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Elmore LR, Bayley EM, Clark BZ, McAuliffe PF, Cowher MS. Is the Number or Proximity of Margins Less than 2 mm Associated with an Increased Mastectomy Rate in Patients Attempting Breast Conservation Therapy for Ductal Carcinoma In Situ? Ann Surg Oncol 2024:10.1245/s10434-024-15794-9. [PMID: 39085550 DOI: 10.1245/s10434-024-15794-9] [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: 04/05/2024] [Accepted: 06/28/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Consensus guidelines recommend ≥ 2 mm margins in patients undergoing partial mastectomy (PM) for ductal carcinoma in situ (DCIS). It is unknown whether the number or proximity of margins less than 2 mm is associated with an increased mastectomy rate in patients attempting breast conservation therapy (BCT) for DCIS. The aim of this study is to examine this relationship. PATIENTS AND METHODS An institutional database review identified 208 patients with DCIS who underwent PM at a tertiary referral center and community hospitals from July 2020 to June 2023. Patients with a history of breast cancer, previous surgery for breast cancer, ipsilateral invasive carcinoma, papillary carcinoma, Paget's disease, more lobular carcinoma in situ (LCIS) than DCIS present, initial mastectomy, no DCIS present, routine shave margins (of all vectors), and ≥ 2 mm margins of all six vectors were excluded. Selective intraoperative margin re-excisions were included. RESULTS A total of 208 patients who met inclusion criteria were retrospectively reviewed. 122 (25%) had one close/positive (< 2 mm) margin and 86 (18%) had two or more close/positive margins. Of the patients with one close/positive margin, 7% (9/122) eventually underwent mastectomy. Of the patients with two or more close/positive margins, 20% (17/86) eventually underwent mastectomy. Overall, no patients with opposing margins underwent mastectomy. CONCLUSIONS Patients undergoing PM for DCIS have a mastectomy rate that is increased threefold, with two or more close/positive margins at initial PM, when compared with those with only one close/positive margin. The presence of opposing close/positive margins at initial PM did not increase the mastectomy rate and most were cleared with re-excision.
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Affiliation(s)
- Leslie R Elmore
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Erin M Bayley
- Department of Surgery, Division of Breast Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Beth Z Clark
- Department of Pathology, Division of Breast and Gynecologic Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Priscilla F McAuliffe
- Department of Surgery, Division of Breast Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael S Cowher
- Department of Surgery, Division of Breast Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Kim Y, Ganduglia-Cazaban C, Tamirisa N, Lucci A, Krause TM. Contemporary Analysis of Reexcision and Conversion to Mastectomy Rates and Associated Healthcare Costs for Women Undergoing Breast-Conserving Surgery. Ann Surg Oncol 2024; 31:3649-3660. [PMID: 38319511 PMCID: PMC11076367 DOI: 10.1245/s10434-024-14902-z] [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: 09/19/2023] [Accepted: 01/02/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE This study was designed to provide a comprehensive and up-to-date understanding of population-level reoperation rates and incremental healthcare costs associated with reoperation for patients who underwent breast-conserving surgery (BCS). METHODS This is a retrospective cohort study using Merative™ MarketScan® commercial insurance data and Medicare 5% fee-for-service claims data. The study included females aged 18-64 years in the commercial cohort and females aged 18 years and older in the Medicare cohort, who underwent initial BCS for breast cancer in 2017-2019. Reoperation rates within a year of the initial BCS and overall 1-year healthcare costs stratified by reoperation status were measured. RESULTS The commercial cohort included 17,129 women with a median age of 55 (interquartile range [IQR] 49-59) years, and the Medicare cohort included 6977 women with a median age of 73 (IQR 69-78) years. Overall reoperation rates were 21.1% (95% confidence interval [CI] 20.5-21.8%) for the commercial cohort and 14.9% (95% CI 14.1-15.7%) for the Medicare cohort. In both cohorts, reoperation rates decreased as age increased, and conversion to mastectomy was more prevalent among younger women in the commercial cohort. The mean healthcare costs during 1 year of follow-up from the initial BCS were $95,165 for the commercial cohort and $36,313 for the Medicare cohort. Reoperations were associated with 24% higher costs in both the commercial and Medicare cohorts, which translated into $21,607 and $8559 incremental costs, respectively. CONCLUSIONS The rates of reoperation after BCS have remained high and have contributed to increased healthcare costs. Continuing efforts to reduce reoperation need more attention.
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Affiliation(s)
- Youngran Kim
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA.
| | - Cecilia Ganduglia-Cazaban
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Nina Tamirisa
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anthony Lucci
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Trudy Millard Krause
- Department of Management, Policy and Community Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
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Cozzi A, Di Leo G, Houssami N, Gilbert FJ, Helbich TH, Álvarez Benito M, Balleyguier C, Bazzocchi M, Bult P, Calabrese M, Camps Herrero J, Cartia F, Cassano E, Clauser P, de Lima Docema MF, Depretto C, Dominelli V, Forrai G, Girometti R, Harms SE, Hilborne S, Ienzi R, Lobbes MBI, Losio C, Mann RM, Montemezzi S, Obdeijn IM, Aksoy Ozcan U, Pediconi F, Pinker K, Preibsch H, Raya Povedano JL, Rossi Saccarelli C, Sacchetto D, Scaperrotta GP, Schlooz M, Szabó BK, Taylor DB, Ulus SÖ, Van Goethem M, Veltman J, Weigel S, Wenkel E, Zuiani C, Sardanelli F. Preoperative breast MRI positively impacts surgical outcomes of needle biopsy-diagnosed pure DCIS: a patient-matched analysis from the MIPA study. Eur Radiol 2024; 34:3970-3980. [PMID: 37999727 PMCID: PMC11166778 DOI: 10.1007/s00330-023-10409-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/16/2023] [Accepted: 10/11/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVES To investigate the influence of preoperative breast MRI on mastectomy and reoperation rates in patients with pure ductal carcinoma in situ (DCIS). METHODS The MIPA observational study database (7245 patients) was searched for patients aged 18-80 years with pure unilateral DCIS diagnosed at core needle or vacuum-assisted biopsy (CNB/VAB) and planned for primary surgery. Patients who underwent preoperative MRI (MRI group) were matched (1:1) to those who did not receive MRI (noMRI group) according to 8 confounding covariates that drive referral to MRI (age; hormonal status; familial risk; posterior-to-nipple diameter; BI-RADS category; lesion diameter; lesion presentation; surgical planning at conventional imaging). Surgical outcomes were compared between the matched groups with nonparametric statistics after calculating odds ratios (ORs). RESULTS Of 1005 women with pure unilateral DCIS at CNB/VAB (507 MRI group, 498 noMRI group), 309 remained in each group after matching. First-line mastectomy rate in the MRI group was 20.1% (62/309 patients, OR 2.03) compared to 11.0% in the noMRI group (34/309 patients, p = 0.003). The reoperation rate was 10.0% in the MRI group (31/309, OR for reoperation 0.40) and 22.0% in the noMRI group (68/309, p < 0.001), with a 2.53 OR of avoiding reoperation in the MRI group. The overall mastectomy rate was 23.3% in the MRI group (72/309, OR 1.40) and 17.8% in the noMRI group (55/309, p = 0.111). CONCLUSIONS Compared to those going directly to surgery, patients with pure DCIS at CNB/VAB who underwent preoperative MRI had a higher OR for first-line mastectomy but a substantially lower OR for reoperation. CLINICAL RELEVANCE STATEMENT When confounding factors behind MRI referral are accounted for in the comparison of patients with CNB/VAB-diagnosed pure unilateral DCIS, preoperative MRI yields a reduction of reoperations that is more than twice as high as the increase in overall mastectomies. KEY POINTS • Confounding factors cause imbalance when investigating the influence of preoperative MRI on surgical outcomes of pure DCIS. • When patient matching is applied to women with pure unilateral DCIS, reoperation rates are significantly reduced in women who underwent preoperative MRI. • The reduction of reoperations brought about by preoperative MRI is more than double the increase in overall mastectomies.
