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Luo H, Zhao S, Yang W, Chen Z, Li Y, Zhou P. Preoperative prediction of extensive intraductal component in invasive breast cancer based on intra- and peri-tumoral heterogeneity in high-resolution ultrafast DCE-MRI. Sci Rep 2024; 14:17396. [PMID: 39075278 PMCID: PMC11286762 DOI: 10.1038/s41598-024-68601-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 07/25/2024] [Indexed: 07/31/2024] Open
Abstract
Preoperatively predicting extensive intraductal component in invasive breast cancer through imaging is crucial for informed decision-making, guiding surgical planning to mitigate risks of incomplete resection or re-operation for positive margins in breast-conserving surgery. This study aimed to characterize intra- and peri-tumor heterogeneity using high-spatial resolution ultrafast DCE-MRI to predict the extensive intraductal component in invasive breast cancer (IBC-EIC) preoperatively. A retrospective analysis included invasive breast cancer patients who underwent preoperative high-spatial resolution ultrafast DCE-MRI, categorized based on intraductal component status (IBC-EIC vs. IBC without EIC). Propensity score matching (PSM) was employed to balance clinicopathological covariates between the groups. Personalized kinetic intra-tumor heterogeneity (ITHkinetic) and peri-tumor heterogeneity (PTHkinetic) scores were quantified using clustered voxels with similar enhancement patterns. An image combined model, incorporating MRI features, ITHkinetic, and PTHkinetic scores, was developed and assessed. Of 368 patients, 26.4% (97/368) had IBC-EIC. PSM yielded well-matched pairs of 97 patients each. After PSM, ITHkinetic and PTHkinetic scores were significantly higher in the IBC-EIC group (ITHkinetic: 0.68 ± 0.23; PTHkinetic: 0.58 ± 0.19) compared to IBC without EIC (ITHkinetic: 0.32 ± 0.25; PTHkinetic: 0.42 ± 0.18; p < 0.001). Before PSM, ITHkinetic (0.71 ± 0.20 vs. 0.49 ± 0.28, p < 0.001) and PTHkinetic (0.61 ± 0.18 vs. 0.50 ± 0.20, p < 0.001) scores remained higher in the IBC-EIC group. The Image Combined Model demonstrated good predictive performance for IBC-EIC, with an AUC of 0.91 (95% CI 0.86-0.95) after PSM and 0.85 (95% CI 0.81-0.90) before PSM. Inclusion of ITHkinetic and PTHkinetic scores significantly improved prediction capability. ITHkinetic and PTHkinetic characterization from high-spatial resolution ultrafast DCE-MRI kinetic curves enhances preoperative prediction of IBC-EIC, offering valuable insights for personalized breast cancer management.
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Affiliation(s)
- Hongbing Luo
- Department of Radiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, No. 55, 4th Section of South Ren-min Road, Chengdu, 610041, China.
- College of Medicine and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Shixuan Zhao
- MOE Key Lab for Neuroinformation, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China
| | - Wenlong Yang
- College of Medicine and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhe Chen
- Department of Radiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, No. 55, 4th Section of South Ren-min Road, Chengdu, 610041, China
| | - Yongjie Li
- MOE Key Lab for Neuroinformation, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, China
| | - Peng Zhou
- Department of Radiology, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, No. 55, 4th Section of South Ren-min Road, Chengdu, 610041, China
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Golan O, Khatib M, Menes TS, Freitas VAR, Kessner R, Neeman R, Mauda-Havakuk M, Mercer D, Amitai Y. Pushing the envelope in breast conserving surgery - is multiple-wire localization (3 or more wires) associated with increased risk of compromised margins and long-term recurrence? Eur J Radiol 2024; 176:111511. [PMID: 38776805 DOI: 10.1016/j.ejrad.2024.111511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION In the last two decades there has been a paradigm shift with breast conserving surgery (BCS) being applied to larger and more extensive breast malignancies. The aim of this study is to examine the success of BCS being performed in patients with extensive breast malignancies requiring at least 3 wires for localization, and to assess possible risk factors for failure. MATERIALS AND METHODS We performed a retrospective single center review of 232 patients who underwent BCS between 2010 and 2020 requiring at least 3 wires for localization, thus comprising the multi-wire group (MWG). The cohort included a control group of 232 single-wire BCS patients (SWG) chronologically matched with the MWG. Patients with either invasive malignancy or ductal carcinoma in situ (DCIS) were included in the study. Clinical, radiological, and pathological data was collected. Proportions of positive surgical margins, re-lumpectomies and conversion to mastectomy were calculated. Survival analysis for locoregional and distant recurrence was performed. RESULTS Women in the MWG were younger (mean age 57 vs. 63.1, P < 0.001), had larger tumor size (mean size 5.1 cm vs. 1.3 cm, p < 0.001), a higher prevalence of calcifications on mammograms (72 % vs. 17 %, P < 0.001), a higher proportion of positive lymph nodes (75 % vs. 45 %, P = 0.019), and an elevated incidence of a ductal carcinoma in situ (DCIS) component (72 % vs. 38 %, P < 0.001). Positive surgical margins were higher in the MWG (13 % vs 7 %, P = 0.03), which lead to higher proportions of re-lumpectomies or conversion to mastectomies (7 % vs 4 %, P = 0.17). On multivariate analysis of the entire cohort, patients with positive margins were more likely to have a DCIS component (77 % vs 53 %, P = 0.001), an infiltrating lobular carcinoma (ILC) component (15 % vs 9 %, P = 0.013), and positive ER hormonal status (94 % vs 85 %, p = 0.05). The number of wires was not an independent predictor of positive margins. On long-term analysis, the locoregional disease-free survival was similar between the SWG and MWG (P = 0.1). However, the MWG showed higher rates of distant metastasis (12 % vs 4 %, P = 0.006). CONCLUSIONS BCS requiring 3 or more wires is associated with a slightly higher proportion of positive margins. The increased risk of positive margins appears to be related to the type of tumor (DCIS component, ILC component and ER status) rather than to the number of wires. The number of wires does not significantly impact locoregional disease-free survival.
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Affiliation(s)
- Orit Golan
- Tel Aviv University, Sackler School of Medicine, Department of Radiology, Sourasky Medical Center, Tel Aviv 6423906, Isreal.
| | - Marian Khatib
- Tel Aviv University, Sackler School of Medicine, Department of Surgery, Sourasky Medical Center, Tel Aviv 6423906, Isreal.
| | - Tehillah S Menes
- Tel Aviv University, Sackler School of Medicine, Department of Surgery, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel.
| | - Vivianne A R Freitas
- University of Toronto, Joint Department of Medical Imaging - University Health Network, Sinai Health System, Women's College Hospital, 610 University Avenue - M5G 2M9, Toronto, Ontario, Canada.
| | - Rivka Kessner
- Tel Aviv University, Sackler School of Medicine, Department of Radiology, Sourasky Medical Center, Tel Aviv 6423906, Isreal.
| | - Rina Neeman
- Tel Aviv University, Sackler School of Medicine, Department of Radiology, Sourasky Medical Center, Tel Aviv 6423906, Isreal.
| | - Michal Mauda-Havakuk
- Tel Aviv University, Sackler School of Medicine, Department of Radiology, Sourasky Medical Center, Tel Aviv 6423906, Isreal
| | - Diego Mercer
- Tel Aviv University, Sackler School of Medicine, Department of Radiology, Sourasky Medical Center, Tel Aviv 6423906, Isreal.
| | - Yoav Amitai
- Tel Aviv University, Sackler School of Medicine, Department of Radiology, Sourasky Medical Center, Tel Aviv 6423906, Isreal.
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Ploumen RAW, Claassens EL, Kooreman LFS, Keymeulen KBMI, van Kats MACE, van Kuijk SMJ, Siesling S, van Nijnatten TJA, Smidt ML. Surgical outcomes and prognosis of HER2+ invasive breast cancer patients with a DCIS component treated with breast-conserving surgery after neoadjuvant systemic therapy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108465. [PMID: 38870869 DOI: 10.1016/j.ejso.2024.108465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 06/04/2024] [Indexed: 06/15/2024]
Abstract
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.
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Affiliation(s)
- Roxanne A W Ploumen
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands; GROW - Research Institute for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Eva L Claassens
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Loes F S Kooreman
- GROW - Research Institute for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands; Department of Pathology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | | | - Maartje A C E van Kats
- Department of Medical Oncology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Sabine Siesling
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - Thiemo J A van Nijnatten
- GROW - Research Institute for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands; Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Marjolein L Smidt
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands; GROW - Research Institute for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands
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Chauhan H, Jiwa N, Nagarajan VR, Thiruchelvam P, Hogben K, Al-Mufti R, Hadjiminas D, Shousha S, Cutress R, Ashrafian H, Takats Z, Leff DR. Clinicopathological Predictors of Positive Resection Margins in Breast-Conserving Surgery. Ann Surg Oncol 2024; 31:3939-3947. [PMID: 38520579 PMCID: PMC11076377 DOI: 10.1245/s10434-024-15153-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/20/2024] [Indexed: 03/25/2024]
Abstract
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.
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MESH Headings
- Humans
- Female
- Margins of Excision
- Mastectomy, Segmental/methods
- Retrospective Studies
- Middle Aged
- Breast Neoplasms/surgery
- Breast Neoplasms/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Aged
- Adult
- Follow-Up Studies
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Ductal, Breast/pathology
- Prognosis
- Aged, 80 and over
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Affiliation(s)
- Hemali Chauhan
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Natasha Jiwa
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Paul Thiruchelvam
- Breast Unit, Charing Cross Hospital, Imperial College NHS Trust, London, UK
| | - Katy Hogben
- Breast Unit, Charing Cross Hospital, Imperial College NHS Trust, London, UK
| | - Ragheed Al-Mufti
- Breast Unit, Charing Cross Hospital, Imperial College NHS Trust, London, UK
| | - Dimitri Hadjiminas
- Breast Unit, Charing Cross Hospital, Imperial College NHS Trust, London, UK
| | - Sami Shousha
- Breast Unit, Charing Cross Hospital, Imperial College NHS Trust, London, UK
- North West London Pathology, Imperial College NHS Trust, London, UK
| | - Ramsey Cutress
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Hutan Ashrafian
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Zoltan Takats
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Daniel Richard Leff
- Department of Surgery and Cancer, Imperial College London, London, UK
- Breast Unit, Charing Cross Hospital, Imperial College NHS Trust, London, UK
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Liu L, He S, Niu Z, Yin R, Guo Y, Dou Z, Ma W, Ye Z, Lu H. Preoperative magnetic resonance imaging identify feasibility of breast-conserving surgery for breast cancer patients. Gland Surg 2024; 13:640-653. [PMID: 38845837 PMCID: PMC11150189 DOI: 10.21037/gs-23-509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/28/2024] [Indexed: 06/09/2024]
Abstract
Background Breast-conserving surgery (BCS) stands as the favored modality for treating early-stage breast cancer. Accurately forecasting the feasibility of BCS preoperatively can aid in surgical planning and reduce the rate of switching of surgical methods and reoperation. The objective of this study is to identify the radiomics features and preoperative breast magnetic resonance imaging (MRI) characteristics that are linked with positive margins following BCS in patients with breast cancer, with the ultimate aim of creating a predictive model for the feasibility of BCS. Methods This study included a cohort of 221 pretreatment MRI images obtained from patients with breast cancer. A total of seven MRI semantic features and 1,561 radiomics features of lesions were extracted. The feature subset was determined by eliminating redundancy and correlation based on the features of the training set. The least absolute shrinkage and selection operator (LASSO) logistic regression was then trained with this subset to classify the final BCS positive and negative margins and subsequently validated using the test set. Results Seven features were significant in the discrimination of cases achieving positive and negative margins. The radiomics signature achieved area under the curve (AUC), accuracy, sensitivity, and specificity of 0.760 [95% confidence interval (CI): 0.630, 0.891], 0.712 (95% CI: 0.569, 0.829), 0.882 (95% CI: 0.623, 0.979) and 0.629 (95% CI: 0.449, 0.780) in the test set, respectively. The combined model of radiomics signature and background parenchymal enhancement (BPE) demonstrated an AUC, accuracy, sensitivity, and specificity of 0.759 (95% CI: 0.628, 0.890), 0.654 (95% CI: 0.509, 0.780), 0.679 (95% CI: 0.476, 0.834) and 0.625 (95% CI: 0.408, 0.804). Conclusions The combination of preoperative MRI radiomics features can well predict the success of breast conserving surgery.
