilizing the nation's largest database of privately billed health insurance claims and Medicare claims data (fairhealth.org). Using the surgical pathway formula and financial inputs, a customizable Pro-Forma was created for immediate cost savings analysis of BCS + FCS and BCS + Marginprobe using variable inputs. Costs are from the perspective of third-party payers. RESULTS Utilizing MarginProbe to reduce re-excisions for positive margins can be associated with better cost-savings than FCS due to the increased pathology processing costs by using an FCS approach. The reduction in re-excision provided by both FCS and MarginProbe offset their increased expense to various degrees with cost savings of each method improving as baseline re-excisions rates increase, until ultimately each may become cost-neutral or cost-prohibitive when compared to BCS alone. Our data suggest that in the privately insured population, MarginProbe provides a cost-savings over BCS alone when baseline re-excision rates are over 20% and that FCS becomes cost-saving when baseline re-excision rates are over 29%. For Medicare patients, MarginProbe provides a cost-savings when baseline re-excision rates exceed 34%, and FCS becomes cost-saving for re-excision rates over 52%. Our Pro-Forma allows an individual provider or institution to evaluate the cost savings of the FCS approach and/or utilization of the MarginProbe device such that the additional cost or cost-savings of utilizing one or both of these methods can be quickly calculated based on their facility's volume and baseline re-excision rate. CONCLUSIONS Our data suggest that utilizing either an FCS approach or the MarginProbe radiofrequency spectroscopy system may be a cost-saving solution to reducing the rate of re-excisions depending on a facility or practice's surgical volume and baseline re-excision rate. The degree to which each of these interventions provides an added cost or cost-savings to healthcare payers can be evaluated by utilizing the Pro-Forma outlined herein with customizable variable inputs.
Collapse
Affiliation(s)
- Richard Gilmore
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Jennifer Chen
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Robert Dembinski
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Yannis Reissis
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - David Milek
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Lisa Cadena
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Mehran Habibi
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA.
- Department of Surgery, Northwell Health, Zucker School of Medicine, New York, United States.
| |
Collapse
|
5
|
Bhutiani N, Holland MM, Mercer MK, Donaldson M, Berry TS, McMasters KM, Ajkay N. Effect of the Ductal Carcinoma In Situ Margin Consensus Guideline Implementation on Re-Excision Rates, Satisfaction, and Cost. Ann Surg Oncol 2021; 28:7432-7438. [PMID: 34043091 DOI: 10.1245/s10434-021-10120-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/18/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The 2016 consensus guideline on margins for breast-conserving surgery (BCS) with whole-breast irradiation (WBI) for ductal carcinoma in situ (DCIS) recommended 2 mm margins to decrease local recurrence rates. We examined re-excision rates, cost, and patient satisfaction before and after guideline implementation. METHODS From an Institutional Review Board-approved database, patients with DCIS who underwent BCS with over 1 year of follow-up at one academic institution and one community cancer center were evaluated. Two groups were compared based on when they received treatment, i.e. before (pre-consensus [PRE]) and after November 2016 (post consensus [POST]), with respect to outcome and cost parameters. RESULTS After consensus guideline implementation, re-excision rate (32.1% vs. 20.0%) and mastectomy conversion (8.3% vs. 2.3%) significantly increased, although total resection volume, operative cost per patient, and satisfaction with breast scores did not differ. Not all patients with <2 mm margins were re-excised, although the re-excision rate among this subset significantly increased (62.4% vs. 31.3%). On multivariable analysis controlling for age, estrogen receptor status, WBI use, and margin status, surgery after consensus guideline publication was independently associated with a higher re-excision rate (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.08-3.59, p = 0.03) and a higher rate of conversion to mastectomy (OR 6.84, 95% CI 1.67-28.00, p = 0.007). CONCLUSIONS Implementation of the 2016 margin consensus guideline for DCIS resulted in an increase in re-excisions and mastectomy conversions at two institutions. Research is needed for operative tools and strategies to decrease DCIS re-excision rates.