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Affiliation(s)
- Andrea Cozzi
- Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097, San Donato Milanese, Italy
- Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Giovanni Di Leo
- Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097, San Donato Milanese, Italy
| | - Nehmat Houssami
- The Daffodil Centre, Faculty of Medicine and Health, The University of Sydney (Joint Venture with Cancer Council NSW), Sydney, Australia
| | - Fiona J Gilbert
- Department of Radiology, School of Clinical Medicine, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Thomas H Helbich
- Division of General and Paediatric Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Division of Molecular and Structural Preclinical Imaging, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Corinne Balleyguier
- Department of Radiology, Institut Gustave Roussy, Villejuif, France
- Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris-Saclay, Villejuif, France
| | - Massimo Bazzocchi
- Institute of Radiology, Department of Medicine, Ospedale Universitario S. Maria della Misericordia, Università degli Studi di Udine, Udine, Italy
| | - Peter Bult
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Massimo Calabrese
- Unit of Oncological and Breast Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Julia Camps Herrero
- Department of Radiology, Hospital Universitario de La Ribera, Alzira, Spain
- Ribera Salud Hospitals, Valencia, Spain
| | - Francesco Cartia
- Unit of Breast Imaging, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Enrico Cassano
- Breast Imaging Division, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Paola Clauser
- Division of General and Paediatric Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Catherine Depretto
- Unit of Breast Imaging, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Valeria Dominelli
- Breast Imaging Division, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Gábor Forrai
- Department of Radiology, MHEK Teaching Hospital, Semmelweis University, Budapest, Hungary
- Department of Radiology, Duna Medical Center, GE-RAD Kft, Budapest, Hungary
| | - Rossano Girometti
- Institute of Radiology, Department of Medicine, Ospedale Universitario S. Maria della Misericordia, Università degli Studi di Udine, Udine, Italy
| | - Steven E Harms
- Breast Center of Northwest Arkansas, Fayetteville, AR, USA
| | - Sarah Hilborne
- Department of Radiology, School of Clinical Medicine, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Raffaele Ienzi
- Department of Radiology, Di.Bi.MED, Policlinico Universitario Paolo Giaccone Università degli Studi di Palermo, Palermo, Italy
| | - Marc B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Claudio Losio
- Department of Breast Radiology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ritse M Mann
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Radiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Stefania Montemezzi
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Inge-Marie Obdeijn
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Umit Aksoy Ozcan
- Department of Radiology, Acıbadem Atasehir Hospital, Istanbul, Turkey
| | - Federica Pediconi
- Department of Radiological, Oncological and Pathological Sciences, Università degli Studi di Roma "La Sapienza", Rome, Italy
| | - Katja Pinker
- Division of General and Paediatric Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Department of Radiology, Breast Imaging Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Heike Preibsch
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | | | | | - Daniela Sacchetto
- Kiwifarm S.R.L., La Morra, Italy
- Disaster Medicine Service 118, ASL CN1, Levaldigi, Italy
| | | | - Margrethe Schlooz
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Botond K Szabó
- Department of Radiology, Barking Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Donna B Taylor
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
- Department of Radiology, Royal Perth Hospital, Perth, Australia
| | - Sila Ö Ulus
- Department of Radiology, Acıbadem Atasehir Hospital, Istanbul, Turkey
| | - Mireille Van Goethem
- Gynecological Oncology Unit, Department of Obstetrics and Gynecology, Department of Radiology, Multidisciplinary Breast Clinic, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Jeroen Veltman
- Maatschap Radiologie Oost-Nederland, Oldenzaal, The Netherlands
| | - Stefanie Weigel
- Clinic for Radiology and Reference Center for Mammography, University of Münster, Münster, Germany
| | - Evelyn Wenkel
- Department of Radiology, University Hospital of Erlangen, Erlangen, Germany
| | - Chiara Zuiani
- Institute of Radiology, Department of Medicine, Ospedale Universitario S. Maria della Misericordia, Università degli Studi di Udine, Udine, Italy
| | - Francesco Sardanelli
- Unit of Radiology, IRCCS Policlinico San Donato, Via Rodolfo Morandi 30, 20097, San Donato Milanese, Italy.
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy.