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Affiliation(s)
- Liangsheng Liu
- Department of Breast Imaging, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of Education, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Shanshan He
- Department of Breast Reconstruction, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of Education, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Zhenhua Niu
- School of Biomedical Engineering & Technology, Tianjin Medical University, Tianjin, China
| | - Rui Yin
- School of Biomedical Engineering & Technology, Tianjin Medical University, Tianjin, China
| | - Yijun Guo
- Department of Breast Imaging, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of Education, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Zhaoxiang Dou
- Department of Breast Imaging, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of Education, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Wenjuan Ma
- Department of Breast Imaging, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of Education, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Zhaoxiang Ye
- Department of Radiology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of Education, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Hong Lu
- Department of Breast Imaging, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of Education, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
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Ma J, Chen K, Li S, Zhu L, Yu Y, Li J, Ma J, Ouyang J, Wu Z, Tan Y, He Z, Liu H, Pan Z, Li H, Liu Q, Song E. MRI-based radiomic models to predict surgical margin status and infer tumor immune microenvironment in breast cancer patients with breast-conserving surgery: a multicenter validation study. Eur Radiol 2024; 34:1774-1789. [PMID: 37658888 DOI: 10.1007/s00330-023-10144-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/18/2023] [Accepted: 07/08/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVES Accurate preoperative estimation of the risk of breast-conserving surgery (BCS) resection margin positivity would be beneficial to surgical planning. In this multicenter validation study, we developed an MRI-based radiomic model to predict the surgical margin status. METHODS We retrospectively collected preoperative breast MRI of patients undergoing BCS from three hospitals (SYMH, n = 296; SYSUCC, n = 131; TSPH, n = 143). Radiomic-based model for risk prediction of the margin positivity was trained on the SYMH patients (7:3 ratio split for the training and testing cohorts), and externally validated in the SYSUCC and TSPH cohorts. The model was able to stratify patients into different subgroups with varied risk of margin positivity. Moreover, we used the immune-radiomic models and epithelial-mesenchymal transition (EMT) signature to infer the distribution patterns of immune cells and tumor cell EMT status under different marginal status. RESULTS The AUCs of the radiomic-based model were 0.78 (0.66-0.90), 0.88 (0.79-0.96), and 0.76 (0.68-0.84) in the testing cohort and two external validation cohorts, respectively. The actual margin positivity rates ranged between 0-10% and 27.3-87.2% in low-risk and high-risk subgroups, respectively. Positive surgical margin was associated with higher levels of EMT and B cell infiltration in the tumor area, as well as the enrichment of B cells, immature dendritic cells, and neutrophil infiltration in the peritumoral area. CONCLUSIONS This MRI-based predictive model can be used as a reliable tool to predict the risk of margin positivity of BCS. Tumor immune-microenvironment alteration was associated with surgical margin status. CLINICAL RELEVANCE STATEMENT This study can assist the pre-operative planning of BCS. Further research on the tumor immune microenvironment of different resection margin states is expected to develop new margin evaluation indicators and decipher the internal mechanism. KEY POINTS • The MRI-based radiomic prediction model (CSS model) incorporating features extracted from multiple sequences and segments could estimate the margin positivity risk of breast-conserving surgery. • The radiomic score of the CSS model allows risk stratification of patients undergoing breast-conserving surgery, which could assist in surgical planning. • With the help of MRI-based radiomics to estimate the components of the immune microenvironment, for the first time, it is found that the margin status of breast-conserving surgery is associated with the infiltration of immune cells in the microenvironment and the EMT status of breast tumor cells.
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Affiliation(s)
- Jiafan Ma
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
- Breast Tumor Center, Yat-sen Breast Tumor Hospital, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
| | - Kai Chen
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
- Breast Tumor Center, Yat-sen Breast Tumor Hospital, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
- Artificial Intelligence Lab, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
| | - Shunrong Li
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
- Breast Tumor Center, Yat-sen Breast Tumor Hospital, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
| | - Liling Zhu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
- Breast Tumor Center, Yat-sen Breast Tumor Hospital, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
| | - Yunfang Yu
- Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
| | - Jingwu Li
- Department of Breast Surgery, Tangshan People's Hospital, Tangshan, 063001, Hebei, China
| | - Jie Ma
- Department of Breast Surgery, Tangshan People's Hospital, Tangshan, 063001, Hebei, China
| | - Jie Ouyang
- Department of Breast Surgery, Tungwah Hospital, Sun Yat-sen University, Dongguan, 523413, China
| | - Zhuo Wu
- Artificial Intelligence Lab, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
| | - Yujie Tan
- Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
| | - Zifan He
- Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
| | - Haiqing Liu
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
| | - Zhilong Pan
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
- Breast Tumor Center, Yat-sen Breast Tumor Hospital, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China
| | - Haojiang Li
- Department of Radiology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, 651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China.
| | - Qiang Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China.
- Breast Tumor Center, Yat-sen Breast Tumor Hospital, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China.
| | - Erwei Song
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China.
- Breast Tumor Center, Yat-sen Breast Tumor Hospital, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, Guangdong, China.
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Palimaru Manhoobi I, Tramm T, Redsted S, Bodilsen A, Foldager L, Christiansen P. Digital breast tomosynthesis versus X-ray of the breast specimen for intraoperative margin assessment: A randomized trial. Breast 2024; 73:103616. [PMID: 38064928 PMCID: PMC10749898 DOI: 10.1016/j.breast.2023.103616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND Involved resection margins after breast conserving surgery (BCS) often require a re-operation with increased patient anxiety and risk of impaired cosmesis. We investigated the number of re-operations due to involved resection margins after BCS comparing digital breast tomosynthesis(DBT) with X-ray for intraoperative margin evaluation. Furthermore, we assessed the diagnostic accuracy of these methods to predict histopathological margin status. Finally, we evaluated risk factors for re-operation. METHODS In this randomized, non-blinded study, 250 invasive breast cancer patients were randomized (1:1), whereof 241 were analyzed intraoperatively with either DBT (intervention, n = 119) or X-ray (standard, n = 122). Pearson's chi-squared test, Fisher's exact test, t-test, logistic and ordinal regression analysis was used as appropriate. RESULTS No difference was found in the number of re-operations between the DBT and X-ray group (16.8 % vs 19.7 %, p = 0.57), or in diagnostic accuracy to predict histopathological margin status (77.5 %, CI: 68.6-84.9 %) and (67.3 %, CI: 57.7-75.9 %), respectively. We evaluated 5 potential risk factors for re-operation: Ductal carcinoma in situ (DCIS) outside tumor, OR = 9.4 (CI: 4.3-20.6, p < 0.001); high mammographic breast density, OR = 6.1 (CI: 1.0-38.1, p = 0.047); non-evaluable margins on imaging, OR = 3.8 (CI: 1.3-10.8, p = 0.016); neoadjuvant chemotherapy, OR = 3.0 (CI: 1.0-8.8, p = 0.048); and T2 tumor-size, OR = 2.6 (CI: 1.0-6.4, p = 0.045). CONCLUSIONS No difference was found in the number of re-operations or in diagnostic accuracy to predict histopathological margin status between DBT and X-ray groups. DCIS outside the tumor showed the highest risk of re-operation. Intraoperative methods with improved visualization of DCIS are needed to obtain tumor free margins in BCS.
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Affiliation(s)
- Irina Palimaru Manhoobi
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Søren Redsted
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Bodilsen
- Department of Abdominal Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Leslie Foldager
- Department of Animal and Veterinary Sciences, Aarhus University, Tjele, Denmark; Bioinformatics Research Centre, Aarhus University, Aarhus, Denmark
| | - Peer Christiansen
- Department of Plastic- and Breast Surgery, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Covington MF, O'Brien SR, Lawhn-Heath C, Pantel AR, Ulaner GA, Linden HM, Dehdashti F. Fluorine-18-Labeled Fluoroestradiol PET/CT: Current Status, Gaps in Knowledge, and Controversies-AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2023. [PMID: 38117098 DOI: 10.2214/ajr.23.30330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
PET/CT using 16α-[18F]-fluoro-17β-estradiol (FES) noninvasively images tissues expressing estrogen receptors (ERs). FES has undergone extensive clinicopathologic validation for ER+ breast cancer and received FDA approval in 2020 for clinical use as an adjunct to biopsy in patients with recurrent or metastatic ER+ breast cancer. Clinical use of FES PET/CT is increasing, but is not widespread in the United States. This AJR Expert Panel Narrative Review explores the present status and future directions of FES PET/CT, including image interpretation, existing and emerging uses, knowledge gaps, and current controversies. Specific controversies discussed include whether both FES PET/CT and FDG PET/CT are warranted in certain scenarios, whether further workup is required after negative FES PET/CT results, whether FES PET/CT findings should inform endocrine therapy selection, and whether immunohistochemistry should remain the standalone reference standard for determining ER status for all breast cancers. Consensus opinions from the panel include agreement with the appropriate clinical uses of FES PET/CT published by a multidisciplinary expert workgroup in 2023; anticipated expanded clinical use of FES PET/CT for staging ER-positive invasive lobular carcinomas and low-grade invasive ductal carcinomas pending ongoing clinical trial results; and the need for further research regarding use of FES PET/CT for ER-expressing nonbreast malignancies.