Collapse
Affiliation(s)
- Neal Bhutiani
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Michelle M Holland
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Megan K Mercer
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Marilyn Donaldson
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Tiffany S Berry
- Division of Breast Surgery, Department of Surgery, Norton Hospital, Louisville, KY, USA
| | - Kelly M McMasters
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Nicolás Ajkay
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY, USA.
| |
Collapse
|
6
|
Howard-McNatt M, Dupont E, Tsangaris T, Garcia-Cantu C, Chiba A, Berger AC, Levine EA, Gass JS, Ollila DW, Chagpar AB. Impact of Cavity Shave Margins on Margin Status in Patients with Pure Ductal Carcinoma In Situ. J Am Coll Surg 2020; 232:373-378. [PMID: 33346081 DOI: 10.1016/j.jamcollsurg.2020.11.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND We examined the impact of cavity shave margins (CSMs) on margin status in patients with pure ductal carcinoma in situ (DCIS) undergoing partial mastectomy (PM). METHODS One hundred and nine patients from 2 multicenter, randomized controlled trials were identified with pure DCIS (no invasive cancer). Surgeons performed their best PM, with specimen radiography and resection of selective margins per surgeon discretion. Patients were then randomized to have CSM resected or not. A positive margin was defined as <2 mm from ink. RESULTS Median patient age was 63 years; median size of DCIS was 1.20 cm; 43.6% of patients had high-grade DCIS; and 58 (53.2%) patients were randomized to take CSM. The "shave" and "no-shave" groups were well-matched for age, race, ethnicity, palpability, grade, and size of DCIS. Although 33 (56.9%) of the patients in the shave group had a positive margin before randomization, only 12 (20.7%) had a positive margin after randomization to CSM (p < 0.001). In the no-shave group, 17 patients (33.3%) had a positive margin. Controlling for size and grade of DCIS, taking CSM resulted in a nearly 65% reduction in the positive-margin rate (odds ratio 0.366; 95% CI, 0.136 to 0.981; p = 0.046). Size of DCIS remained an independent predictor of positive margins in the model (odds ratio 1.646; 95% CI, 1.227 to 2.209; p = 0.001). CONCLUSIONS CSM reduces positive-margin rates in patients with pure DCIS, and can be a practical solution for DCIS patients who tend to have a high rate of margin positivity.
Collapse
Affiliation(s)
| | | | | | | | - Akiko Chiba
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Adam C Berger
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Edward A Levine
- Department of Surgery, Wake Forest University, Winston-Salem, NC
| | - Jennifer S Gass
- Department of Surgery, Women and Infants Hospital, Providence, RI
| | - David W Ollila
- Department of Surgery, University of North Carolina, Chapel Hill, NC
| | | | | |
Collapse
|
7
|
Smith BL, Lanahan CR, Specht MC, Kelly BN, Brown C, Strasfeld DB, Ferrer JM, Rai U, Tang R, Rice-Stitt T, Biernacka A, Brachtel EF, Gadd MA. Feasibility Study of a Novel Protease-Activated Fluorescent Imaging System for Real-Time, Intraoperative Detection of Residual Breast Cancer in Breast Conserving Surgery. Ann Surg Oncol 2020; 27:1854-1861. [PMID: 31898104 PMCID: PMC7210242 DOI: 10.1245/s10434-019-08158-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Obtaining tumor-free margins is critical to prevent recurrence after lumpectomy for breast cancer. Unfortunately, current approaches leave positive margins that require second surgeries in 20-40% of patients. We assessed the LUM Imaging System for real-time, intraoperative detection of residual tumor. METHODS Breast lumpectomy cavity walls and excised specimens were assessed with the LUM Imaging System after 1 mg/kg intravenous LUM015, a protease-activatable fluorescent agent. Fluorescence at potential sites of residual tumor in lumpectomy cavity walls was evaluated intraoperatively with a sterile hand-held probe, with real-time predictive results displayed on a monitor intraoperatively, and later correlated with histopathology. RESULTS In vivo lumpectomy cavities and excised specimens were imaged after LUM015 injection in 45 women undergoing breast cancer surgery. Invasive ductal and lobular cancers and intraductal cancer (DCIS) were included. A total of 570 cavity margin surfaces in 40 patients were used for algorithm development. Image analysis and display took approximately 1 s per 2.6-cm-diameter circular margin surface. All breast cancer subtypes could be distinguished from adjacent normal tissue. For all imaged cavity surfaces, sensitivity for tumor detection was 84%. Among 8 patients with positive margins after standard surgery, sensitivity for residual tumor detection was 100%; 2 of 8 were spared second surgeries because additional tissue was excised at sites of LUM015 signal. Specificity was 73%, with some benign tissues showing elevated fluorescent signal. CONCLUSIONS The LUM015 agent and LUM Imaging System allow rapid identification of residual tumor in the lumpectomy cavity of breast cancer patients and may reduce rates of positive margins.