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Xu D, Wang K, Lin C, Li D, Pan C, Hu K, Chen H, Huang F, Tian W, Chen Y, Pan T. Can We Do Breast-Conserving Surgery Without Intraoperative Frozen Section of Margin? Clin Breast Cancer 2024; 24:191-198. [PMID: 38368247 DOI: 10.1016/j.clbc.2024.01.019] [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: 10/16/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/19/2024]
Abstract
PURPOSE This study was a retrospective and nonrandomized study to assess the safety and reliability of identifying the surgical margin in breast cancer breast-conserving surgery (BCS) by using intraoperative ultrasonic location and specimen mammography instead of traditional intraoperative frozen pathological section. METHODS Among the patients who underwent BCS from May 2019 to October 2021, according to the different methods of evaluating the intraoperative margin, 104 breast cancer patients were included in the frozen edge group, 53 breast cancer patients were included in the freeze-free group, and the surgeon judged whether extended resection was needed based on the results of pathological section or evaluation of intraoperative ultrasound and mammography. The surgical margins of the two groups were judged by postoperative pathological results as the gold standard. RESULTS The median waiting pathology results time in the frozen edge group was 64 minutes, while the waiting time in the freeze-free group was 30 minutes, and the difference was statistically significant (P < .0001). The postoperative pathological results showed that the positive rate of the surgical margin in the frozen edge group was 0.96%. The coincidence rate of intraoperative frozen and postoperative pathological results was 99.04%. The coincidence rate between intraoperative mammography and postoperative pathological results was 100%. CONCLUSIONS In BCS, the method of using intraoperative staining markers combined with mammography to evaluate the resection margin is highly accurate, reliable, economical and convenient, and at the same time reduces the waiting time of the operator during the operation. However, this was not a randomized controlled study, and there was patient selection bias, and its safety needs to be confirmed by long-term follow-up. In the future, it is expected to become the mainstream means of evaluating.
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Affiliation(s)
- Dongyan Xu
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Kaiyue Wang
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chen Lin
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Dan Li
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chi Pan
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Kaimin Hu
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Huihui Chen
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Fengbo Huang
- The Department of Pathology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Wei Tian
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yiding Chen
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Tao Pan
- Department of Breast Surgery and Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences), The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
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Blackburn AZ, Homere A, Alpaugh K, Melnic CM, Bedair HS. Intersurgeon Variability of Minimal Clinically Important Difference for Worsening Achievement Rates After Total Joint Arthroplasty. J Arthroplasty 2023; 38:2573-2579.e2. [PMID: 37321518 DOI: 10.1016/j.arth.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Using the Patient-Reported Outcome Measurement Information System, we sought to evaluate surgeon performance variability via minimal clinically important difference for worsening (MCID-W) achievement rates in primary and revision total knee and hip arthroplasty. METHODS This retrospective study analyzed 3,496 primary total hip arthroplasty (THA), 4,622 primary total knee arthroplasty (TKA), 592 revision THA, and 569 revision TKA patients. Patient factors collected included demographics, comorbidities, and Patient-Reported Outcome Measurement Information System physical function short form 10a scores. Surgeon factors collected included caseload, years of experience, and fellowship training. The MCID-W rate was calculated as the percent of patients in each surgeon's cohort who achieved MCID-W. Distribution was presented via a histogram with associated average, standard deviation, range, and interquartile range (IQR). Linear regressions were performed to evaluate the potential correlation between surgeon- and patient-level factors with MCID-W rate. RESULTS The average MCID-W rates of the surgeons represented in the primary THA and TKA cohorts were 12.7 ± 9.2% (range, 0 to 35.3%; IQR, 6.7 to 15.5%) and 18.0 ± 8.2% (range, 0 to 36%; IQR, 14.3 to 22.0%). The average MCID-W rates among the revision THA and TKA surgeons were 36.0 ± 22.2% (range, 9.1 to 90%; IQR, 25.0 to 41.4%) and 21.2 ± 7.7% (range, 8.1 to 37.0%; IQR, 16.6 to 25.4%). Strong correlations were not found between patient- or surgeon-level factors and MCID-W rate of the surgeon. CONCLUSION We demonstrated variance in MCID-W achievement rates across surgeons in both primary and revision joint arthroplasty, independent of patient- or surgeon-level factors.
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Affiliation(s)
- Amy Z Blackburn
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Andrew Homere
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Kyle Alpaugh
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Christopher M Melnic
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Hany S Bedair
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
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Gilmore R, Chen J, Dembinski R, Reissis Y, Milek D, Cadena L, Habibi M. Cost minimization in breast conserving surgery: a comparative study of radiofrequency spectroscopy and full cavity shave margins. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:66. [PMID: 37716980 PMCID: PMC10504787 DOI: 10.1186/s12962-023-00477-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 09/09/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND In an effort to minimize positive margins and subsequent re-excision after breast conserving surgery (BCS), many providers and facilities have implemented either a Full Cavity Shave (FCS) approach or adding the MarginProbe Radiofrequency Spectroscopy System. OBJECTIVE We sought to create a functioning Pro-Forma for use by facilities and payers to evaluate and compare the cost savings of implementing FCS or MarginProbe based on personalized variable inputs. METHODS A decision tree demonstrating three possible surgical pathways, BCS, BCS + FCS, and BCS + MarginProbe was developed with clinical inputs for re-excision rate, mastectomy as 2nd surgery, rate of reconstruction, and rate of 3rd surgery derived by a literature review. A surgical pathway cost formula was created using the decision tree and financial inputs derived by utilizing the nation's largest database of privately billed health insurance claims and Medicare claims data (fairhealth.org). Using the surgical pathway formula and financial inputs, a customizable Pro-Forma was created for immediate cost savings analysis of BCS + FCS and BCS + Marginprobe using variable inputs. Costs are from the perspective of third-party payers. RESULTS Utilizing MarginProbe to reduce re-excisions for positive margins can be associated with better cost-savings than FCS due to the increased pathology processing costs by using an FCS approach. The reduction in re-excision provided by both FCS and MarginProbe offset their increased expense to various degrees with cost savings of each method improving as baseline re-excisions rates increase, until ultimately each may become cost-neutral or cost-prohibitive when compared to BCS alone. Our data suggest that in the privately insured population, MarginProbe provides a cost-savings over BCS alone when baseline re-excision rates are over 20% and that FCS becomes cost-saving when baseline re-excision rates are over 29%. For Medicare patients, MarginProbe provides a cost-savings when baseline re-excision rates exceed 34%, and FCS becomes cost-saving for re-excision rates over 52%. Our Pro-Forma allows an individual provider or institution to evaluate the cost savings of the FCS approach and/or utilization of the MarginProbe device such that the additional cost or cost-savings of utilizing one or both of these methods can be quickly calculated based on their facility's volume and baseline re-excision rate. CONCLUSIONS Our data suggest that utilizing either an FCS approach or the MarginProbe radiofrequency spectroscopy system may be a cost-saving solution to reducing the rate of re-excisions depending on a facility or practice's surgical volume and baseline re-excision rate. The degree to which each of these interventions provides an added cost or cost-savings to healthcare payers can be evaluated by utilizing the Pro-Forma outlined herein with customizable variable inputs.