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Affiliation(s)
- Matthew F Covington
- Center for Quantitative Cancer Imaging, Huntsman Cancer Institute
- Department of Radiology and Imaging Sciences, University of Utah
| | - Sophia R O'Brien
- Department of Radiology, Hospital of the University of Pennsylvania
| | - Courtney Lawhn-Heath
- Department of Radiology and Biomedical Imaging, University of California San Francisco
| | - Austin R Pantel
- Department of Radiology, Hospital of the University of Pennsylvania
| | - Gary A Ulaner
- Molecular Imaging and Therapy, Hoag Family Cancer Institute
- Radiology and Translational Genomics, University of Southern California, Los Angeles, CA
| | - Hannah M Linden
- Department of Medicine, Division of Hematology and Oncology University of Washington, and Fred Hutchinson Cancer Center
| | - Farrokh Dehdashti
- Mallinckrodt Institute of Radiology, Siteman Cancer Center, Washington University in St. Louis
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9
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Lyons W, Lamm R, Duffner ER, Shames J, Willis AI, Lazar M. Bracketed Localization in Breast-Conserving Surgery: Indications and Success Rates From a Single, High Volume, Academic Breast Cancer Center. Am Surg 2023; 89:4373-4378. [PMID: 35758520 DOI: 10.1177/00031348221111516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Bracketed localization is a technique used to help localize lesions for breast-conserving surgery (BCS). To date, there are no guidelines for when bracketed localization should be used in clinical practice. Based on our experience, we aim to provide criteria that should prompt surgeons to consider bracketing. METHODS A single-institution retrospective chart review was performed on patients who underwent bracketed localization for BCS between 2015 and 2021. Lesion characteristics were recorded including lesion span, number of lesions, histology type on core needle biopsy and surgical specimen, margin status, and need for additional surgery. RESULTS One hundred and thirteen cases were analyzed. Imaging showed an average lesion span of 5.0-cm. Multifocal lesions represented 45% of cases. Ductal carcinoma in situ (DCIS) was a histological component in 64% of core needle biopsies and 76% of surgical specimens. Negative margins were achieved in 82% of patients on the first excision. Additional surgery was performed in 17% of patients. Invasive lobular carcinoma had the highest additional surgery rate at 23%. Negative margins with BCS were achieved in 96% of cases, including those with successful re-excision. DISCUSSION This descriptive study shows that bracketed localization was most often employed for patients with large lesion spans, multifocality, and a DCIS or invasive lobular component. While these characteristics are typically associated with higher rates of positive margins, our cohort's rate of additional surgery was comparable to the national average for all BCS operations. These results argue that surgeon utilization of bracketed localization may be beneficial in these clinical scenarios.
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MESH Headings
- Humans
- Female
- Breast Neoplasms/surgery
- Breast Neoplasms/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Mastectomy, Segmental/methods
- Retrospective Studies
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Ductal, Breast/pathology
- Reoperation
- Margins of Excision
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Affiliation(s)
- Walker Lyons
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ryan Lamm
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Emily R Duffner
- Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA, USA
| | - Jason Shames
- Breast Imaging Division, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alliric I Willis
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Melissa Lazar
- Department of General Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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10
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Goh SSN, Syn NLX, Lim CJE, Lee RE, Samuel M, Ng CWQ. Oncologic outcomes after breast-conserving surgery with radiotherapy versus mastectomy in patients with Paget's disease of the breast: systematic review and meta-analysis. Br J Surg 2023; 110:1451-1457. [PMID: 37682691 DOI: 10.1093/bjs/znad199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/09/2023] [Accepted: 06/11/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND The conventional approach to treatment for Paget's disease of the breast has been mastectomy, but there is an increasing trend to consider breast-conserving surgery (BCS) followed by radiotherapy (RT) in these patients. This study aimed to provide an updated systematic review and meta-analysis comparing outcomes after BCS with RT versus mastectomy in the treatment of Paget's disease of the breast. METHODS Studies before May 2021 were included. Primary outcomes were overall survival and local recurrence. Separate analyses of Paget's disease associated with ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) were undertaken. Meta-regression was used to adjust for imbalance in the proportion of IDC among patients selected to undergo BCS versus mastectomy. RESULTS Overall survival in patients with Paget's disease who underwent BCS with RT was higher than for those who underwent mastectomy with pooled mortality hazard ratio (HR) of 0.68, (95% per cent c.i. 0.45 to 1.01). Patients with Paget's disease with DCIS had higher overall survival after BCS with or without RT versus mastectomy, with adjusted HR of 0.14 (0.10 to 0.20) and 0.28 (0.22 to 0.36), respectively. For patients with Paget's disease and IDC, overall survival was lower for BCS with or without RT versus mastectomy, with adjusted HR of 0.84 (0.57 to 1.25) and 1.64 (1.04 to 2.58), respectively. In Paget's disease and IDC, local recurrence risk was much higher for BCS with RT, RR 26.8 (1.60 to 456) versus without RT, RR 51.8 (6.80 to 391). In patients with Paget's disease and DCIS, risk of local recurrence versus mastectomy was lower for BCS with RT 0.72 (0.11 to 4.50) but slightly higher for BCS alone 1.38 (0.09 to 21.20). CONCLUSION BCS with RT may be a comparable treatment alternative to mastectomy for patients with Paget's disease with DCIS, and for selected patients with Paget's disease and IDC.
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Affiliation(s)
- Serene S N Goh
- Department of Surgery, University Surgical Cluster, National University Health System, Singapore
| | - Nicholas L X Syn
- Department of Surgery, University Surgical Cluster, National University Health System, Singapore
| | - Cheryl J E Lim
- Department of Surgery, University Surgical Cluster, National University Health System, Singapore
| | - Rui En Lee
- Department of Surgery, University Surgical Cluster, National University Health System, Singapore
| | - Miny Samuel
- Research Support Unit, National University of Singapore, Singapore
| | - Celene W Q Ng
- Department of Surgery, University Surgical Cluster, National University Health System, Singapore
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11
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Heeling E, van Hemert AKE, Vrancken Peeters MJTFD. A clinical perspective on oncoplastic breast conserving surgery. TRANSLATIONAL BREAST CANCER RESEARCH : A JOURNAL FOCUSING ON TRANSLATIONAL RESEARCH IN BREAST CANCER 2023; 4:29. [PMID: 38751480 PMCID: PMC11093003 DOI: 10.21037/tbcr-23-40] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/14/2023] [Indexed: 05/18/2024]
Abstract
Breast conserving surgery (BCS) plus radiation treatment is the favored alternative for mastectomy in patients with breast cancer. To allow for breast conservation in patients with large invasive tumors and poor response to neoadjuvant systemic treatment (NST) or patients with extensive ductal carcinoma in situ (DCIS), oncoplastic breast conserving surgery (OPBCS) techniques are introduced. OPBCS allows for breast conservation in a selective group of breast cancer patients who initially would have been treated with mastectomy due to the unfavorable tumor-to-breast ratio. With OPBCS, the oncological tumor excision is combined with plastic surgical breast conservation techniques without compromising oncological safety and maintaining aesthetic outcomes by preserving the shape of the breast. OPBCS should however not be applied to all breast cancer patients and the selection of patients who benefit from OPBCS and the timing of OPBCS are best discussed in a multidisciplinary team (MDT). Caution is required in patients with higher risk of positive margins [e.g., multifocal breast cancer, invasive lobular carcinoma (ILC), larger tumors and DCIS]. In these patients, delayed OPBCS is recommended to facilitate re-excision and maintain excellent breast conserving rates. Despite proven benefits in selected patients, the increase in the adoption of OPBCS is relatively low. This article provides a clinical perspective on OPBCS.
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Affiliation(s)
- Eva Heeling
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Annemiek K. E. van Hemert
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marie-Jeanne T. F. D. Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Surgical Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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12
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Shanthakumar D, Leiloglou M, Kelliher C, Darzi A, Elson DS, Leff DR. A Comparison of Spectroscopy and Imaging Techniques Utilizing Spectrally Resolved Diffusely Reflected Light for Intraoperative Margin Assessment in Breast-Conserving Surgery: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:cancers15112884. [PMID: 37296847 DOI: 10.3390/cancers15112884] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023] Open
Abstract
Up to 19% of patients require re-excision surgery due to positive margins in breast-conserving surgery (BCS). Intraoperative margin assessment tools (IMAs) that incorporate tissue optical measurements could help reduce re-excision rates. This review focuses on methods that use and assess spectrally resolved diffusely reflected light for breast cancer detection in the intraoperative setting. Following PROSPERO registration (CRD42022356216), an electronic search was performed. The modalities searched for were diffuse reflectance spectroscopy (DRS), multispectral imaging (MSI), hyperspectral imaging (HSI), and spatial frequency domain imaging (SFDI). The inclusion criteria encompassed studies of human in vivo or ex vivo breast tissues, which presented data on accuracy. The exclusion criteria were contrast use, frozen samples, and other imaging adjuncts. 19 studies were selected following PRISMA guidelines. Studies were divided into point-based (spectroscopy) or whole field-of-view (imaging) techniques. A fixed-or random-effects model analysis generated pooled sensitivity/specificity for the different modalities, following heterogeneity calculations using the Q statistic. Overall, imaging-based techniques had better pooled sensitivity/specificity (0.90 (CI 0.76-1.03)/0.92 (CI 0.78-1.06)) compared with probe-based techniques (0.84 (CI 0.78-0.89)/0.85 (CI 0.79-0.91)). The use of spectrally resolved diffusely reflected light is a rapid, non-contact technique that confers accuracy in discriminating between normal and malignant breast tissue, and it constitutes a potential IMA tool.
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Affiliation(s)
- Dhurka Shanthakumar
- Department of Surgery and Cancer, Imperial College London, London W12 0HS, UK
- The Hamlyn Centre, Imperial College London, London SW7 2AZ, UK
| | - Maria Leiloglou
- Department of Surgery and Cancer, Imperial College London, London W12 0HS, UK
- The Hamlyn Centre, Imperial College London, London SW7 2AZ, UK
| | - Colm Kelliher
- Department of Surgery and Cancer, Imperial College London, London W12 0HS, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London W12 0HS, UK
- The Hamlyn Centre, Imperial College London, London SW7 2AZ, UK
| | - Daniel S Elson
- Department of Surgery and Cancer, Imperial College London, London W12 0HS, UK
- The Hamlyn Centre, Imperial College London, London SW7 2AZ, UK
| | - Daniel R Leff
- Department of Surgery and Cancer, Imperial College London, London W12 0HS, UK
- The Hamlyn Centre, Imperial College London, London SW7 2AZ, UK
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13
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van Loevezijn AA, Geluk CS, van den Berg MJ, van Werkhoven ED, Vrancken Peeters MJTFD, van Duijnhoven FH, Hoornweg MJ. Immediate or delayed oncoplastic surgery after breast conserving surgery at the Netherlands Cancer Institute: a cohort study of 251 cases. Breast Cancer Res Treat 2023; 198:295-307. [PMID: 36690822 DOI: 10.1007/s10549-022-06841-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/03/2022] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Ariane A van Loevezijn
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Surgical Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Charissa S Geluk
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Marieke J van den Berg
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Erik D van Werkhoven
- Department of Biometrics, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Surgical Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marije J Hoornweg
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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14
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Duffield JA, Blanch AJ, Bochner MA. Breast cancer care and surgery in Australia and New Zealand: compliance of the BreastSurgANZ quality audit with international standards. ANZ J Surg 2023; 93:881-888. [PMID: 36856199 DOI: 10.1111/ans.18347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 02/11/2023] [Accepted: 02/14/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND The Breast Surgeons of Australia and New Zealand (BreastSurgANZ) Quality Audit (BQA) of Breast Cancer Care is a prospective population-based database designed for annual audit of compliance with internally derived Quality Indicators (QI)s. While there is no international consensus for QIs, audit against an external international benchmark is possible through use of QIs defined by the 2017 European Society of Breast Cancer Specialists (EUSOMA) Guidelines. METHODS BQA data from 29,088 female patients between 1/1/2018 and 31/12/2019 were stratified by the EUSOMA definition of low-volume hospitals (LVH <150 patients p.a.) and high-volume hospitals (HVH ≥150 patients p.a.), and percentage compliance (±95% CI) with 14 mandatory EUSOMA QI sub-parts were determined. RESULTS ANZ LVH met the quality threshold for 10, and HVH for 8 EUSOMA QI that assessed MDT, surgical approach, adjuvant radiotherapy in the LVH setting, avoidance of overtreatment, and use of endocrine therapy. ANZ did not meet the quality thresholds for QIs assessing use of neoadjuvant chemotherapy, and adjuvant radiotherapy in the HVH setting. CONCLUSION Breast cancer care in ANZ is comparable with an international standard. ANZ surgeons performed at a high standard in discussion of breast cancer patients by MDT, and appropriate use of adjuvant radiotherapy by LVH. Improvements can be made in completeness of data capture, and inclusion of genetic syndrome and Ki67% in data collection. Due to the rapid evolution of breast cancer treatments, there is need for contemporary update of QI relating to the use of neoadjuvant systemic therapies.
