Predictors of local recurrence after breast-conservation therapy

Residual Risk of Ipsilateral Tumor Recurrence in Patients Who Achieved Clear Lumpectomy Margins After Repeated Resection

PURPOSE

Patients with breast cancer with positive lumpectomy margins have a two-fold increased risk of ipsilateral breast tumor recurrence (IBTR). This can be the result of either technically incomplete resection or the biological characteristics of the tumor that lead to a positive margin. We hypothesized that if achieving negative margins by re-excision nullifies the IBTR risk, then the increased risk is mainly attributed to the technical incompleteness of the initial surgeries. Thus, we investigated IBTR rates in patients with breast cancer who achieved clear margins after re-excision.

METHODS

We retrospectively reviewed patients who underwent breast lumpectomy for invasive breast cancer between 2004 and 2018 at a single institution, and investigated IBTR events.

RESULTS

Among 5,598 patients, 793 achieved clear margins after re-excision of their initial positive margins. During the median follow-up period of 76.4 months, 121 (2.2%) patients experienced IBTR. Patients who underwent re-excision to achieve negative margin experienced significantly higher IBTR rates compared to those achieving clear margin at first lumpectomy (10-year IBTR rate: 5.3% vs. 2.6% [25 vs. 84 events]; unadjusted p = 0.031, hazard ratio, 1.61, 95% confidence interval [CI], 1.04-2.48; adjusted p = 0.030, hazard ratio, 1.69, 95% CI, 1.05-2.72). This difference was more evident in patients aged < 50 years and those with delayed IBTR. Additionally, no statistically significant differences were observed in the spatial distribution of IBTR locations.

CONCLUSION

Patients who underwent re-excision for initial positive margins had an increased risk of IBTR, even after achieving a final negative margin, compared to patients with negative margins initially. This increased risk of IBTR is mostly observed in young patients and delayed cases.

Conventional specimen radiography in breast-conserving therapy: a useful tool for intraoperative margin assessment after neoadjuvant therapy?

PURPOSE

A previous study in our breast unit showed that the diagnostic accuracy of intraoperative specimen radiography and its potential to reduce second surgeries in a cohort of patients treated with neoadjuvant chemotherapy were low, which questions the routine use of Conventional specimen radiography (CSR) in this patient group. This is a follow-up study in a larger cohort to further evaluate these findings.

METHODS

This retrospective study included 376 cases receiving breast-conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) of primary breast cancer. CSR was performed to assess potential margin infiltration and recommend an intraoperative re-excision of any radiologically positive margin. The histological workup of the specimen served as gold standard for the evaluation of the accuracy of CSR and the potential reduction of second surgeries by CSR-guided re-excisions.

RESULTS

362 patients with 2172 margins were assessed. The prevalence of positive margins was 102/2172 (4.7%). CSR had a sensitivity of 37.3%, a specificity of 85.6%, a positive predictive value (PPV) of 11.3%, and a negative predictive value (NPV) of 96.5%. The rate of secondary procedures was reduced from 75 to 37 with a number needed to treat (NNT) of CSR-guided intraoperative re-excisions of 10. In the subgroup of patients with clinical complete response (cCR), the prevalence of positive margins was 38/1002 (3.8%), PPV was 6.5% and the NNT was 34.

CONCLUSION

This study confirms our previous finding that the rate of secondary surgeries cannot be significantly reduced by CSR-guided intraoperative re-excisions in cases with cCR after NACT. The routine use CSR after NACT is questionable, and alternative tools of intraoperative margin assessment should be evaluated.