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Affiliation(s)
- Richard Gilmore
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Jennifer Chen
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Robert Dembinski
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Yannis Reissis
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - David Milek
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Lisa Cadena
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Mehran Habibi
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA.
- Department of Surgery, Northwell Health, Zucker School of Medicine, New York, United States.
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Fernandez-Pacheco M, Ortmann O, Ignatov A, Inwald EC. Does cavity margin shaving reduce residual tumor and re-excision rates? A systematic review. Arch Gynecol Obstet 2023; 307:1295-1309. [PMID: 35593951 PMCID: PMC10023760 DOI: 10.1007/s00404-022-06512-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/06/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Cavity shaving (CS) is a surgical technique used in the treatment of breast cancer (BC). It may reduce margin positivity in histologic assessment and consequently reduces re- excision rates in breast conserving surgery (BCS). The evidence for this assumption is described in the present review. METHODS A systematic review of relevant literature in English from January 1999 to April 2019 was conducted. The analysis included studies on CS and its effects on re-excision rates and margin positivity. We searched PubMed databases for relevant publications. In total, 22 studies were included in the present review. RESULTS The benefit from CS on re-excision rates and histologic margin positivity was variable. Out of 22 studies, 17 reported a reduction in both re-excision rates and histologic margin positivity in margin shaved patients. Four studies could not find a significant reduction of second surgeries and residual tumor rates. One study suggested that CS after BCS was superior to single BCS only in subgroup analysis in IDC tumors. CONCLUSION CS is a surgical technique that was shown to reduce re-excision and margin positivity rates in most of the studies. Furthermore, it can be a useful tool to assess specimen margins and detect multifocality.
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Affiliation(s)
- M Fernandez-Pacheco
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany.
| | - O Ortmann
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - A Ignatov
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - E C Inwald
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
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8
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Dhak S, Baliski C, Bakos B. Factors influencing suboptimal pathologic margins and re-excision following breast conserving surgery for ductal carcinoma in-situ. Am J Surg 2023; 225:866-870. [PMID: 36894415 DOI: 10.1016/j.amjsurg.2023.02.025] [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: 11/13/2022] [Revised: 01/28/2023] [Accepted: 02/24/2023] [Indexed: 02/27/2023]
Abstract
INTRODUCTION Re-excisions following breast conserving surgery (BCS) are common, occurring more frequently in ductal carcinoma in-situ (DCIS) than its' malignant counterpart. Although one quarter of patients with breast cancer will have DCIS, there is limited information available regarding factors predisposing to inadequate pathologic margins, and the need for re-excision. METHODS Retrospective review of patients treated for DCIS between the years 2010-2016 was conducted. Patients with DCIS undergoing BCS were identified and evaluated for demographic and pathologic factors associated with suboptimal pathologic margins and re-excision. Multivariate analysis with Wald Chi-Square testing was performed. RESULTS 241 patients underwent BCS with suboptimal margins (SOM) in 51.7% (123/238), with 27.8% undergoing re-excision (67/241). Tumor size was the most influential variable, positively associated with SOM (OR = 10.25, CI: 5.50-19.13) and re-excision (OR = 6.36, CI: 3.92-10.31). Patient age was inversely associated with SOM (OR = 0.58, CI: 0.39-0.85) and subsequent re-excisions (OR = 0.56, CI: 0.36-0.86). Low tumour grade was associated with re-excision (OR = 1.31, CI: 0.63-2.71), while ER negative disease was associated with SOM (OR = 2.24, CI: 1.21-4.14). DISCUSSION Inadequate pathologic margins following BCS, and subsequent re-excision rates are common in patients with DCIS, and consistent with the literature. Tumour size is the dominant factor driving this occurrence, with patient age and tumour grade also impacting outcomes.
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Affiliation(s)
- Sahej Dhak
- University of British Columbia, Southern Medical Program, 1088 Discovery Ave, Kelowna, BC V1V 1V7, Canada.
| | - Christopher Baliski
- BC Cancer Sindi-Ahluwalia Hawkins Centre for the Southern Interior, 399 Royal Ave, Kelowna, BC V1Y 5L3, Canada.
| | - Brendan Bakos
- BC Cancer Sindi-Ahluwalia Hawkins Centre for the Southern Interior, 399 Royal Ave, Kelowna, BC V1Y 5L3, Canada
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9
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Paleari L, Tassinari F, Astengo M, Amicizia D, Paganino C, Paoli G, Pronzato P, Ansaldi F. The Impact of the Introduction of the Breast Unit Model in a Northwestern Italian Region. Healthcare (Basel) 2022; 10:healthcare10081512. [PMID: 36011169 PMCID: PMC9407722 DOI: 10.3390/healthcare10081512] [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: 07/05/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 12/24/2022] Open
Abstract
Breast cancer is the most common tumor in middle-aged and older women. In 2003, the European Parliament recommended to Member States that all women with breast cancer should be treated by a multidisciplinary team and that a network of certified breast centers be organized (the centers have been called Breast Units (BUs)). With the present study, we aim to explore the impact of the introduction of the BU organizational model in the Liguria region, Italy, through different outcome indicators. An explorative retrospective analysis was conducted through the period from 2013 to 2019 to assess the impact of the introduction of the BU model in our region. We identified two periods: before (2014–2015) and after (2017–2018) the introduction of this organizational model to assess its value impact through the definition of six measurable outcome indicators. Length of hospitalization, repeated specialist outpatient diagnostic procedures and the rate of subjects who started radiotherapy treatment within 60 days improved after the introduction of BUs. The passive health migration rate only improved significantly for one local health unit (LHU), while reintervention and diagnosis–surgery time did not show any enhancement after the introduction of the BU model. The BU model seems to provide an increase in several aspects of the healthcare offered to breast cancer patients in Liguria, specifically in those areas where a shared guideline could assist healthcare workers. Future research, such as pilot studies, are needed to assess the impact of the introduction of the BU model in our reality.