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Affiliation(s)
- Jaime A Duffield
- Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Adam J Blanch
- Breast Quality Audit, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Melissa A Bochner
- Medical School, The University of Adelaide, Adelaide, South Australia, Australia.,Breast Quality Audit Steering Committee, Breast Surgeons of Australia and New Zealand, Sydney, New South Wales, Australia
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15
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De la Flor M, Delgado C, Martínez S, Arenas M, Gómez M, Reig R. Rate of effect of surgical margins after breast conserving surgery and estimation of direct costs. Cir Esp 2022; 100:702-708. [PMID: 35850474 DOI: 10.1016/j.cireng.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/13/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Assessment of the reoperation rate in patients with positive resection margins after initial breast-conserving surgery for breast cancer and estimation of the cost to the hospital. METHOD 146 patients with diagnosis of invasive breast cancer were included, who were initially intervened with conservative surgery by the Gynecology and Obstetrics Service of Hospital Universitario de Tarragona Juan XXIII (HUTJ23) during the years 2018 and 2019. We calculated the rate of involvement of the surgical margins of the resection piece after initial conservative surgery, establishing in which cases it was necessary to carry out a second resection, estimating the added direct costs of the second surgical procedure, and comparing them with the costs established by the Catalan Health Service according to the level of the hospital and the Diagnosis-Related Groups (DRG) established by the National Health System. RESULTS The rate of positive margins after initial conservative surgery was 20.55% and 19.17% patients underwent reoperation, generating a total expense of € 129,696.89, € 82,654.34 in conservative surgeries (€ 3757.01 on average per patient) and € 47,042.55 in mastectomies (€ 6720.36 on average per patient). CONCLUSIONS Margin involvement after breast-conserving surgery is synonymous for reoperation, this involves a series of direct costs. It is advisable to control the factors related to affected margins to minimize their impact.
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Affiliation(s)
- Miriam De la Flor
- Unidad de Patología Mamaria, Servicio de Ginecología y Obstetricia, H.U. Tarragona Joan XXIII, URV, Tarragona, Spain.
| | - Cinthia Delgado
- Departamento de Medicina y Cirugía, Universitat Rovira i Virgili, Tarragona, Spain
| | - Salomé Martínez
- Unidad de Patología Mamaria, Servicio de Anatomía Patológica, H.U. Tarragona Joan XXIII, URV, Tarragona, Spain
| | - Meritxell Arenas
- Unidad de Patología Mamaria, Servicio de Oncología Radioterápica, H.U. Sant Joan Reus, URV, Tarragona, Spain
| | - María Gómez
- Unidad de Patología Mamaria, Servicio de Oncología Radioterápica, H.U. Sant Joan Reus, URV, Tarragona, Spain
| | - Rosaura Reig
- Dirección Médica, H.U. Tarragona Joan XXIII, Tarragona, Spain
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16
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Stachs A, Bollmann J, Martin A, Stubert J, Reimer T, Gerber B, Hartmann S. Radiopaque tissue transfer and X-ray system versus standard specimen radiography for intraoperative margin assessment in breast-conserving surgery: randomized clinical trial. BJS Open 2022; 6:6659244. [PMID: 35946449 PMCID: PMC9364380 DOI: 10.1093/bjsopen/zrac091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/21/2022] [Indexed: 11/26/2022] Open
Abstract
Background Reduction of positive margin rate (PMR) in breast-conserving surgery (BCS) of non-palpable breast cancer remains a challenge. The efficacy of intraoperative specimen radiography (SR) is unclear. This randomized trial evaluated whether the PMR was reduced by the use of devices that allow precise localization of the affected margins. Methods Patients with microcalcification-associated breast cancer undergoing planned BCS were enrolled. Study participants were randomized to receive either SR with radiopaque tissue transfer and X-ray system (KliniTrayTM) or the institutional standard procedure (ISO). In all patients with a radiological margin less than 5 mm, an immediate re-excision was conducted. The primary outcome was the PMR. Risk factors for positive margins and the effect of immediate re-excision on final surgery were secondary analyses. Results Among 122 randomized patients, 5 patients were excluded due to the extent of primary surgery and 117 were available for analysis. Final histopathology revealed a PMR of 31.7 per cent for the KliniTrayTM group and 26.3 per cent for the ISO group (P = 0.127). Independent factors for positive margins were histological tumour size more than 30 mm (adjusted OR (aOR) 10.73; 95 per cent c.i. 3.14 to 36.75; P < 0.001) and specimen size more than 50 mm (aOR 6.65; 95 per cent c.i. 2.00 to 22.08; P = 0.002). Immediate re-excision due to positive SR led to an absolute risk reduction in positive margins of 13.6 per cent (from 42.7 to 29.1 per cent). Conclusion Specimen orientation with a radiopaque tissue transfer and X-ray system did not decrease the PMR in patients with microcalcification-associated breast cancer; however, SR and immediate re-excision proved to be helpful in the reduction of PMR. Registration number DRKS00011527 (https://www.drks.de).
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Affiliation(s)
- Angrit Stachs
- Multidisciplinary Breast Unit, Department of Radiology, University of Rostock , Rostock , Germany
| | - Julia Bollmann
- Multidisciplinary Breast Unit, Department of Gynaecology and Obstetrics, University of Rostock , Rostock , Germany
| | - Annett Martin
- Multidisciplinary Breast Unit, Department of Gynaecology and Obstetrics, University of Rostock , Rostock , Germany
| | - Johannes Stubert
- Multidisciplinary Breast Unit, Department of Gynaecology and Obstetrics, University of Rostock , Rostock , Germany
| | - Toralf Reimer
- Multidisciplinary Breast Unit, Department of Gynaecology and Obstetrics, University of Rostock , Rostock , Germany
| | - Bernd Gerber
- Multidisciplinary Breast Unit, Department of Gynaecology and Obstetrics, University of Rostock , Rostock , Germany
| | - Steffi Hartmann
- Multidisciplinary Breast Unit, Department of Gynaecology and Obstetrics, University of Rostock , Rostock , Germany
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17
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Edmonds CE, O'Brien SR, Mankoff DA, Pantel AR. Novel applications of molecular imaging to guide breast cancer therapy. Cancer Imaging 2022; 22:31. [PMID: 35729608 PMCID: PMC9210593 DOI: 10.1186/s40644-022-00468-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/30/2022] [Indexed: 11/10/2022] Open
Abstract
The goals of precision oncology are to provide targeted drug therapy based on each individual’s specific tumor biology, and to enable the prediction and early assessment of treatment response to allow treatment modification when necessary. Thus, precision oncology aims to maximize treatment success while minimizing the side effects of inadequate or suboptimal therapies. Molecular imaging, through noninvasive assessment of clinically relevant tumor biomarkers across the entire disease burden, has the potential to revolutionize clinical oncology, including breast oncology. In this article, we review breast cancer positron emission tomography (PET) imaging biomarkers for providing early response assessment and predicting treatment outcomes. For 2-18fluoro-2-deoxy-D-glucose (FDG), a marker of cellular glucose metabolism that is well established for staging multiple types of malignancies including breast cancer, we highlight novel applications for early response assessment. We then review current and future applications of novel PET biomarkers for imaging the steroid receptors, including the estrogen and progesterone receptors, the HER2 receptor, cellular proliferation, and amino acid metabolism.
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Affiliation(s)
- Christine E Edmonds
- Department of Radiology, Hospital of the University if Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Sophia R O'Brien
- Department of Radiology, Hospital of the University if Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - David A Mankoff
- Department of Radiology, Hospital of the University if Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Austin R Pantel
- Department of Radiology, Hospital of the University if Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
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18
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Ozcan LC, Donovan CA, Srour M, Chung A, Mirocha J, Frankel SD, Hakim P, Giuliano AE, Amersi F. Invasive Lobular Carcinoma-Correlation Between Imaging and Final Pathology: Is MRI Better? Am Surg 2022:31348221101600. [PMID: 35639048 DOI: 10.1177/00031348221101600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Invasive lobular carcinoma (ILC) is associated with high re-excision rates following breast-conserving surgery (BCS). The correlation between lesion size on different imaging modalities and final tumor size has not been well characterized. METHODS A prospective database of patients with stage I-III breast cancer undergoing BCS between 2006 and 2016 was reviewed. Pearson correlation analysis was used to correlate tumor size on breast imaging to final pathology. RESULTS Of these, 111 patients with ILC were identified. Mean lesion size was 1.93 cm for MMG, 1.61 cm for US, and 2.51 cm for MRI. Mean tumor size on surgical excision was 2.64 cm. The correlation coefficient between pathology and the different imaging modalities were as follows: MMG .17, US 0.37, and MRI .58. Actual tumor size was underestimated by 1 cm in 27.1% of MMGs, 50% of USs, and in 13.3% of MRIs. 38 patients (34.2%) underwent re-excision. No differences in re-excision rates were noted in patients with and without MRI, 30.3% vs 40.0%, respectively (P = .31). CONCLUSION While MRI provides a better estimate of tumor size than MMG and US, the size of the tumor on imaging only weakly correlated with pathology. The use of MRI does not decrease re-excision rates.
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Affiliation(s)
- Lerna C Ozcan
- Division of Surgical Oncology, Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Cory A Donovan
- Division of Surgical Oncology, Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marissa Srour
- Division of Surgical Oncology, Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alice Chung
- Division of Surgical Oncology, Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - James Mirocha
- Biostatistics Core, Research Institute and Samuel-Oschin Cancer Center, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Steven D Frankel
- Department of Breast Imaging, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Paul Hakim
- Department of Breast Imaging, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Armando E Giuliano
- Division of Surgical Oncology, Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Farin Amersi
- Division of Surgical Oncology, Department of Surgery, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
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19
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Xu H, Liu J, Chen Z, Wang C, Liu Y, Wang M, Zhou P, Luo H, Ren J. Intratumoral and peritumoral radiomics based on dynamic contrast-enhanced MRI for preoperative prediction of intraductal component in invasive breast cancer. Eur Radiol 2022; 32:4845-4856. [DOI: 10.1007/s00330-022-08539-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/01/2021] [Accepted: 12/22/2021] [Indexed: 12/11/2022]
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20
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Lepomäki M, Karhunen-Enckell U, Tuominen J, Kronqvist P, Oksala N, Murtola T, Roine A. Tumor margins that lead to reoperation in breast cancer: A retrospective register study of 4,489 patients. J Surg Oncol 2021; 125:577-588. [PMID: 34779520 PMCID: PMC9298886 DOI: 10.1002/jso.26749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 10/15/2021] [Accepted: 11/04/2021] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Maiju Lepomäki
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Ulla Karhunen-Enckell
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - Jalmari Tuominen
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Niku Oksala
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Vascular surgery, Vascular Centre, Tampere University Hospital, Tampere, Finland
| | - Teemu Murtola
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Urology, Tays Cancer Center, Tampere University Hospital, Tampere, Finland.,Department of Surgery, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Antti Roine
- Surgery, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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21
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Ellbrant J, Gulis K, Plasgård E, Svensjö T, Bendahl PO, Rydén L. Validated prediction model for positive resection margins in breast-conserving surgery based exclusively on preoperative data. BJS Open 2021; 5:6382014. [PMID: 34611702 PMCID: PMC8493005 DOI: 10.1093/bjsopen/zrab092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/17/2021] [Indexed: 12/14/2022] Open
Abstract
Background Positive margins after breast-conserving surgery (BCS) and subsequent second surgery are associated with increased costs and patient discomfort. The aim of this study was to develop a prediction model for positive margins based on risk factors available before surgery. Methods Patients undergoing BCS for in situ or invasive cancer between 2015 and 2016 at site A formed a development cohort; those operated during 2017 in site A and B formed two validation cohorts. MRI was not used routinely. Preoperative radiographic and tumour characteristics and method of operation were collected from patient charts. Multivariable logistic regression was used to develop a prediction model for positive margins including variables with discriminatory capacity identified in a univariable model. The discrimination and calibration of the prediction model was assessed in the validation cohorts, and a nomogram developed. Results There were 432 patients in the development cohort, and 190 and 157 in site A and B validation cohorts respectively. Positive margins were identified in 77 patients (17.8 per cent) in the development cohort. A non-linear transformation of mammographic tumour size and six variables (visible on mammography, ductal carcinoma in situ, lobular invasive cancer, distance from nipple–areola complex, calcification, and type of surgery) were included in the final prediction model, which had an area under the curve of 0.80 (95 per cent c.i. 0.75 to 0.85). The discrimination and calibration of the prediction model was assessed in the validation cohorts, and a nomogram developed. Conclusion The prediction model showed good ability to predict positive margins after BCS and might, after further validation, be used before surgery in centres without the routine use of preoperative MRI. Presented in part to the San Antonio Breast Cancer Symposium, San Antonio, Texas, USA, December 2018 and the Swedish Surgical Society Annual Meeting, Helsingborg, Sweden, August 2018.