Toward Intraoperative Margin Assessment Using a Deep Learning-Based Approach for Automatic Tumor Segmentation in Breast Lumpectomy Ultrasound Images

There is an unmet clinical need for an accurate, rapid and reliable tool for margin assessment during breast-conserving surgeries. Ultrasound offers the potential for a rapid, reproducible, and non-invasive method to assess margins. However, it is challenged by certain drawbacks, including a low signal-to-noise ratio, artifacts, and the need for experience with the acquirement and interpretation of images. A possible solution might be computer-aided ultrasound evaluation. In this study, we have developed new ensemble approaches for automated breast tumor segmentation. The ensemble approaches to predict positive and close margins (distance from tumor to margin ≤ 2.0 mm) in the ultrasound images were based on 8 pre-trained deep neural networks. The best optimum ensemble approach for segmentation attained a median Dice score of 0.88 on our data set. Furthermore, utilizing the segmentation results we were able to achieve a sensitivity of 96% and a specificity of 76% for predicting a close margin when compared to histology results. The promising results demonstrate the capability of AI-based ultrasound imaging as an intraoperative surgical margin assessment tool during breast-conserving surgery.

Effect of three-dimensional intraoperative imaging on surgical outcomes with breast conservation therapy

BACKGROUND

Breast conservation therapy (BCT) is frequently performed for breast cancer and associated with a significant risk for positive margins. Intraoperative three-dimensional (3-D) tomosynthesis potentially could limit the risk of positive margins.

METHODS

Retrospective review of an institutional breast cancer registry. Evaluated BCT cases for a two year time period prior to and after the introduction of intraoperative 3-D tomosynthesis. Primary outcome was the effect of 3-D tomosynthesis on margin positivity rates. Secondary measures were the impact of 3-D tomosynthesis on additional margin procurements at the index surgery and operative time.

RESULTS

A total of 228 cases were evaluated with 106 cases utilizing 3-D tomosynthesis and 122 cases with standard imaging. No significant difference in margin positivity rates between the cohorts at 23.9% versus 15.8% for 3-D tomosynthesis and standard imaging respectively (OR 1.53, CI 0.772-3.032, P = 0.221). 3-D tomosynthesis was associated with increased margin procurement rates (OR 2.34, 95%CI 1.303-4.190, P = 0.004) and longer operative times (P < 0.001).

CONCLUSION

Intraoperative 3-D tomosynthesis was not found to limit margin positivity rates or improve the performance of the procedure.

Quantitative tumor depth determination using dual wavelength excitation fluorescence

Quantifying solid tumor margins with fluorescence-guided surgery approaches is a challenge, particularly when using near infrared (NIR) wavelengths due to increased penetration depths. An NIR dual wavelength excitation fluorescence (DWEF) approach was developed that capitalizes on the wavelength-dependent attenuation of light in tissue to determine fluorophore depth. A portable dual wavelength excitation fluorescence imaging system was built and tested in parallel with an NIR tumor-targeting fluorophore in tissue mimicking phantoms, chicken tissue, and in vivo mouse models of breast cancer. The system showed high accuracy in all experiments. The low cost and simplicity of this approach make it ideal for clinical use.

Trends in surgery and adjuvant treatment for early-stage breast cancer: a population-based study in Queensland, Australia

PURPOSE

Our aim was to describe variations in the treatment of early-stage breast cancer and to examine factors associated with disease-specific survival (DSS).

METHODS

The study used linked data for 24,190 women with a T1 (≤ 20 mm) breast cancer who underwent surgery from 2005 to 2019. Multivariate logistic regression was used to model predictors of receiving breast-conserving surgery (BCS) compared to mastectomy and a multinomial model was used to examine factors associated with type(s) of treatment received.

RESULTS

Overall, 70.3% had BCS, with a reduced likelihood of BCS observed for younger women (p < 0.001), rural residence, (p < 0.001), socioeconomic disadvantage (p = 0.004), higher tumour grade (p < 0.001) and surgery in a public versus private hospital (p < 0.001). Compared to women who received BCS and radiation therapy (RT), those having mastectomy alone or mastectomy plus RT were more likely to be younger (p < 0.001), live in a rural area (p < 0.001), have higher-grade tumours (p < 0.001) and positive lymph nodes (p < 0.001). Overall 5-year survival was 95.3% and breast cancer-specific survival was 98.3%. Highest survival was observed for women having BCS and RT and lowest for those having mastectomy and RT (p < 0.001).