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Affiliation(s)
- Laura Paleari
- Research, Innovation, HTA Unit, Liguria Health Authority (A.Li.Sa.), Genoa 16121, Italy
- Correspondence: ; Tel.: +39-010-5484243
| | - Federico Tassinari
- Health Planning Unit, Liguria Health Authority (A.Li.Sa.), Genoa 16121, Italy
| | - Matteo Astengo
- Health Planning Unit, Liguria Health Authority (A.Li.Sa.), Genoa 16121, Italy
| | - Daniela Amicizia
- Health Planning Unit, Liguria Health Authority (A.Li.Sa.), Genoa 16121, Italy
- Department of Health Sciences, University of Genoa, Genoa 16121, Italy
- Health Planning Unit, Ospedale Policlinico San Martino—IRCCS, Genoa 16121, Italy
| | - Chiara Paganino
- Health Planning Unit, Liguria Health Authority (A.Li.Sa.), Genoa 16121, Italy
| | - Gabriella Paoli
- Research, Innovation, HTA Unit, Liguria Health Authority (A.Li.Sa.), Genoa 16121, Italy
| | - Paolo Pronzato
- Department of Medical Oncology, UO Oncologia Medica 2, IRCCS AOU San Martino-IST, Genoa 16121, Italy
| | - Filippo Ansaldi
- Health Planning Unit, Liguria Health Authority (A.Li.Sa.), Genoa 16121, Italy
- Department of Health Sciences, University of Genoa, Genoa 16121, Italy
- Health Planning Unit, Ospedale Policlinico San Martino—IRCCS, Genoa 16121, Italy
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10
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Martins Maia C, Siderides C, Jaffer S, Weltz C, Cate S, Ahn S, Boolbol S, Ru M, Moshier E, Port E, Schmidt H. Mastectomy or Margin Re-excision? A Nomogram for Close/Positive Margins After Lumpectomy for DCIS. Ann Surg Oncol 2022; 29:3740-3748. [DOI: 10.1245/s10434-021-11293-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/15/2021] [Indexed: 11/18/2022]
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11
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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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12
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A New Look into Cancer-A Review on the Contribution of Vibrational Spectroscopy on Early Diagnosis and Surgery Guidance. Cancers (Basel) 2021; 13:cancers13215336. [PMID: 34771500 PMCID: PMC8582426 DOI: 10.3390/cancers13215336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 02/05/2023] Open
Abstract
Simple Summary Cancer is a leading cause of death worldwide, with the detection of the disease in its early stages, as well as a correct assessment of the tumour margins, being paramount for a successful recovery. While breast cancer is one of most common types of cancer, head and neck cancer is one of the types of cancer with a lower prognosis and poor aesthetic results. Vibrational spectroscopy detects molecular vibrations, being sensitive to different sample compositions, even when the difference was slight. The use of spectroscopy in biomedicine has been extensively explored, since it allows a broader assessment of the biochemical fingerprint of several diseases. This literature review covers the most recent advances in breast and head and neck cancer early diagnosis and intraoperative margin assessment, through Raman and Fourier transform infrared spectroscopies. The rising field of spectral histopathology was also approached. The authors aimed at expounding in a more concise and simple way the challenges faced by clinicians and how vibrational spectroscopy has evolved to respond to those needs for the two types of cancer with the highest potential for improvement regarding an early diagnosis, surgical margin assessment and histopathology. Abstract In 2020, approximately 10 million people died of cancer, rendering this disease the second leading cause of death worldwide. Detecting cancer in its early stages is paramount for patients’ prognosis and survival. Hence, the scientific and medical communities are engaged in improving both therapeutic strategies and diagnostic methodologies, beyond prevention. Optical vibrational spectroscopy has been shown to be an ideal diagnostic method for early cancer diagnosis and surgical margins assessment, as a complement to histopathological analysis. Being highly sensitive, non-invasive and capable of real-time molecular imaging, Raman and Fourier transform infrared (FTIR) spectroscopies give information on the biochemical profile of the tissue under analysis, detecting the metabolic differences between healthy and cancerous portions of the same sample. This constitutes tremendous progress in the field, since the cancer-prompted morphological alterations often occur after the biochemical imbalances in the oncogenic process. Therefore, the early cancer-associated metabolic changes are unnoticed by the histopathologist. Additionally, Raman and FTIR spectroscopies significantly reduce the subjectivity linked to cancer diagnosis. This review focuses on breast and head and neck cancers, their clinical needs and the progress made to date using vibrational spectroscopy as a diagnostic technique prior to surgical intervention and intraoperative margin assessment.
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13
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Davey MG, Ryan ÉJ, Boland MR, Barry MK, Lowery AJ, Kerin MJ. Clinical utility of the 21-gene assay in predicting response to neoadjuvant endocrine therapy in breast cancer: A systematic review and meta-analysis. Breast 2021; 58:113-120. [PMID: 34022714 PMCID: PMC8142274 DOI: 10.1016/j.breast.2021.04.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION OncotypeDX© Recurrence Score (RS) is a multigene panel used to aid therapeutic decision making in early-stage, estrogen receptor positive (ER+)/human epidermal growth factor receptor-2 negative (HER2-) breast cancer. AIM To compare responses to neoadjuvant endocrine therapy (NET) in patients with ER+/HER2-breast cancer following substratification by RS testing. METHODS This systematic review was performed in accordance to the PRISMA guidelines. Studies evaluating pathological complete response (pCR), partial response (PR), and successful conversion to breast conservation surgery (BCS) rates following NET guided by RS were retrieved. Dichotomous outcomes were reported as odds ratios (ORs) with 95% confidence intervals (CIs) following estimation by Mantel-Haenszel method. RESULTS Eight prospective studies involving 691 patients were included. The mean age was 62.6 years (range 25-85) and the mean RS was 14.5 (range 0-68). Patients with RS < 25 (OR: 4.60, 95% CI: 2.53-8.37, P < 0.001) and RS < 30 (OR: 3.40, 95% CI: 1.96-5.91, P < 0.001) were more likely to achieve PR than their counterparts. NET prescription failed to increase BCS conversion rates for patients with RS < 18 (OR: 0.23, 95% CI: 0.04-1.47, P = 0.120) and RS > 30 (OR: 1.27, 95% CI: 0.64-2.49, P = 0.490) respectively. Only 22 patients achieved pCR (2.8%) and RS group failed to predict pCR following NET (P = 0.850). CONCLUSION Estimations from this analysis indicate that those with low-intermediate RS on core biopsy are four times more likely to respond to NET than those with high-risk RS. Performing RS testing on diagnostic biopsy may be useful in guiding NET prescription.