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Affiliation(s)
- J Ellbrant
- Department of Surgery, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences Lund, Division of Surgery, Lund University, Lund, Sweden
| | - K Gulis
- Department of Clinical Sciences Lund, Division of Surgery, Lund University, Lund, Sweden.,Department of Surgery, Kristianstad Central Hospital, Kristianstad, Sweden
| | - E Plasgård
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - T Svensjö
- Department of Surgery, Kristianstad Central Hospital, Kristianstad, Sweden
| | - P O Bendahl
- Department of Clinical Sciences Lund, Division of Oncology and Pathology, Lund University, Lund, Sweden
| | - L Rydén
- Department of Clinical Sciences Lund, Division of Surgery, Lund University, Lund, Sweden.,Department of Surgery, Skåne University Hospital, Lund, Sweden
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22
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Wj H, As E, Js R, C P, Dh B. Rates of margin positive resection with breast conservation for invasive breast cancer using the NCDB. Breast 2021; 60:86-89. [PMID: 34520952 PMCID: PMC8441089 DOI: 10.1016/j.breast.2021.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/20/2021] [Accepted: 08/22/2021] [Indexed: 11/28/2022] Open
Abstract
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. Predictors of PSM are lobular histology, increasing T and N stage, grade, and Her2+ histology.
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Affiliation(s)
- Hotsinpiller Wj
- University of Alabama at Birmingham, Department of Radiation Oncology, USA
| | - Everett As
- Alliance Cancer Care in Huntsville, Alabama, USA
| | - Richman Js
- University of Alabama at Birmingham, Division of Gastrointestinal Surgery, USA
| | - Parker C
- University of Alabama at Birmingham, Division of Surgical Oncology, USA
| | - Boggs Dh
- University of Alabama at Birmingham, Department of Radiation Oncology, USA.
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23
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De la Flor M, Delgado C, Martínez S, Arenas M, Gómez M, Reig R. Rate of effect of surgical margins after breast conserving surgery and estimation of direct costs. Cir Esp 2021; 100:S0009-739X(21)00244-X. [PMID: 34399974 DOI: 10.1016/j.ciresp.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Assessment of the reoperation rate in patients with positive resection margins after initial breast-conserving surgery for breast cancer and estimation of the cost to the hospital. METHOD 146 patients with diagnosis of invasive breast cancer were included, who were initially intervened with conservative surgery by the Gynecology and Obstetrics Service of Hospital Universitario de Tarragona Juan XXIII (HUTJ23) during the years 2018 and 2019. We calculated the rate of involvement of the surgical margins of the resection piece after initial conservative surgery, establishing in which cases it was necessary to carry out a second resection, estimating the added direct costs of the second surgical procedure, and comparing them with the costs established by the Catalan Health Service according to the level of the hospital and the Diagnosis-Related Groups (DRG) established by the National Health System. RESULTS The rate of positive margins after initial conservative surgery was 20.55% and 19.17% patients underwent reoperation, generating a total expense of € 129.696,89, € 82.654,34 in conservative surgeries (€ 3.757,01 on average per patient) and € 47.042,55 in mastectomies (€ 6.720,36 on average per patient). CONCLUSIONS Margin involvement after breast-conserving surgery is synonymous for reoperation, this involves a series of direct costs. It is advisable to control the factors related to affected margins to minimize their impact.
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Affiliation(s)
- Miriam De la Flor
- Unidad de Patología Mamaria, Servicio de Ginecología y Obstetricia, H.U. Tarragona Joan XXIII, URV, Tarragona, España.
| | - Cinthia Delgado
- Departamento de Medicina y Cirugía, Universitat Rovira i Virgili, Tarragona, España
| | - Salomé Martínez
- Unidad de Patología Mamaria, Servicio de Anatomía Patológica, H.U. Tarragona Joan XXIII, URV, Tarragona, España
| | - Meritxell Arenas
- Unidad de Patología Mamaria, Servicio de Oncología Radioterápica, H.U. Sant Joan Reus, URV, Tarragona, España
| | - María Gómez
- Unidad de Patología Mamaria, Servicio de Oncología Radioterápica, H.U. Sant Joan Reus, URV, Tarragona, España
| | - Rosaura Reig
- Dirección Médica, H.U. Tarragona Joan XXIII, Tarragona, España
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24
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Toft NJ, Axelsen TV, Pedersen HL, Mele M, Burton M, Balling E, Johansen T, Thomassen M, Christiansen PM, Boedtkjer E. Acid-base transporters and pH dynamics in human breast carcinomas predict proliferative activity, metastasis, and survival. eLife 2021; 10:68447. [PMID: 34219652 PMCID: PMC8282339 DOI: 10.7554/elife.68447] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 07/02/2021] [Indexed: 12/13/2022] Open
Abstract
Breast cancer heterogeneity in histology and molecular subtype influences metabolic and proliferative activity and hence the acid load on cancer cells. We hypothesized that acid-base transporters and intracellular pH (pHi) dynamics contribute inter-individual variability in breast cancer aggressiveness and prognosis. We show that Na+,HCO3- cotransport and Na+/H+ exchange dominate cellular net acid extrusion in human breast carcinomas. Na+/H+ exchange elevates pHi preferentially in estrogen receptor-negative breast carcinomas, whereas Na+,HCO3- cotransport raises pHi more in invasive lobular than ductal breast carcinomas and in higher malignancy grade breast cancer. HER2-positive breast carcinomas have elevated protein expression of Na+/H+ exchanger NHE1/SLC9A1 and Na+,HCO3- cotransporter NBCn1/SLC4A7. Increased dependency on Na+,HCO3- cotransport associates with severe breast cancer: enlarged CO2/HCO3--dependent rises in pHi predict accelerated cell proliferation, whereas enhanced CO2/HCO3--dependent net acid extrusion, elevated NBCn1 protein expression, and reduced NHE1 protein expression predict lymph node metastasis. Accordingly, we observe reduced survival for patients suffering from luminal A or basal-like/triple-negative breast cancer with high SLC4A7 and/or low SLC9A1 mRNA expression. We conclude that the molecular mechanisms of acid-base regulation depend on clinicopathological characteristics of breast cancer patients. NBCn1 expression and dependency on Na+,HCO3- cotransport for pHi regulation, measured in biopsies of human primary breast carcinomas, independently predict proliferative activity, lymph node metastasis, and patient survival.
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Affiliation(s)
- Nicolai J Toft
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Trine V Axelsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Helene L Pedersen
- Department of Pathology, Regionshospitalet Randers, Randers, Denmark
| | - Marco Mele
- Department of Surgery, Regionshospitalet Randers, Randers, Denmark
| | - Mark Burton
- Department of Clinical Genetics, University of Southern Denmark, Odense, Denmark.,Clinical Genome Center, University and Region of Southern Denmark, Odense, Denmark
| | - Eva Balling
- Department of Surgery, Regionshospitalet Randers, Randers, Denmark
| | - Tonje Johansen
- Department of Pathology, Regionshospitalet Randers, Randers, Denmark
| | - Mads Thomassen
- Department of Clinical Genetics, University of Southern Denmark, Odense, Denmark.,Clinical Genome Center, University and Region of Southern Denmark, Odense, Denmark
| | - Peer M Christiansen
- Department of Surgery, Regionshospitalet Randers, Randers, Denmark.,Department of Plastic and Breast Surgery, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Ebbe Boedtkjer
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
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25
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Siegel JB, Mukherjee R, Park Y, Cluver AR, Chung C, Cole DJ, Lockett MA, Klauber-DeMore N, Abbott AM. Prognostic factors for residual occult disease in shave margins during partial mastectomy. Breast Cancer Res Treat 2021; 189:471-481. [PMID: 34132936 DOI: 10.1007/s10549-021-06282-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Shave margins have been shown to decrease positive final margins in partial mastectomy. We investigated prognostic factors associated with residual disease in shave margins. METHODS Patients with invasive breast carcinoma and ductal carcinoma in situ (DCIS) who had circumferential shave margins excised during lumpectomy were abstracted from a retrospective database from 2015 to 2018. We defined residual occult disease (ROD) as either (1) residual disease in a shave margin when the initial lumpectomy specimen had negative margins or (2) residual disease in a shave margin that did not correspond with the positive lumpectomy margin. We identified the frequency of ROD and conducted logistic regression analysis to identify associated prognostic factors. RESULTS 166 Patients (139 invasive carcinoma, 27 DCIS) were included with median follow-up of 28 months (9-50 months). Residual occult disease existed in 34 (24.5%) with invasive carcinoma and 8 (29.6%) with DCIS. In univariate analyses of the invasive group, invasive lobular carcinoma and a positive initial, non-corresponding lumpectomy margin were predictive of ROD (OR 3.63, p = 0.04, OR 3.48, p = 0.003 respectively). In multivariate analysis, a positive lumpectomy margin remained significant, p = 0.007. No variables were associated with ROD in DCIS. CONCLUSION Residual occult disease was shown to be a frequent event in this analysis of lumpectomy with circumferential shave margins. Having a positive initial lumpectomy margin was predictive of ROD in a non-corresponding margin. Surgeons should consider not being selective in their shave margins or margin of re-excision if shave margins were not obtained in their initial surgery.