Collapse
Affiliation(s)
- Barbara L Smith
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA.
| | - Conor R Lanahan
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle C Specht
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Bridget N Kelly
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Carson Brown
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Upahvan Rai
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Rong Tang
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Travis Rice-Stitt
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Anna Biernacka
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Elena F Brachtel
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Michele A Gadd
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
8
|
Tay THC, Ng WY, Ong KW, Wong CY, Tan BKT, Yong WS, Madhukumar P, Tan VKM, Lim SZ, Sim Y. Impact of hormonal status on ductal carcinoma in situ of the breast: Outcome and prognostic factors. Breast J 2019; 26:937-945. [DOI: 10.1111/tbj.13738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 12/04/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Affiliation(s)
| | - Wai Yee Ng
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
| | - Kong Wee Ong
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
| | - Chow Yin Wong
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| | - Benita Kiat Tee Tan
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| | - Wei Sean Yong
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| | - Preetha Madhukumar
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| | - Veronique Kiak Mien Tan
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| | - Sue Zann Lim
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| | - Yirong Sim
- Division of Surgical Oncology National Cancer Centre Singapore Singapore City Singapore
- SingHealth Duke‐NUS Breast Centre Singapore General Hospital Singapore City Singapore
| |
Collapse
|
9
|
Kho E, Dashtbozorg B, de Boer LL, Van de Vijver KK, Sterenborg HJCM, Ruers TJM. Broadband hyperspectral imaging for breast tumor detection using spectral and spatial information. BIOMEDICAL OPTICS EXPRESS 2019; 10:4496-4515. [PMID: 31565506 PMCID: PMC6757478 DOI: 10.1364/boe.10.004496] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/26/2019] [Accepted: 07/29/2019] [Indexed: 05/20/2023]
Abstract
Complete tumor removal during breast-conserving surgery remains challenging due to the lack of optimal intraoperative margin assessment techniques. Here, we use hyperspectral imaging for tumor detection in fresh breast tissue. We evaluated different wavelength ranges and two classification algorithms; a pixel-wise classification algorithm and a convolutional neural network that combines spectral and spatial information. The highest classification performance was obtained using the full wavelength range (450-1650 nm). Adding spatial information mainly improved the differentiation of tissue classes within the malignant and healthy classes. High sensitivity and specificity were accomplished, which offers potential for hyperspectral imaging as a margin assessment technique to improve surgical outcome.