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Affiliation(s)
- M G Davey
- The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland.
| | - É J Ryan
- The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - M R Boland
- The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - M K Barry
- The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - A J Lowery
- The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - M J Kerin
- The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
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14
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Wang Z, Chen M, Liu JJ, Chen RH, Yu Q, Wang GM, Nie LM, Huang WH, Zhang GJ. Human Serum Albumin Decorated Indocyanine Green Improves Fluorescence-Guided Resection of Residual Lesions of Breast Cancer in Mice. Front Oncol 2021; 11:614050. [PMID: 33763353 PMCID: PMC7983674 DOI: 10.3389/fonc.2021.614050] [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: 10/05/2020] [Accepted: 01/28/2021] [Indexed: 11/13/2022] Open
Abstract
Objective Achieving negative resection margin is critical but challenging in breast-conserving surgery. Fluorescence-guided surgery allows the surgeon to visualize the tumor bed in real-time and to facilitate complete resection. We envisioned that intraoperative real-time fluorescence imaging with a human serum albumin decorated indocyanine green probe could enable complete surgical removal of breast cancer in a mouse model. Methods We prepared the probe by conjugating indocyanine green (ICG) with human serum albumin (HSA). In vitro uptake of the HSA-ICG probe was compared between human breast cancer cell line MDA-MB-231 and normal breast epithelial cell line MCF 10A. In vivo probe selectivity for tumors was examined in nude mice bearing MDA-MB-231-luc xenografts and the FVB/N-Tg (MMTV-PyMT) 634Mul/J mice model with spontaneous breast cancer. A positive-margin resection mice model bearing MDA-MB-231-luc xenograft was established and the performance of the probe in assisting surgical resection of residual lesions was examined. Results A significantly stronger fluorescence intensity was detected in MDA-MB-231 cells than MCF 10A cells incubated with HSA-ICG. In vivo fluorescence imaging showed that HSA-ICG had an obvious accumulation at tumor site at 24 h with tumor-to-normal tissue ratio of 8.19 ± 1.30. The same was true in the transgenic mice model. The fluorescence intensity of cancer tissues was higher than that of non-cancer tissues (58.53 ± 18.15 vs 32.88 ± 11.34). During the surgical scenarios, the residual tumors on the surgical bed were invisible with the naked eye, but were detected and resected with negative margin under HSA-ICG guidance in all the mice (8/8). Recurrence rate among mice that underwent resection with HSA-ICG (0/8) was significantly lower than the rates among mice with ICG (4/8), as well as the control group under white light (7/7). Conclusions This study suggests that real-time in vivo visualization of breast cancer with an HSA-ICG fluorescent probe facilitates complete surgical resection of breast cancer in a mouse xenograft model.
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Affiliation(s)
- Zun Wang
- ChangJiang Scholar's Laboratory, Medical College, Shantou University, Shantou, China
| | - Min Chen
- Clinical Central Research Core, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Key Laboratory for Endocrine-Related Cancer Precision Medicine of Xiamen, Xiang'an Hospital of Xiamen University, Xiamen, China.,Cancer Research Center, School of Medicine, Xiamen University, Xiamen, China
| | - Jing-Jing Liu
- Key Laboratory for Endocrine-Related Cancer Precision Medicine of Xiamen, Xiang'an Hospital of Xiamen University, Xiamen, China.,Cancer Research Center, School of Medicine, Xiamen University, Xiamen, China.,Cancer Center & Department of Breast and Thyroid Surgery, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Rong-He Chen
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnosis & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen, China
| | - Qian Yu
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnosis & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen, China
| | - Gui-Mei Wang
- Department of Pathology, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Li-Ming Nie
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnosis & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen, China
| | - Wen-He Huang
- Cancer Center & Department of Breast and Thyroid Surgery, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Guo-Jun Zhang
- ChangJiang Scholar's Laboratory, Medical College, Shantou University, Shantou, China.,Key Laboratory for Endocrine-Related Cancer Precision Medicine of Xiamen, Xiang'an Hospital of Xiamen University, Xiamen, China.,Cancer Research Center, School of Medicine, Xiamen University, Xiamen, China.,Cancer Center & Department of Breast and Thyroid Surgery, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
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15
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Baliski C. ASO Author Reflections: Quality Improvement and Measurement in Breast Conserving Surgery: Surgeon Case Volumes, Reexcisions, and Pursuit of the Holy Grail. Ann Surg Oncol 2020; 27:830-831. [PMID: 32671608 DOI: 10.1245/s10434-020-08848-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 06/30/2020] [Indexed: 11/18/2022]
Affiliation(s)
- C Baliski
- Department of Surgical Oncology, BCCA, Kelowna, Canada.
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16
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Baliski C, Hughes L, Bakos B. Lowering Re-excision Rates After Breast-Conserving Surgery: Unraveling the Intersection Between Surgeon Case Volumes and Techniques. Ann Surg Oncol 2020; 28:894-901. [PMID: 32638167 DOI: 10.1245/s10434-020-08731-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The re-excision rates after breast-conserving surgery (BCS) are significantly varied, with surgeon case volume as one influential factor. Surgeons with higher case volumes have been shown to have lower reoperation rates. This study attempted to determine whether this may be attributable to excessive breast tissue removal during initial BCS. METHODS A retrospective study analyzed referrals to the authors' cancer center during 3 years. Patients undergoing initial BCS for ductal carcinoma in situ or T1-T3 breast cancers were included. Patient age, tumor factors, surgeon case volume, and the calculated resection ratio (CRR) were analyzed. The total resection volume was divided by the optimal resection volume to produce the CRR, which reflected the magnitude of excess tissue resected during initial BCS. Comparison of the mean CRR between surgeon case-volume categories was performed with a repeated measures analysis of variance. A multivariate regression model assessed the effects of the CRR and surgeon case volume on re-excision rates. RESULTS Larger tumor size, lobular histology, and lower CRR were associated with increased re-excision rates. The CRR was similar for each surgeon case-volume group. Surgeon case volume was not independently associated with re-excision rates, but surgeons with very high case volumes had lower odds of re-excision than surgeons with intermediate case volumes (odds ratio 0.44; 95% confidence interval 0.21-0.91). CONCLUSIONS When control was used for the CRR, apparent differences in re-excision rates between surgeon case-volume groups were observed, suggesting that surgeons with higher case volumes may be more accurate when performing BCS.