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Affiliation(s)
- Julie B Siegel
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA.
| | - Rupak Mukherjee
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA
| | - Yeonhee Park
- Department of Public Health Science, Medical University of South Carolina, Charleston, SC, USA
| | - Abbie R Cluver
- Department of Radiology and Radiologic Science, Medical University of South Carolina, Charleston, SC, USA
| | - Catherine Chung
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA
| | - David J Cole
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA
| | - Mark A Lockett
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA
| | - Nancy Klauber-DeMore
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA
| | - Andrea M Abbott
- Department of Surgery, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC, 29425, USA
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26
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de Boer LL, Kho E, Van de Vijver KK, Vranken Peeters MJTFD, van Duijnhoven F, Hendriks BHW, Sterenborg HJCM, Ruers TJM. Optical tissue measurements of invasive carcinoma and ductal carcinoma in situ for surgical guidance. Breast Cancer Res 2021; 23:59. [PMID: 34022928 PMCID: PMC8141169 DOI: 10.1186/s13058-021-01436-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/05/2021] [Indexed: 11/10/2022] Open
Abstract
Background Although the incidence of positive resection margins in breast-conserving surgery has decreased, both incomplete resection and unnecessary large resections still occur. This is especially the case in the surgical treatment of ductal carcinoma in situ (DCIS). Diffuse reflectance spectroscopy (DRS), an optical technology based on light tissue interactions, can potentially characterize tissue during surgery thereby guiding the surgeon intraoperatively. DRS has shown to be able to discriminate pure healthy breast tissue from pure invasive carcinoma (IC) but limited research has been done on (1) the actual optical characteristics of DCIS and (2) the ability of DRS to characterize measurements that are a mixture of tissue types. Methods In this study, DRS spectra were acquired from 107 breast specimens from 107 patients with proven IC and/or DCIS (1488 measurement locations). With a generalized estimating equation model, the differences between the DRS spectra of locations with DCIS and IC and only healthy tissue were compared to see if there were significant differences between these spectra. Subsequently, different classification models were developed to be able to predict if the DRS spectrum of a measurement location represented a measurement location with “healthy” or “malignant” tissue. In the development and testing of the models, different definitions for “healthy” and “malignant” were used. This allowed varying the level of homogeneity in the train and test data. Results It was found that the optical characteristics of IC and DCIS were similar. Regarding the classification of tissue with a mixture of tissue types, it was found that using mixed measurement locations in the development of the classification models did not tremendously improve the accuracy of the classification of other measurement locations with a mixture of tissue types. The evaluated classification models were able to classify measurement locations with > 5% malignant cells with a Matthews correlation coefficient of 0.41 or 0.40. Some models showed better sensitivity whereas others had better specificity. Conclusion The results suggest that DRS has the potential to detect malignant tissue, including DCIS, in healthy breast tissue and could thus be helpful for surgical guidance. Supplementary Information The online version contains supplementary material available at 10.1186/s13058-021-01436-5.
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Affiliation(s)
- Lisanne L de Boer
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Postbus 90203, 1006, Amsterdam, BE, Netherlands.
| | - Esther Kho
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Postbus 90203, 1006, Amsterdam, BE, Netherlands
| | - Koen K Van de Vijver
- Department of Pathology, Ghent University Hospital, and Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium
| | | | - Frederieke van Duijnhoven
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Postbus 90203, 1006, Amsterdam, BE, Netherlands
| | - Benno H W Hendriks
- Philips Research, In-body Systems Group, Eindhoven, Netherlands.,Biomechanical Engineering Department, Delft University of Technology, Delft, The Netherlands
| | - Henricus J C M Sterenborg
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Postbus 90203, 1006, Amsterdam, BE, Netherlands.,Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Theo J M Ruers
- Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Postbus 90203, 1006, Amsterdam, BE, Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, the Netherlands
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27
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Gommers JJJ, Duijm LEM, Bult P, Strobbe LJA, Kuipers TP, Hooijen MJH, Mann RM, Voogd AC. The Impact of Preoperative Breast MRI on Surgical Margin Status in Breast Cancer Patients Recalled at Biennial Screening Mammography: An Observational Cohort Study. Ann Surg Oncol 2021; 28:5929-5938. [PMID: 33796997 PMCID: PMC8460561 DOI: 10.1245/s10434-021-09868-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/02/2021] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Jessie J J Gommers
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Lucien E M Duijm
- Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Peter Bult
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luc J A Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Toon P Kuipers
- Department of Radiology, Bernhoven Hospital, Uden, The Netherlands
| | | | - Ritse M Mann
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Adri C Voogd
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
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Cen C, Chun J, Kaplowitz E, Axelrod D, Shapiro R, Guth A, Schnabel F. Margin Assessment and Re-excision Rates for Patients Who Have Neoadjuvant Chemotherapy and Breast-Conserving Surgery. Ann Surg Oncol 2021; 28:5142-5148. [PMID: 33635409 DOI: 10.1245/s10434-020-09524-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/10/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) has enabled more patients to be eligible for breast-conservation surgery (BCS). Achieving negative lumpectomy margins, however, is challenging due to changes in tissue composition and potentially scattered residual carcinoma in the tumor bed. Data regarding BCS after NAC have shown variable re-excision rates. MarginProbe (Dilon Technologies, Newport News, VA, USA) has been shown to identify positive resection margins intraoperatively and to reduce the number of re-excisions in primary BCS, but has not been studied in NAC+BCS cases. This study aimed to investigate the clinicopathologic characteristics, margin status, and re-excision rates for NAC+BCS patients with and without the use of MarginProbe. METHODS The Institutional Breast Cancer Database was queried for patients who received NAC and had BCS from 2010 to 2019. The variables of interest were demographics, tumor characteristics, pathologic complete response (pCR), MarginProbe use, and re-excision rates. RESULTS The study population consisted of 214 patients who had NAC, 61 (28.5 %) of whom had NAC+BCS. The median age of the patients was 53.5 years. A pCR was achieved for 19 of the patients (31.1 %). Of the remaining 42 patients, 9 (21 %) had close or positive margins that required re-excision. Re-excision was associated with a larger residual tumor size (p = 0.025) and estrogen receptor (ER)-positive disease before NAC (p = 0.041). MarginProbe use was associated with a lower re-excision rate for the patients who had NAC+BCS (6 % vs. 31 %, respectively). CONCLUSION The patients with a larger residual tumor burden and ER-positive disease had a greater risk for inadequate margins at surgery. MarginProbe use was associated with a lower re-excision rate. Techniques to reduce the need for re-excision will support the use of BCS after NAC.
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Affiliation(s)
- Cindy Cen
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Jennifer Chun
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Elianna Kaplowitz
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Deborah Axelrod
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Richard Shapiro
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Amber Guth
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Freya Schnabel
- Department of Surgery, New York University Langone Health, New York, NY, USA.
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Civil YA, Duvivier KM, Perin P, Baan AH, van der Velde S. Optimization of Wire-guided Technique With Bracketing Reduces Resection Volumes in Breast-conserving Surgery for Early Breast Cancer. Clin Breast Cancer 2020; 20:e749-e756. [PMID: 32653472 DOI: 10.1016/j.clbc.2020.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/26/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Wire-guided localization (WGL) of early breast cancer can be facilitated using multiple wires, which is called bracketing wire-guided localization (BWL). The primary aim of this study is to compare BWL and conventional WGL regarding minimization of resection volumes without compromising margin status. Secondly, BWL is evaluated as an alternative method for intraoperative ultrasound (US) guidance in poorly definable breast tumors on US. PATIENTS AND METHODS In this retrospective cohort study, patients with preoperatively diagnosed breast cancer undergoing wide local excision between January 2016 and December 2018 were analyzed. Patients with multifocal disease or neoadjuvant treatment were excluded from this study. Optimal resection with minimal healthy breast tissue removal was assessed using the calculated resection ratio (CRR). RESULTS BWL was performed in 17 (9%) patients, WGL in 44 (22%), and US in 139 (70%). The rate of negative margins was comparable in all 3 groups. The CRR was significantly smaller for BWL (0.6) than WGL (1.3) in tumors larger than 1.5 cm. Additionally, BWL (0.8) led to smaller CRRs than US (1.7). This could be explained by the high number of small tumors (≤ 1.5 cm) in the US group for which greater CRRs are obtained than for large tumors (> 1.5 cm) (1.9 vs. 1.4; P = .005). CONCLUSION For breast tumors larger than 1.5 cm, BWL achieves more optimal resection volumes without compromising margin status compared with WGL. Moreover, BWL seems a suitable alternative to US in patients with poorly ultrasound-visible breast tumors and patients with a small tumor in a (large) breast.
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Affiliation(s)
- Yasmin A Civil
- Department of Surgical Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Katya M Duvivier
- Department of Radiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paola Perin
- Department of Surgery, Ziekenhuis Amstelland, Amstelveen, The Netherlands
| | - Astrid H Baan
- Department of Surgery, Ziekenhuis Amstelland, Amstelveen, The Netherlands
| | - Susanne van der Velde
- Department of Surgical Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
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LeeVan E, Ho BT, Seto S, Shen J. Use of MarginProbe as an adjunct to standard operating procedure does not significantly reduce re-excision rates in breast conserving surgery. Breast Cancer Res Treat 2020; 183:145-151. [PMID: 32607640 DOI: 10.1007/s10549-020-05773-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/23/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE A positive margin after breast conserving surgery has consistently been shown to be a significant predictor for ipsilateral breast tumor recurrence. Currently, there is no standard for intraoperative margin assessment during lumpectomy, and up to 20% of cases result in positive margins. MarginProbe is a device that provides real-time evaluation of lumpectomy margins during surgery. The aim of this study was to evaluate the impact of MarginProbe as an adjunct to standard operating procedure (SOP). METHODS Patients diagnosed with breast cancer scheduled for breast conserving surgery were consented for intraoperative use of MarginProbe. Shaved margins were excised based on margin assessment using the surgeon's SOP which included specimen radiography and gross pathologic examination, and feedback from the device. The primary endpoint was re-excision rate. Secondary endpoints included sensitivity, specificity, false-positive and negative rates. RESULTS Of the 60 breast cancers, initial histologically close/positive margins were identified in 18 patients (30%). The re-excision rate in the overall cohort was 6.6%, compared to a historical re-excision rate of 8.6% (p < 0.01). Based on 360 measurement sites, MarginProbe demonstrated a sensitivity of 67% and specificity of 60%, with a positive predictive value of 16%, and of negative predictive value of 94%, which was similar to the accuracy of SOP. CONCLUSIONS MarginProbe performs equally as well as specimen radiography and gross pathologic examination. In this setting where the baseline re-excision rate was low, the use of MarginProbe as an adjunct to SOP resulted in a small 2% absolute reduction in re-excision rate.
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Affiliation(s)
- Elyse LeeVan
- Department of Surgery, Huntington Hospital, 100 W California Blvd, Pasadena, CA, 91105, USA
| | - Be Thi Ho
- Department of Surgery, Huntington Hospital, 100 W California Blvd, Pasadena, CA, 91105, USA
| | - Sadie Seto
- Department of Clinical Research, Huntington Hospital, 100 W California Blvd, Pasadena, CA, 91105, USA
| | - Jeannie Shen
- Department of Surgery, Huntington Hospital, 100 W California Blvd, Pasadena, CA, 91105, USA. .,Department of Surgery, University of California Los Angeles, 10833 Le Conte Ave #72, Los Angeles, CA, 90024, USA. .,, 625 S Fair Oaks Ave, Suite 300, Pasadena, CA, 91105, USA.