CONCLUSION

Our results indicate some variation in the management of early-stage breast cancer. Lower rates of BCS were observed for rural and disadvantaged women and for those treated in a public or low-volume hospital. Whilst survival was high for this cohort, differences in tumour biology likely explain the differences in survival according to treatment type.

Does conventional specimen radiography after neoadjuvant chemotherapy of breast cancer help to reduce the rate of second surgeries?

Purpose

This is the first study to systematically evaluate the diagnostic accuracy of intraoperative specimen radiography on margin level and its potential to reduce second surgeries in patients treated with neoadjuvant chemotherapy.

Methods

This retrospective study included 174 cases receiving breast conserving surgery (BCS) after neoadjuvant chemotherapy (NACT) of primary breast cancer. Conventional specimen radiography (CSR) was performed to assess potential margin infiltration and recommend an intraoperative re-excision of any radiologically positive margin. The histological workup of the specimen served as gold standard for the evaluation of the accuracy of CSR and the potential reduction of second surgeries by CSR-guided re-excisions.

Results

1044 margins were assessed. Of 47 (4.5%) histopathological positive margins, CSR identified 9 correctly (true positive). 38 infiltrated margins were missed (false negative). This resulted in a sensitivity of 19.2%, a specificity of 89.2%, a positive predictive value (PPV) of 7.7%, and a negative predictive value (NPV) of 95.9%. The rate of secondary procedures was reduced from 23 to 16 with a number needed to treat (NNT) of CSR-guided intraoperative re-excisions of 25.

In the subgroup of patients with cCR, the prevalence of positive margins was 10/510 (2.0%), PPV was 1.9%, and the NNT was 85.

Conclusion

Positive margins after NACT are rare and CSR has only a low sensitivity to detect them. Thus, the rate of secondary surgeries cannot be significantly reduced by recommending targeted re-excisions, especially in cases with cCR. In summary, CSR after NACT is inadequate for intraoperative margin assessment but remains useful to document removal of the biopsy site clip.

Concept for using magnetic particle imaging for intraoperative margin analysis in breast-conserving surgery

Breast-conserving surgery (BCS) is a commonly utilized treatment for early stage breast cancers but has relatively high reexcision rates due to post-surgical identification of positive margins. A fast, specific, sensitive, easy-to-use tool for assessing margins intraoperatively could reduce the need for additional surgeries, and while many techniques have been explored, the clinical need is still unmet. We assess the potential of Magnetic Particle Imaging (MPI) for intraoperative margin assessment in BCS, using a passively or actively tumor-targeted iron oxide agent and two hardware devices: a hand-held Magnetic Particle detector for identifying residual tumor in the breast, and a small-bore MPI scanner for quickly imaging the tumor distribution in the excised specimen. Here, we present both hardware systems and demonstrate proof-of-concept detection and imaging of clinically relevant phantoms.

Evaluating optical coherence tomography for surgical margin assessment of canine mammary tumours

Optical coherence tomography (OCT) uses near-infrared light waves to generate real-time, high-resolution images on the microscopic scale similar to low power histopathology. Previous studies have demonstrated the use of OCT for real-time surgical margin assessment for human breast cancer. The use of OCT for canine mammary tumours (CMT) could allow intra-operative visualisation of residual tumour at the surgical margins. The purpose of this study was to assess OCT imaging for the detection of incomplete tumour resection following CMT surgery. We hypothesized that the OCT images would have comparable features to histopathological images of tissues at the surgical margins of CMT resections along with a high sensitivity of OCT detection of incomplete surgical excision of CMT. Thirty surgical specimens were obtained from nineteen client-owned dogs undergoing surgical resection of CMT. OCT image appearance and characteristics of adipose tissue, skin, mammary tissue and mammary tumour at the surgical margins were distinct and different. The OCT images of normal and abnormal tissues at the surgical margins were utilized to develop a dataset of OCT images for observer evaluation. The sensitivity and specificity for ex vivo images were 83.3% and 82.0% (observer 1) and 70.0% and 67.9% (observer 2). The sensitivity and specificity for in vivo images were 70.0% and 89.3% (observer 1) and 76.7% and 67.9% (observer 2). These results indicate a potential use of OCT for surgical margin assessment for CMT to optimize surgical intervention and clinical outcomes. Improved training and experience of observers may improve sensitivity and specificity.