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Affiliation(s)
| | - Lauren Hughes
- Southern Medical Program, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Brendan Bakos
- Cancer Surveillance and Outcomes, BC Cancer, Vancouver, BC, Canada
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17
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Lesniak DM, Clough KB, Killelea BK. Revisiting the modern toolkit to optimize breast conservation surgery. Gland Surg 2020; 9:478-480. [PMID: 32420278 DOI: 10.21037/gs.2020.01.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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18
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Schwarz J, Schmidt H. Technology for Intraoperative Margin Assessment in Breast Cancer. Ann Surg Oncol 2020; 27:2278-2287. [PMID: 32350717 DOI: 10.1245/s10434-020-08483-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND As breast-conserving surgery (BCS) has become standard for treatment of breast cancer, the need for new technology to improve intraoperative margin assessment (IMA) has become clear. Close or positive margins during BCS lead to additional surgeries, treatment delay, additional stress for patients, and healthcare cost. Academia and industry have developed a diverse field of new technologies to allow surgeons to assess margins in the operating room. These technologies aim to reduce current rates of positive margins on final pathology. METHODS We selected recently developed IMA technologies, some of which have undergone large clinical trials and others that are still in early stage development. Technologies were categorized based on underlying methodology to differentiate malignant and normal tissue: spectroscopy, electrical properties, optical imaging and molecular imaging. Additionally, this review details clinical investigations, relevant statistical analysis as well as strengths and weaknesses of the various technologies. CONCLUSION Numerous technical innovations are being implemented to diminish rates of positive margins at breast tumor resection. Close collaboration among cross-disciplinary teams to further develop many of these technologies as well as completion of larger scale clinical studies are required to define an optimal approach. Development with an eye toward prioritizing sensitivity/specificity as well as healthcare cost containment has the potential to make a significant impact on this ongoing clinical need in breast cancer surgery.
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Affiliation(s)
- Julia Schwarz
- Dubin Breast Center, Tisch Cancer Institute, New York, USA.,Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Breast Surgical Oncology, The Mount Sinai Hospital, New York, NY, USA
| | - Hank Schmidt
- Dubin Breast Center, Tisch Cancer Institute, New York, USA. .,Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Breast Surgical Oncology, The Mount Sinai Hospital, New York, NY, USA.
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19
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Eaglehouse YL, Georg MW, Jatoi I, Shriver CD, Zhu K. Factors related to re-excision procedures following primary breast-conserving surgery for women with breast cancer in the U.S. Military Health System. J Surg Oncol 2020; 121:200-209. [PMID: 31784990 DOI: 10.1002/jso.25788] [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: 09/03/2019] [Accepted: 11/17/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Re-excision surgery is undertaken to obtain clear margins after breast-conserving surgery (BCS) for localized breast cancer. This study examines patient and tumor characteristics related to re-excision surgery in the universal-access Military Health System (MHS). METHODS Retrospective analysis of patients with pathologically confirmed stage I-III breast cancer between 1998 and 2014 in the Department of Defense Central Cancer Registry and MHS Data Repository-linked databases who received primary BCS. Multivariable stepwise logistic regression methods identified characteristics associated with re-excision surgery (lumpectomy and mastectomy) and conversion to mastectomy, given as adjusted odds ratios (AOR) and 95% confidence intervals (CIs). RESULTS Of 7637 women receiving BCS, 26.3% had a re-excision and 9.9% converted to mastectomy. Tumor location, larger tumor size (≥4 cm), and regional lymph node involvement were associated with a greater likelihood of re-excision and mastectomy conversion. Pathology before BCS (AOR, 0.39; 95% CI, 0.35, 0.44 for re-excision) and neoadjuvant treatment (AOR, 0.50; 95% CI, 0.36, 0.69 for re-excision) were associated with a decreased likelihood of these outcomes. Additionally, age, tumor histology, and military-specific variables were associated with mastectomy conversion. CONCLUSION Comprehensive preoperative workup, including tumor pathology, may better inform surgical decision-making and reduce re-excision rates.
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Affiliation(s)
- Yvonne L Eaglehouse
- Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Matthew W Georg
- Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Ismail Jatoi
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Craig D Shriver
- Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Kangmin Zhu
- Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland.,Department of Preventive Medicine and Biostatistics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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20
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Landercasper J, Bennie B, Ahmad HF, Linebarger JH. Opportunities to reduce reoperations and to improve inter-facility profiling after initial breast-conserving surgery for cancer. A report from the NCDB. Eur J Surg Oncol 2019; 45:2026-2036. [DOI: 10.1016/j.ejso.2019.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/24/2019] [Accepted: 07/02/2019] [Indexed: 12/21/2022] Open
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21
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de Boer LL, Kho E, Jóźwiak K, Van de Vijver KK, Vrancken Peeters MJTFD, van Duijnhoven F, Hendriks BHW, Sterenborg HJCM, Ruers TJM. Influence of neoadjuvant chemotherapy on diffuse reflectance spectra of tissue in breast surgery specimens. JOURNAL OF BIOMEDICAL OPTICS 2019; 24:115004. [PMCID: PMC7003145 DOI: 10.1117/1.jbo.24.11.115004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/04/2019] [Indexed: 05/28/2023]
Abstract
Diffuse reflectance spectroscopy (DRS) can discriminate different tissue types based on optical characteristics. Since this technology has the ability to detect tumor tissue, several groups have proposed to use DRS for margin assessment during breast-conserving surgery for breast cancer. Nowadays, an increasing number of patients with breast cancer are being treated by neoadjuvant chemotherapy. Limited research has been published on the influence of neoadjuvant chemotherapy on the optical characteristics of the tissue. Hence, it is unclear whether margin assessment based on DRS is feasible in this specific group of patients. We investigate whether there is an effect of neoadjuvant chemotherapy on optical measurements of breast tissue. To this end, DRS measurements were performed on 92 ex-vivo breast specimens from 92 patients, treated with neoadjuvant chemotherapy and without neoadjuvant chemotherapy. Generalized estimating equation (GEE) models were generated, comparing the measurements of patients with and without neoadjuvant chemotherapy in datasets of different tissue types using a significance level of 5%. As input for the GEE models, either the intensity at a specific wavelength or a fit parameter, derived from the spectrum, was used. In the evaluation of the intensity, no influence of neoadjuvant chemotherapy was found, since none of the wavelengths were significantly different between the measurements with and the measurements without neoadjuvant chemotherapy in any of the datasets. These results were confirmed by the analysis of the fit parameters, which showed a significant difference for the amount of collagen in only one dataset. All other fit parameters were not significant for any of the datasets. These findings may indicate that assessment of the resection margin with DRS is also feasible in the growing population of breast cancer patients who receive neoadjuvant chemotherapy. However, it is possible that we did not detect neoadjuvant chemotherapy effect in the some of the datasets due to the small number of measurements in those datasets.