Collapse
Affiliation(s)
- Esther Kho
- Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, Netherlands
| | - Behdad Dashtbozorg
- Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, 5600MB Eindhoven, Netherlands
| | - Lisanne L. de Boer
- Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, Netherlands
| | - Koen K. Van de Vijver
- Department of Pathology, Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, Netherlands
- Department of Pathology, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Gent, Belgium
| | - Henricus J. C. M. Sterenborg
- Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, Meibergdreef 9, 1105AZ Amsterdam, Netherlands
| | - Theo J. M. Ruers
- Department of Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066CX Amsterdam, Netherlands
- Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522NB Enschede, Netherlands
| |
Collapse
|
10
|
Hanna WM, Parra-Herran C, Lu FI, Slodkowska E, Rakovitch E, Nofech-Mozes S. Ductal carcinoma in situ of the breast: an update for the pathologist in the era of individualized risk assessment and tailored therapies. Mod Pathol 2019; 32:896-915. [PMID: 30760859 DOI: 10.1038/s41379-019-0204-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 12/30/2022]
Abstract
Ductal carcinoma in situ (DCIS) is a neoplastic proliferation of mammary ductal epithelial cells confined to the ductal-lobular system, and a non-obligate precursor of invasive disease. While there has been a significant increase in the diagnosis of DCIS in recent years due to uptake of mammography screening, there has been little change in the rate of invasive recurrence, indicating that a large proportion of patients diagnosed with DCIS will never develop invasive disease. The main issue for clinicians is how to reliably predict the prognosis of DCIS in order to individualize patient treatment, especially as treatment ranges from surveillance only, breast-conserving surgery only, to breast-conserving surgery plus radiotherapy and/or hormonal therapy, and mastectomy with or without radiotherapy. We conducted a semi-structured literature review to address the above issues relating to "pure" DCIS. Here we discuss the pathology of DCIS, risk factors for recurrence, biomarkers and molecular signatures, and disease management. Potential mechanisms of progression from DCIS to invasive cancer and problems faced by clinicians and pathologists in diagnosing and treating this disease are also discussed. Despite the tremendous research efforts to identify accurate risk stratification predictors of invasive recurrence and response to radiotherapy and endocrine therapy, to date there is no simple, well-validated marker or group of variables for risk estimation, particularly in the setting of adjuvant treatment after breast-conserving surgery. Thus, the standard of care to date remains breast-conserving surgery plus radiotherapy, with or without hormonal therapy. Emerging tools, such as pathologic or biologic markers, may soon change such practice. Our review also includes recent advances towards innovative treatment strategies, including targeted therapies, immune modulators, and vaccines.
Collapse
Affiliation(s)
- Wedad M Hanna
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Carlos Parra-Herran
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Fang-I Lu
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Elzbieta Slodkowska
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Eileen Rakovitch
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sharon Nofech-Mozes
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| |
Collapse
|
11
|
Kho E, de Boer LL, Van de Vijver KK, van Duijnhoven F, Vrancken Peeters MJT, Sterenborg HJ, Ruers TJ. Hyperspectral Imaging for Resection Margin Assessment during Cancer Surgery. Clin Cancer Res 2019; 25:3572-3580. [DOI: 10.1158/1078-0432.ccr-18-2089] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/24/2018] [Accepted: 03/12/2019] [Indexed: 11/16/2022]
|
12
|
Krug D, Baumann R. Radiotherapy for Ductal Cancer In Situ (DCIS) of the Breast. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_58-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
13
|
Kuerer HM, Smith BD, Chavez-MacGregor M, Albarracin C, Barcenas CH, Santiago L, Edgerton ME, Rauch GM, Giordano SH, Sahin A, Krishnamurthy S, Woodward W, Tripathy D, Yang WT, Hunt KK. DCIS Margins and Breast Conservation: MD Anderson Cancer Center Multidisciplinary Practice Guidelines and Outcomes. J Cancer 2017; 8:2653-2662. [PMID: 28928852 PMCID: PMC5604195 DOI: 10.7150/jca.20871] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 07/14/2017] [Indexed: 12/31/2022] Open
Abstract
Recent published guidelines suggest that adequate margins for DCIS should be ≥ 2 mm after breast conserving surgery followed by radiotherapy (RT). Many groups now use this guideline as an absolute indication for additional surgery. This article describes detailed multidisciplinary practices including extensive preoperative/intraoperative pathologic/histologic image-guided assessment of margins, offering some patients with small low/intermediate grade DCIS no RT, the use/magnitude of radiation boost tailoring to margin width, and endocrine therapy for ER-positive DCIS. Use of these protocols over the past 20-years has resulted in 10-year local recurrence rates below 5% for patients with negative margins < 2 mm who received RT. Patients with margins < 2 mm who do not receive RT experience significantly higher local failure rates. Thus, there is not an absolute need to achieve wider negative surgical margins when < 2 mm for patients treated with RT and this should be determined by the multidisciplinary team. Utilization of these multidisciplinary treatment protocols and techniques may not be exportable and extrapolated to all hospitals, breast programs and systems as they can be complex and resource intensive.