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Tamburelli F, Ponzone R. The Value of Repeated Breast Surgery as a Quality Indicator in Breast Cancer Care. Ann Surg Oncol 2020; 28:340-352. [PMID: 32524463 DOI: 10.1245/s10434-020-08704-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Indexed: 02/06/2023]
Abstract
Breast-conserving surgery, a major achievement in surgical oncology, has allowed an increasing number of breast cancer patients to avoid the mutilation of mastectomy. However, mastectomy still is performed in certain circumstances although breast-conserving surgery would be equally safe. Many reasons, including patients' and surgeons' personal motivations, influence the decision-making process before the final choice between breast preservation and mastectomy. The importance of quality measurement and reporting in medicine is increasingly recognized, and breast surgery is no exception. The substantial variability of re-excision rates for positive surgical margins after a first attempt at breast-conserving surgery suggests that improvement is possible. Therefore, the re-excision rate has been proposed as a quality metric for assessing and comparing the performance of different institutions. Indeed, re-excision rates can be reduced by actionable factors such as accurate preoperative local staging, localization of occult lesions, and intraoperative assessment of the oriented specimen. However, equally important non-actionable risk factors pertaining the biology, detectability, and resectability of the tumor also should be taken into account. Therefore, if the re-excision rate has to be used as a performance indicator of breast surgical care, critical interpretation of results with accurate case-mix adjustment are mandatory, and reasonable targets must be appropriately set so that surgeons treating patients at higher risk of positive margins are not unduly penalized.
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Affiliation(s)
- Francesca Tamburelli
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - Riccardo Ponzone
- Gynecological Oncology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy.
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Munford C, Clayton E, Ji D, Eskew J, Burak W. Preoperative Predictive Factors of Positive Margin Status After Breast Conserving Therapy (BCT) with Intraoperative Radiation Therapy (IORT): A Retrospective Study of 400 Patients. Clin Breast Cancer 2020; 20:e618-e622. [PMID: 32434712 DOI: 10.1016/j.clbc.2020.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 02/29/2020] [Accepted: 03/24/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Christina Munford
- Department of Surgery, Center of Breast Care, Memorial Health University Medical Center, Savannah, GA.
| | - Eric Clayton
- Department of Surgery, Center of Breast Care, Memorial Health University Medical Center, Savannah, GA
| | - Dabin Ji
- Department of Surgery, Center of Breast Care, Memorial Health University Medical Center, Savannah, GA
| | - Joshua Eskew
- Department of Surgery, Center of Breast Care, Memorial Health University Medical Center, Savannah, GA
| | - William Burak
- Department of Surgery, Center of Breast Care, Memorial Health University Medical Center, Savannah, GA
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Nowikiewicz T, Śrutek E, Głowacka-Mrotek I, Tarkowska M, Żyromska A, Zegarski W. Clinical outcomes of an intraoperative surgical margin assessment using the fresh frozen section method in patients with invasive breast cancer undergoing breast-conserving surgery - a single center analysis. Sci Rep 2019; 9:13441. [PMID: 31530867 PMCID: PMC6748937 DOI: 10.1038/s41598-019-49951-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/30/2019] [Indexed: 11/10/2022] Open
Abstract
Breast conserving treatment (BCT) is a safe standard therapeutic method in patients with early invasive breast cancer. However, it is associated with an increased risk of residual neoplastic tissues in surgical margins. The aim of this study was to assess the outcome of the use of the intraoperative pathologic analysis by the frozen section (FS) method for evaluation of the extent of the primary lumpectomy. The study concerns a retrospective analysis of a group of 1102 patients who underwent BCT between Jan 2015 and Dec 2016. The assessment focused on the frequency of the intraoperative pathologic analysis of the primary lumpectomy extent (fresh frozen section method). The influence of the BCT specimen analysis method on the free margins width, as well as the rate and the cause of reoperation were evaluated. The intraoperative lumpectomy evaluation was performed in 45.8% (505/1102) of patients (Group I), while in the remaining 54.2% of the cases it was decided to abandon this procedure (Group II). Although in 72 (14.3%) patients the intraoperative analysis gave negative results, the margins contained residual tumor tissue (vs. 16.9% in Group II). In Group I, conversion from the previously planned BCT to mastectomy was necessary in 5.9% (30/505) patients (vs. 9.7% in Group II). The duration of surgery was 48.9 ± 17.3 minutes (Group I) and 42.9 ± 13.6 minutes (Group II). In patients undergoing BCT, the use of the intraoperative pathologic analysis by the FS method resulted in a reduction of the total number of reoperations performed due to residual tumor found in the margins following the primary lumpectomy. However, it statistically significantly extended the duration of the surgery.
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Affiliation(s)
- Tomasz Nowikiewicz
- Chair and Department of Surgical Oncology, Ludwik Rydygier's Collegium Medicum UMK in Bydgoszcz, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland. .,Department of Clinical Breast Cancer and Reconstructive Surgery, Oncology Centre-Prof. Franciszek Łukaszczyk Memorial Hospital, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland.
| | - Ewa Śrutek
- Chair and Department of Surgical Oncology, Ludwik Rydygier's Collegium Medicum UMK in Bydgoszcz, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland
| | - Iwona Głowacka-Mrotek
- Department of Rehabilitation, Ludwik Rydygier's Collegium Medicum UMK in Bydgoszcz, M. Sklodowskiej-Curie 9, 85-001, Bydgoszcz, Poland
| | - Magdalena Tarkowska
- Department of Laser Therapy and Physiotherapy, Ludwik Rydygier's Collegium Medicum UMK in Bydgoszcz, M. Sklodowskiej-Curie 9, 85-001, Bydgoszcz, Poland
| | - Agnieszka Żyromska
- Chair and Clinic of Oncology and Brachytherapy, Nicolaus Copernicus University Ludwik Rydygier Collegium Medicum in Bydgoszcz, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland.,Amethyst Radiotherapy Centre, Zgorzelec, Poland
| | - Wojciech Zegarski
- Chair and Department of Surgical Oncology, Ludwik Rydygier's Collegium Medicum UMK in Bydgoszcz, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland
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Kantor O, Pesce C, Kopkash K, Barrera E, Winchester DJ, Kuchta K, Yao K. Impact of the Society of Surgical Oncology-American Society for Radiation Oncology Margin Guidelines on Breast-Conserving Surgery and Mastectomy Trends. J Am Coll Surg 2019; 229:104-114. [DOI: 10.1016/j.jamcollsurg.2019.02.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/07/2019] [Accepted: 02/27/2019] [Indexed: 01/31/2023]
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Bae MS, Bernard-Davila B, Sung JS, Morris EA. Preoperative breast MRI features associated with positive or close margins in breast-conserving surgery. Eur J Radiol 2019; 117:171-177. [PMID: 31307644 DOI: 10.1016/j.ejrad.2019.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 05/31/2019] [Accepted: 06/11/2019] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Min Sun Bae
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, United States.
| | - Blanca Bernard-Davila
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, United States.
| | - Janice S Sung
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, United States.
| | - Elizabeth A Morris
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 300 E 66th Street, New York, NY, 10065, United States.
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Can enhancement types on preoperative MRI reflect prognostic factors and surgical outcomes in invasive breast cancer? Eur Radiol 2019; 29:7000-7008. [DOI: 10.1007/s00330-019-06236-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 02/28/2019] [Accepted: 04/11/2019] [Indexed: 12/16/2022]
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37
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Surgeon Re-Excision Rates after Breast-Conserving Surgery: A Measure of Low-Value Care. J Am Coll Surg 2019; 228:504-512.e2. [DOI: 10.1016/j.jamcollsurg.2018.12.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 12/19/2018] [Indexed: 11/19/2022]
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38
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Influence of ductal carcinoma in situ on the outcome of invasive breast cancer. A prospective cohort study. Int J Surg 2019; 63:98-106. [DOI: 10.1016/j.ijsu.2019.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/22/2018] [Accepted: 01/25/2019] [Indexed: 11/19/2022]
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39
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Hormone- and HER2-receptor assessment in 33,046 breast cancer patients: a nationwide comparison of positivity rates between pathology laboratories in the Netherlands. Breast Cancer Res Treat 2019; 175:487-497. [PMID: 30825048 PMCID: PMC6533417 DOI: 10.1007/s10549-019-05180-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/19/2019] [Indexed: 01/13/2023]
Abstract
Purpose Patient management of invasive breast cancer (IBC) is to a large extent based on hormone- and HER2-receptor assessment. High-quality, reliable receptor assessment is of key importance as false results may lead to under- or overtreatment of patients. Surveillance of case-mix adjusted positivity rates has been suggested as a tool to identify laboratories with insufficient testing assays, as this covers the whole process of receptor assessment and enables laboratories to benchmark their positivity rates against other laboratories. We studied laboratory-specific variation in hormone- and HER2 positivity rates of 33,046 breast cancer patients using real-life nationwide data. Methods All synoptic pathology reports of IBC resection-specimens, obtained between 2013 and 2016, were retrieved from the nationwide Dutch pathology registry (PALGA). Absolute and case-mix adjusted receptor positivity rates were compared to the mean national proportion and presented in funnel plots in separate analyses for estrogen (ER), progesterone (PR) and HER2. Case-mix adjustment was performed by multivariable logistic regression. Results 33,794 IBC lesions from 33,046 patients of 39 pathology laboratories were included. After case-mix adjustment, mean positivity rates were 87.2% for ER (range 80.4–94.3), 71.3% for PR (62.5–77.5%), and 9.9% for HER2 (5.5–12.7%). Overall, 14 (35.9%), 17 (43.6%) and 11 (28.2%) laboratories showed positivity rates outside the 95% confidence interval for ER, PR and HER2, respectively. Conclusion This nationwide study shows that absolute variation in hormone- and HER2-receptor positivity rates between Dutch pathology laboratories is limited. Yet, the considerable number of outlying laboratories shows that there is still need for improvement. Continuous monitoring and benchmarking of positivity rates may help to realize this.
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Clement Z, McLeay W, Hoffmann C, Shin P, Chowdhry M, Eaton M. Re-excision rate after sector resection for breast cancer: A 5-year retrospective cohort study. Breast Dis 2018; 38:7-13. [PMID: 30198861 DOI: 10.3233/bd-180339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Positive margins after Breast conserving surgery (BCS) for breast cancer can result in local recurrence (LR) requiring further surgery. This can lead to unnecessary patient anxiety, poor prognosis and impose additional economic burden to our health system. The aim of this study is to assess the rate of re-excision for positive margins after BCS using the sector resection technique. METHODS This single centre retrospective cohort study included all women who underwent BCS using sector resection between the years of 2012 and 2016. A total of 456 patients underwent sector resection. We evaluated the margin status, re-excision rates and their predictive risk factors. RESULTS 415 (91%) patients had clear margins. 41 (9%) patients underwent further re-excision for positive or close margin. 75.6% of those patients had DCIS and 51% had invasive carcinoma involving the margins. Patient and tumour characteristics associated with an increased risk of positive margin were women under the age of 50 (p = 0.19), tumours >50 mm (p = 0.001), grade-2 (p = 0.48) and grade-3 (p = 0.63), HER-2 positivity (p = 0.02), sentinel lymph node positivity (p = 0.03), and patients undergoing axillary lymph node dissection (p = 0.01). CONCLUSION BCS using the sector resection technique has a low re-excision rate for positive margins. Younger patients and aggressive tumour biology are important predictive risk factors for positive margins.
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Affiliation(s)
- Zackariah Clement
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - William McLeay
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - Clive Hoffmann
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - Peter Shin
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - Munir Chowdhry
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - Michael Eaton
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia.,Medical School, Flinders University, Adelaide, Australia
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Abstract
Breast-conserving surgery (BCS) followed by radiation therapy is the current standard of care for early stage breast cancer. Successful BCS necessitates complete tumor resection with clear margins at the pathologic assessment of the specimen ("no ink on tumor"). The presence of positive margins warrants additional surgery to obtain negative final margins, which has significant physical, psychological, and financial implications for the patient. The challenge lies in developing accurate real-time intraoperative margin assessment techniques to minimize the presence of "ink on tumor" and the subsequent need for additional surgery.