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Affiliation(s)
- Lisanne L. de Boer
- The Netherlands Cancer Institute, Department of Surgery, Amsterdam, The Netherlands
| | - Esther Kho
- The Netherlands Cancer Institute, Department of Surgery, Amsterdam, The Netherlands
| | - Katarzyna Jóźwiak
- The Netherlands Cancer Institute, Department of Epidemiology and Biostatistics, The Netherlands
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Koen K. Van de Vijver
- The Netherlands Cancer Institute, Department of Pathology, Amsterdam, The Netherlands
- Ghent University Hospital, Department of Pathology, Gent, Belgium
| | | | | | - Benno H. W. Hendriks
- Philips Research, Eindhoven, The Netherlands
- Delft University of Technology, Biomechanical Engineering Department, Delft, The Netherlands
| | - Henricus J. C. M. Sterenborg
- The Netherlands Cancer Institute, Department of Surgery, Amsterdam, The Netherlands
- Amsterdam University Medical Center, Department of Biomedical Engineering and Physics, Amsterdam, The Netherlands
| | - Theo J. M. Ruers
- The Netherlands Cancer Institute, Department of Surgery, Amsterdam, The Netherlands
- University of Twente, TNW, Technical Medical Centre, Enschede, The Netherlands
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22
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Landercasper J, Borgert AJ, Fayanju OM, Cody H, Feldman S, Greenberg C, Linebarger J, Pockaj B, Wilke L. Factors Associated with Reoperation in Breast-Conserving Surgery for Cancer: A Prospective Study of American Society of Breast Surgeon Members. Ann Surg Oncol 2019; 26:3321-3336. [PMID: 31342360 PMCID: PMC6733824 DOI: 10.1245/s10434-019-07547-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Indexed: 11/18/2022]
Abstract
Background More than 20% of patients undergoing initial breast-conserving surgery (BCS) for cancer require reoperation. To address this concern, the American Society of Breast Surgeons (ASBrS) endorsed 10 processes of care (tools) in 2015 to be considered by surgeons to de-escalate reoperations. In a planned follow-up, we sought to determine which tools were associated with fewer reoperations. Methods A cohort of ASBrS member surgeons prospectively entered data into the ASBrS Mastery® registry on consecutive patients undergoing BCS in 2017. The association between tools and reoperations was estimated via multivariate and hierarchical ranking analyses. Results Seventy-one surgeons reported reoperations in 486 (12.3%) of 3954 cases (mean 12.7% [standard deviation (SD) 7.7%], median 11.5% [range 0–32%]). There was an eightfold difference between surgeons in the 10th and 90th percentile performance groups. Actionable factors associated with fewer reoperations included routine planned cavity side-wall shaves, surgeon use of ultrasound (US), neoadjuvant chemotherapy, intra-operative pathologic margin assessment, and use of a pre-operative diagnostic imaging modality beyond conventional 2D mammography. For patients with invasive cancer, ≥ 24% of those who underwent reexcision did so for reported margins of < 1 or 2 mm, representing noncompliance with the SSO-ASTRO margin guideline. Conclusions Although ASBrS member surgeons had some of the lowest rates of reoperation reported in any registry, significant intersurgeon variability persisted. Further efforts to lower rates are therefore warranted. Opportunities to do so were identified by adopting those processes of care, including improved compliance with the SSO-ASTRO margin guideline, which were associated with fewer reoperations.
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Affiliation(s)
- Jeffrey Landercasper
- Norma J. Vinger Center for Breast Cancer, Gundersen Health System, La Crosse, WI, USA. .,Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, 54601, USA.
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, 54601, USA
| | | | - Hiram Cody
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sheldon Feldman
- Montefiore Einstein Center for Cancer Care, Montefiore Medical Center, Bronx, NY, USA
| | - Caprice Greenberg
- University of Wisconsin School of Public Health and Medicine, Madison, WI, USA
| | - Jared Linebarger
- Norma J. Vinger Center for Breast Cancer, Gundersen Health System, La Crosse, WI, USA.,Department of Surgery, Gundersen Health System, La Crosse, WI, USA
| | | | - Lee Wilke
- University of Wisconsin School of Public Health and Medicine, Madison, WI, USA
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23
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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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24
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Resection margins and local recurrences in breast cancer: Comparison between conventional and oncoplastic breast conserving surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2019; 45:976-982. [PMID: 30795953 DOI: 10.1016/j.ejso.2019.02.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/11/2019] [Accepted: 02/06/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND This retrospective cohort study aims to compare surgical margins, reoperations and local recurrences after conventional or oncoplastic breast conservation surgery (BCS). Furthermore, we aim to investigate differences between various oncoplastic techniques. MATERIAL AND METHODS We reviewed 1800 consecutive patients with primary invasive breast cancer (N = 1707) or ductal carcinoma in situ (N = 93) who underwent BCS at Helsinki University Hospital between 2010 and 2012. RESULTS Conventional BCS was performed in 1189 (66.1%) patients, oncoplastic BCS in 611 (33.9%). Various oncoplastic techniques were used. Patients with oncoplastic BCS had more often multifocal (p < 0.001), larger (p < 0.001), palpable tumours (p < 0.001) with larger resection specimens (p < 0.001). The amount of resected tissue varied substantially depending on the oncoplastic technique. Patients treated with oncoplastic BCS were younger (p < 0.001) and their tumours were more aggressive according to histological grade (p < 0.001), T-stage (p < 0.001), Ki-67 (p < 0.001) and lymph node status (p < 0.001). There was no difference, however, in surgical margins (p = 0.578) or reoperation rates (p = 0.430) between the groups. A total of 152 (8.4%) patients were reoperated because of insufficient margins, 96 (8.1%) in the conventional, 56 (9.2%) in the oncoplastic BCS group. The median follow-up time was 75 (2-94) months. There was no difference in local recurrence-free survival between the conventional and oncoplastic BCS groups (log-rank test, p = 0.172). CONCLUSIONS Oncoplastic BCS was used for larger, multifocal and more aggressive tumours. Nevertheless, no difference in reoperation rate or local recurrences were found. Oncoplastic BCS is as safe as conventional BCS enabling breast conserving for patients who otherwise were candidates for mastectomy.
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