Does Preoperative MRI Reduce Positive Margins after Breast-Conserving Surgery?

Identifying Factors Predicting Margin Status After Mastectomy

INTRODUCTION

A positive margin after mastectomy increases the risk of breast cancer recurrence and the morbidity associated with re-excision or chest wall irradiation. This study aimed to identify factors that may predict margin status after mastectomy.

METHODS

Women with Tis-T3 breast cancers who underwent mastectomy from 2014 to 2020 were retrospectively analyzed. Comparisons of clinicopathologic data were made between patients with negative margins (> 1 mm) and close (≤ 1 mm) or positive margins.

RESULTS

Of 938 women who underwent mastectomy, negative margins were reported for 794 (85%) women, while 144 (15%) women experienced close (97/144, 10%) or positive (47/144, 5%) margins. Re-excision of margins was performed in 37 (26%) of those patients, and 9 (24%) had residual cancer after re-excision. On multivariate analysis, increasing age (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.96-0.99, p = 0.002), increased body mass index (BMI; OR 0.97, 95% CI 0.93-1.00, p = 0.049), and neoadjuvant chemotherapy (NAC; OR 0.44, 95% CI 0.25-0.79, p = 0.006) decreased the risk of close or positive margins. Tumors located in the lower inner quadrant (OR 3.83, 95% CI 1.90-7.72, p < 0.001), multifocal tumors (OR 1.78, 95% CI 1.19-2.66, p = 0.005), immediate reconstruction (OR 1.63, 95% CI 1.03-2.58, p = 0.039), and a preoperative tumor to breast volume ratio > 4.14 (OR 2.66, 95% CI 1.43-4.94, p = 0.002) significantly increased the risk of close or positive margins.

CONCLUSIONS

Age, BMI, tumor location, multifocality, NAC, immediate reconstruction, and tumor to breast volume ratio independently predicted margin status after mastectomy. These data should be considered when counseling women considering mastectomy.

A comparative study of learning curves among general surgery residents for intraoperative ultrasound-guided breast-conserving surgery

Breast-conserving surgery (BCS) followed by radiotherapy is preferred for early-stage breast cancer because its survival rate is equivalent to that of mastectomy. Achieving negative surgical margins in BCS is crucial to minimize the risk of recurrence. Intraoperative ultrasound (IOUS) enhances surgical accuracy, but its efficacy is operator dependent. This study aimed to compare the success of achieving negative margins using IOUS between an experienced breast surgeon and general surgical residents and to evaluate the learning curve for the residents. A prospective study involving 96 patients with BCS who underwent IOUS guidance was conducted. Both the breast surgeon and residents assessed the surgical margins using IOUS, with the breast surgeon making the final margin adequacy decision. Permanent histopathological analysis was used to confirm the status of the margins and was considered the gold standard for comparison. The breast surgeon accurately assessed the margin status in all 96 cases (100% accuracy), with 93 negative and three positive margins. All of these were ductal carcinomas in situ. Initially, the residents demonstrated low accuracy rates in predicting margin positivity using intraoperative ultrasonography. However, the learning curves of the three residents demonstrated that, with an average 12th case onwards, a significant improvement in the cumulative accuracy rates was observed, which reached the level of the breast surgeon. IOUS is an effective tool for accurately predicting the margin status in BCS, with an acceptable learning curve for novice surgeons. Training and experience are pivotal for optimizing surgical outcomes. These findings support the integration of IOUS training into surgical education programs to enhance proficiency and improve patient outcomes.

[Updated surgical indications and quality and safety indicators in the management of infiltrative breast carcinoma]

OBJECTIVES

Breast surgery is the cornerstone of breast cancer treatment. Its indications and procedures are constantly evolving. To update best practices, four questions were submitted to the Senology Commission (SC) of the Collège national des gynécologues et obstétriciens français (CNGOF), covering the indications and modalities of tumor surgery: (1) initially, (2) following neoadjuvant systemic treatment, (3) in case of local recurrence, and (4) the quality and safety of care indicators applicable to this surgery.

METHODS

The CNGOF SC essentially based its responses on the clinical practice recommendations and guidelines of the French Cancer Institute concerning invasive carcinomas of the breast. Exclusion criteria were carcinoma in situ, sarcoma and axillary surgery.

RESULTS

To define the type of breast surgery, knowledge of four parameters is essential: the patient's level of risk, the presence of metastases, the size of the breast tumor and its focality (assessed by the clinical/mammography/ultrasound tripod). (1) In the case of initial management, the 6 indications for mastectomy are patient choice (particularly in case of high risk), contraindication to radiotherapy, inflammatory cancer (T4d), surgery with positive margins (after several surgical intervention), surgery that cannot be performed as a monobloc in the case of tumors with multiple foci, and poor expected aesthetic results. All other situations should be treated conservatively. (2) The same criteria apply after neoadjuvant systemic treatment, with conservative treatment still possible whatever the size (excluding carcinomatous mastitis) and focality of the initial tumor. (3) In case of local recurrence, total mastectomy is the reference treatment, with a second conservative treatment reserved for patients with no risk factors for a second recurrence, and no poor prognostic factors, after validation in a multidisciplinary meeting. (4) Four quality and safety indicators apply to breast surgery: it must be performed after obtaining a histological diagnosis, within less than 6 weeks of mammography, in a single surgery in over 80% of cases, and followed by local radiotherapy in the case of conservative treatment.

CONCLUSION

The indications and modalities of breast surgery are evolving rapidly. To improve aesthetic results, oncoplastic techniques, immediate breast reconstruction, and preservation of the skin or nipple-areolar complex need to be further developed and evaluated in the long-term. These developments must necessarily be accompanied in France by a training policy for breast surgeons.