Collapse
Affiliation(s)
- Henry M. Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Benjamin D. Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mariana Chavez-MacGregor
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Constance Albarracin
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos H. Barcenas
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lumarie Santiago
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mary E. Edgerton
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gaiane M. Rauch
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sharon H. Giordano
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Aysegul Sahin
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Savitri Krishnamurthy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wendy Woodward
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Debasish Tripathy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wei T. Yang
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kelly K. Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
14
|
Narod S, Ahmed H, Sopik V. Wherein the authors attempt to minimize the confusion generated by their study "Breast cancer mortality after a diagnosis of ductal carcinoma in situ" by several commentators who disagree with them and a few who don't: a qualitative study. Curr Oncol 2017; 24:e255-e260. [PMID: 28874895 PMCID: PMC5576464 DOI: 10.3747/co.24.3626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Various parties might wish to measure the impact of a given paper for the purpose of assigning merit to an author or institution [...]
Collapse
Affiliation(s)
- S.A. Narod
- Women’s College Research Institute
- Dalla Lana School of Public Health, University of Toronto; and
| | - H. Ahmed
- Women’s College Research Institute
- Institute of Medical Science, University of Toronto, Toronto; ON
| | - V. Sopik
- Women’s College Research Institute
- Institute of Medical Science, University of Toronto, Toronto; ON
| |
Collapse
|
15
|
Cavity Shaving plus Lumpectomy versus Lumpectomy Alone for Patients with Breast Cancer Undergoing Breast-Conserving Surgery: A Systematic Review and Meta-Analysis. PLoS One 2017; 12:e0168705. [PMID: 28046058 PMCID: PMC5207394 DOI: 10.1371/journal.pone.0168705] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 12/04/2016] [Indexed: 12/11/2022] Open
Abstract
The margin status is a well-established prognostic predictor for patients undergoing breast-conserving surgery (BCS). Recent data suggested that cavity shaving in addition to lumpectomy might be a promising approach for improving the clinical outcomes. We aimed to compare the efficacy and safety between cavity shaving plus lumpectomy and lumpectomy alone with a systematic review and meta-analysis. We searched the PubMed, Embase, and Cochrane CENTRAL databases for studies comparing cavity shaving with lumpectomy before June 10, 2016. Both comparative studies and self-control studies were included. A random-effects model was used to estimate the odds ratios (ORs) for positive margin rate, reoperation rate, recurrence rate, and weighted mean difference (WMD) for excised tissue volume. Twenty-six studies were included in the meta-analysis. The cavity shaving group had a significantly lower positive margin rate than the BCS-alone group (16.4% vs. 31.9%; OR = 0.41, 95% CI 0.32-0.53, P < 0.05). Cavity shaving was associated with a significantly decreased rate of reoperation (OR = 0.42, 95% CI 0.30-0.59, P < 0.05). The overall locoregional rate was low for cavity shaving and BCS-alone (3% vs. 4%). Cavity shaving had no significant effect on the risk of locoregional recurrence (OR = 0.86, 95% CI 0.32-2.35; P = 0.78). The excised tissue volume did not differ substantially between cavity shaving and BCS alone (WMD = -23.88, 95% CI -55.20 to 7.44, P = 0.14). For patients undergoing BCS, additional cavity shaving was an effective method to decrease the positive margin rate and avoid reoperation. The addition of cavity shaving did not appear to have excessive excised tissue volume compared with partial mastectomy alone.
Collapse
|
16
|
Toss MS, Pinder SE, Green AR, Thomas J, Morgan DAL, Robertson JFR, Ellis IO, Rakha EA. Breast conservation in ductal carcinomain situ(DCIS): what defines optimal margins? Histopathology 2016; 70:681-692. [DOI: 10.1111/his.13116] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Michael S Toss
- Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| | - Sarah E Pinder
- Department of Research Oncology; King's College London, Guy's Hospital; London UK
| | - Andrew R Green
- Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| | - Jeremy Thomas
- Department of Pathology; Western General Hospital; Edinburgh UK
| | - David A L Morgan
- Department of Oncology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| | - John F R Robertson
- Division of Breast Surgery, Graduate Entry Medicine and Health School (GEMS); University of Nottingham, Royal Derby Hospital; Derby UK
| | - Ian O Ellis
- Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| | - Emad A Rakha
- Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| |
Collapse
|