Multimodal image-guided surgery of HER2-positive breast cancer using [111In]In-DTPA-trastuzumab-IRDye800CW in an orthotopic breast tumor model

Background

Combining modalities using dual-labeled antibodies may allow preoperative and intraoperative tumor localization and could be used in image-guided surgery to improve complete tumor resection. Trastuzumab is a monoclonal antibody against the human epidermal growth factor-2 (HER2) receptor and dual-labeled trastuzumab with both a fluorophore (IRDye800CW) and a radioactive label (¹¹¹In) can be used for multimodal imaging of HER2-positive breast cancer. The aim of this study was to demonstrate the feasibility of HER2-targeted multimodal imaging using [¹¹¹In]In-DTPA-trastuzumab-IRDye800CW in an orthotopic breast cancer model.

Methods

Trastuzumab was conjugated with p-isothiocyanatobenzyl (ITC)-diethylenetriaminepentaacetic acid (DTPA) and IRDye800CW-NHS ester and subsequently labeled with ¹¹¹In. In a dose escalation study, the biodistribution of 10, 30, and 100 μg [¹¹¹In]In-DTPA-trastuzumab-IRDye800CW was determined 48 h after injection in BALB/c nude mice with orthotopic high HER2-expressing tumors. Also, a biodistribution study was performed in a low HER2-expressing breast cancer model. In addition, multimodal image-guided surgery was performed in each group. Autoradiography, fluorescence microscopy, and immunohistochemically stained slices of the tumors were compared for co-localization of tumor tissue, HER2 expression, fluorescence, and radiosignal.

Results

Based on the biodistribution data, a 30 μg dose of dual-labeled trastuzumab (tumor-to-blood ratio 13 ± 2) was chosen for all subsequent studies. [¹¹¹In]In-DTPA-trastuzumab-IRDye800CW specifically accumulated in orthotopic HER2-positive BT474 tumors (101 ± 7 %IA/g), whereas uptake in orthotopic low HER2-expressing MCF7 tumor was significantly lower (1.2 ± 0.2 %IA/g, p = 0.007). BT474 tumors could clearly be visualized with both micro-SPECT/CT, fluorescence imaging and subsequently, image-guided resection was performed. Immunohistochemical analyses of BT474 tumors demonstrated correspondence in fluorescence, radiosignal, and high HER2 expression.

Conclusions

Dual-labeled trastuzumab showed specific accumulation in orthotopic HER2-positive BT474 breast tumors with micro-SPECT/CT and fluorescence imaging and enabled image-guided tumor resection. In the clinical setting, [¹¹¹In]In-DTPA-trastuzumab-IRDye800CW could be valuable for preoperative detection of (metastatic) tumors by SPECT/CT imaging, and intraoperative localization by using a gamma probe and fluorescence image-guided surgery to improve radical resection of tumor tissue in patients with HER2-positive tumors.