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Brouwer de Koning SG, Vrancken Peeters MJTFD, Jóźwiak K, Bhairosing PA, Ruers TJM. Tumor Resection Margin Definitions in Breast-Conserving Surgery: Systematic Review and Meta-analysis of the Current Literature. Clin Breast Cancer 2018; 18:e595-e600. [PMID: 29731404 DOI: 10.1016/j.clbc.2018.04.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 03/28/2018] [Accepted: 04/04/2018] [Indexed: 12/11/2022]
Abstract
Worldwide, various guidelines recommend what constitutes an adequate margin of excision for invasive breast cancer or for ductal carcinoma-in-situ (DCIS). We evaluated the use of different tumor resection margin guidelines and investigated their impact on positive margin rates (PMR) and reoperation rates (RR). Thirteen guidelines reporting on the extent of a positive margin were reviewed along with 31 studies, published between 2011 and 2016, reporting on a well-defined PMR. Studies were categorized according to the margin definition. Pooled PMR and RR were determined with random-effect models. For invasive breast cancer, most guidelines recommend a positive margin of tumor on ink. However, definitions of reported positive margins in the clinic vary from more than focally positive to the presence of tumor cells within 3 to 5 mm from the resection surface. Within the studies analyzed (59,979 patients), pooled PMRs for invasive breast cancer ranged from 9% to 36% and pooled RRs from 77% to 99%. For DCIS, guidelines vary between no DCIS on the resection surface to DCIS cells found within a distance of 2 mm from the resection edge. Pooled PMRs for DCIS varied from 4% to 23% (840 patients). Given the differences in tumor margin definition between countries worldwide, quality control data expressed as PMR or RR should be interpreted with caution. Furthermore, the overall definition for positive resection margins for both invasive disease and DCIS seems to have become more liberal.
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Affiliation(s)
| | | | - Katarzyna Jóźwiak
- Department of Epidemiology and Biostatistics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Patrick A Bhairosing
- Scientific Information Service, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Theo J M Ruers
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, The Netherlands; MIRA Institute, University of Twente, Enschede, The Netherlands
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van Leeuwen MT, Falster MO, Vajdic CM, Crowe PJ, Lujic S, Klaes E, Jorm L, Sedrakyan A. Reoperation after breast-conserving surgery for cancer in Australia: statewide cohort study of linked hospital data. BMJ Open 2018; 8:e020858. [PMID: 29643165 PMCID: PMC5898348 DOI: 10.1136/bmjopen-2017-020858] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To investigate between-hospital variation in the probability of reoperation within 90 days of initial breast-conserving surgery (BCS), and the contribution of health system-level and other factors. DESIGN Population-based, retrospective cohort study. SETTING New South Wales (NSW), Australia. PARTICIPANTS Linked administrative hospitalisation data were used to define a cohort of adult women undergoing initial BCS for breast cancer in NSW between 1 July 2002 and 31 December 2013. PRIMARY OUTCOME MEASURES Multilevel, cross-classified models with patients clustered within hospitals and residential areas were used to examine factors associated with any reoperation, and either re-excision or mastectomy, within 90 days. RESULTS Of 34 458 women undergoing BCS, 29.1% underwent reoperation within 90 days, half of which were mastectomies. Overall, the probability of reoperation decreased slightly over time. However, there were divergent patterns by reoperation type; the probability of re-excision increased alongside a concomitant decrease in the probability of mastectomy. Significant between-hospital variation was observed. Non-metropolitan location and surgery at low-volume hospitals were associated with a higher overall probability of reoperation, and of mastectomy specifically, after accounting for patient-level factors, calendar year and area-level socioeconomic status. The magnitude of association with geographical location and surgical volume decreased over time. CONCLUSIONS Reoperation rates within 90 days of BCS varied significantly between hospitals. For women undergoing mastectomy after BCS, this represents a dramatic change in clinical course. Multilevel modelling suggests unwarranted clinical variation may be an issue, likely due to disparities in access to multidisciplinary breast cancer care and preoperative diagnostic procedures. However, the observed reduction in disparities over time is encouraging and indicates that guidelines and policy initiatives have the potential to improve regional breast cancer care.
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Affiliation(s)
- Marina T van Leeuwen
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael O Falster
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Claire M Vajdic
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Philip J Crowe
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Sanja Lujic
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Elizabeth Klaes
- Breast Cancer Network Australia, Camberwell, Victoria, Australia
| | - Louisa Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, New York, USA
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Hernanz F, González-Noriega M, Sánchez S, Paz L, Muñoz P, Hermana S. Oncoplastic breast conserving surgery with tailored needle-guided excision. Gland Surg 2018; 6:698-705. [PMID: 29302488 DOI: 10.21037/gs.2017.06.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Breast conserving surgery (BCS) administered with oncoplastic approach (OBCS), when it is required, is currently the gold standard for the treatment of early breast cancer. Wire-guided localization (WL) is the most popular technique used to help surgeon in breast cancer excision. Currently, a universal and undeniable goal is to minimize the rate of positive margins and re-excision operation after BCS improving cosmetic outcome and decreasing health care costs. This study is aimed to report our experience combining OBCS and tailored WL as surgical approach for early breast cancers. Methods We performed a retrospective study on 148 breast cancer patients who were treated with OBCS and tailored WL, which consists in individualization of the number and location of wires depending on patient particularities, in our Breast Unit from March 2013 to December 2015. A multivariate analysis was used to determine the association between clinic-pathologic variables, which can be known preoperatively, and margin status. Results The rate of affected margins was 13.5% and 10.8% patients underwent re-interventions for oncologic reasons. Multifocality was strongly associated with involved margins [odds ratio (OR) 4.67]. Conclusions OBCS together with tailored WL obtains an acceptable rate of positive margins and high rate of final BCS.
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Affiliation(s)
- Fernando Hernanz
- Oncoplastic Breast Unit, Hospital Universitario Valdecilla, University of Cantabria, Santander, Spain
| | - Mónica González-Noriega
- Oncoplastic Breast Unit, Hospital Universitario Valdecilla, University of Cantabria, Santander, Spain
| | - Sonia Sánchez
- Oncoplastic Breast Unit, Hospital Universitario Valdecilla, University of Cantabria, Santander, Spain
| | - Lucia Paz
- Oncoplastic Breast Unit, Hospital Universitario Valdecilla, University of Cantabria, Santander, Spain
| | - Pedro Muñoz
- Oncoplastic Breast Unit, Hospital Universitario Valdecilla, University of Cantabria, Santander, Spain
| | - Sandra Hermana
- Oncoplastic Breast Unit, Hospital Universitario Valdecilla, University of Cantabria, Santander, Spain
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Heiss N, Rousson V, Ifticene-Treboux A, Lehr HA, Delaloye JF. Risk factors for positive resection margins of breast cancer tumorectomy specimen following breast-conserving surgery. Horm Mol Biol Clin Investig 2017; 32:/j/hmbci.ahead-of-print/hmbci-2017-0023/hmbci-2017-0023.xml. [PMID: 29222935 DOI: 10.1515/hmbci-2017-0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 09/20/2017] [Indexed: 11/15/2022]
Abstract
Background The aim of the study was to identify risk factors for positive surgical margins in breast-conserving surgery for breast cancer and to evaluate the influence of surgical experience in obtaining complete resection. Methods All lumpectomies for invasive breast carcinoma and ductal carcinoma in situ (DCIS) between April 2008 and March 2010 were selected from the database of a single institution. Re-excision rates for positive margins as well as patient and histopathologic tumor characteristics were analyzed. Surgical experience was staged by pairs made of Resident plus Specialist or Consultant. Two periods were defined. During period A, the majority of operations were performed by Residents under supervision of Specialist or Consultant. During period B, only palpable tumors were operated by Residents. Results The global re-excision rate was 27% (50 of 183 patients). The presence of DCIS increased the risk for positive margins: 60% (nine of 15 patients) in the case of sole DCIS compared to 26% (41 of 160 patients) for invasive cancer (p = 0.005) and 35% (42 of 120 patients) in the case of peritumoral DCIS compared to 11% (seven of 62 patients) in the case of sole invasive cancer (p = 0.001). Re-excision rate decreased from 36% (23 of 64 patients) during period A to 23% (27 of 119 patients) during period B (p = 0.055). There was no significant difference between the surgical pairs. Conclusion In our study, DCIS was the only risk factor for positive surgical margins. Breast-conserving surgery for non-palpable tumors should be performed by Specialists, however, palpable tumors can be safely operated by Residents under supervision.
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Affiliation(s)
- Niko Heiss
- Gynécologie-Obstétrique, 65, Avenue Jean Jaurès, F-30900 Nîmes, France, Phone: +0033/466047720, Fax: +0033/466047722
| | - Valentin Rousson
- Institut de médecine sociale et préventive, CHUV Lausanne, Lausanne, Switzerland
| | | | - Hans-Anton Lehr
- Institut für Pathologie im Medizin Campus Bodensee, Friedrichshafen, Germany
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Vos EL, Gaal J, Verhoef C, Brouwer K, van Deurzen CHM, Koppert LB. Focally positive margins in breast conserving surgery: Predictors, residual disease, and local recurrence. Eur J Surg Oncol 2017; 43:1846-1854. [PMID: 28688723 DOI: 10.1016/j.ejso.2017.06.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/30/2017] [Accepted: 06/06/2017] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- E L Vos
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands
| | - J Gaal
- Department of Pathology, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - C Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands
| | - K Brouwer
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands
| | - C H M van Deurzen
- Department of Pathology, Erasmus MC, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - L B Koppert
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE, Rotterdam, The Netherlands.
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Gweon HM, Jeong J, Son EJ, Youk JH, Kim JA, Ko KH. The clinical significance of accompanying NME on preoperative MR imaging in breast cancer patients. PLoS One 2017; 12:e0178445. [PMID: 28558007 PMCID: PMC5448772 DOI: 10.1371/journal.pone.0178445] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/12/2017] [Indexed: 12/02/2022] Open
Abstract
Purpose To investigate the significance of accompanying NME in invasive ductal carcinoma (IDC) on preoperative MR imaging and assess the factors affecting the significance. Methods Between January 2015 and February 2016, 163 consecutive patients with IDC who underwent preoperative MR imaging and subsequent surgery were enrolled and reviewed. Index cancer mass size and total extent with accompanying NME on MR images was measured and compared with pathologic size. Positive NME was defined as pathological result of IDC or DCIS. To identify affecting factors associated with frequency of accompanying NME on MR and positive pathologic result, clinicopathologic features were compared between breast cancers with NME and without NME, and between breast cancers with positive NME and negative NME using the Student t-test or Chi-square test. Results Of the 163 invasive breast cancers, 123(75.5%) cancers presented as only mass feature and 40(24.5%) cancers had accompanying NME around the index mass. Of the 40 accompanying NME, 22 (55%) had positive pathologic results and 18 (45%) had negative results. The HER2 positive status was significantly associated with positive pathologic results of accompanying NME (P = .016). Conclusion Accompanying NME on preoperative MR imaging showed malignant pathologic results in 55%. The HER2 positive IDC was more frequently accompanied by malignant NME.
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Affiliation(s)
- Hye Mi Gweon
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Ju Son
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- * E-mail:
| | - Ji Hyun Youk
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Ah Kim
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung Hee Ko
- Department of Radiology, CHA Bundang Medical Center, CHA University, School of Medicine, Gyeonggi-do, Republic of Korea
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