Intraoperative inking is superior to suture marking for specimen orientation in breast cancer

Margin status is an important indicator of residual disease after breast-conserving surgery (BCS). Intraoperatively, surgeons orient specimens to aid assessment of margins and guide re-excision of positive margins. We performed a retrospective review of BCS cases from 2013 to 2017 to compare the two specimen orientation methods: suture marking and intraoperative inking. Patients with ductal carcinoma in situ, T1/T2 invasive cancer treated with BCS were included. Rates of positive margins and residual disease at re-excision were evaluated. 189 patients underwent BCS; 83 had suture marking, 103 had intraoperative inking and 3 had un-oriented specimens. The incidence of positive margins was 29% (24 patients) in the suture marked group and 20% (21 patients) in the intraoperative inked group (P = .18). Among the 45 patients with positive margins, 60% of tumors were stage T1, 76% were node negative, 36% were palpable with median tumor size of 1.5 cm. Residual disease was identified on re-excision in 21% of the suture marked specimens and 57% of intraoperative inked specimens (P = .028). The incidence of residual cancer at re-excision for positive margins was higher for intraoperatively inked versus suture marked specimens. This finding suggests that intraoperative inking is more effective at guiding re-excision of positive margins.

Rapid pathology of lumpectomy margins with open-top light-sheet (OTLS) microscopy

Open-top light-sheet microscopy is a technique that can potentially enable rapid ex vivo inspection of large tissue surfaces and volumes. Here, we have optimized an open-top light-sheet (OTLS) microscope and image-processing workflow for the comprehensive examination of surgical margin surfaces, and have also developed a novel fluorescent analog of H&E staining that is robust for staining fresh unfixed tissues. Our tissue-staining method can be achieved within 2.5 minutes followed by OTLS microscopy of lumpectomy surfaces at a rate of up to 1.5 cm2/minute. An image atlas is presented to show that OTLS image quality surpasses that of intraoperative frozen sectioning and can approximate that of gold-standard H&E histology of formalin-fixed paraffin-embedded (FFPE) tissues. Qualitative evidence indicates that these intraoperative methods do not interfere with downstream post-operative H&E histology and immunohistochemistry. These results should facilitate the translation of OTLS microscopy for intraoperative guidance of lumpectomy and other surgical oncology procedures.

Breast-conserving therapy for breast carcinoma: Margins, re-excision and recurrence rates

Background: Breast-conserving therapy (BCT) is a wide local excision of the tumour usually followed by radiation treatment to the breast. It is the mainstay treatment for carefully selected patients with early breast cancer. There has not been a formal audit to review BCT outcomes in our unit.Objectives: To determine excision margins, re-excision and local recurrence rates.Methods: A histopathological and oncology records’ review of BCT patients from 01 January 2006 to 31 December 2010. The health faculty’s ethics committee granted approval. Data points accrued included age, histological tumour size, nodal status, tumour type, oestrogen receptor status, lymphovascular invasion, volume of specimen, margin status, management of involved or close margins, radiotherapy, ipsilateral breast recurrence rate and duration of follow-up.Results: A total of 192 patients had BCT. The mean age is 53 years. A median of 229.5 cm3 volume of specimen was excised. Infiltrating ductal carcinoma was the commonest histological type at 79.1%. The resection margin status: positive margins rate 15.1%, close margin rate 8.3% (≤ 1 mm), 35.9% (1 mm–5 mm), 23.4% (6 mm–10 mm) and 17.2% (> 10 mm). Overall, 27 (14.0%) patients underwent a second procedure, 16 (8.3%) patients had re-excision and 10 (5.2%) patients had a mastectomy. At a median follow-up of 60 months, a total of 11 (6.8%) patients had recurrence. Median time to recurrence is 39 months.Conclusion: Positive and close margin re-excision and local recurrence rates in our unit are acceptable and comparable to other units in South Africa and internationally.

Evaluating feasibility of an automated 3-dimensional scanner using Raman spectroscopy for intraoperative breast margin assessment

Breast conserving surgery is the preferred treatment for women diagnosed with early stage invasive breast cancer. To ensure successful breast conserving surgeries, efficient tumour margin resection is required for minimizing tumour recurrence. Currently surgeons rely on touch preparation cytology or frozen section analysis to assess tumour margin status intraoperatively. These techniques have suboptimal accuracy and are time-consuming. Tumour margin status is eventually confirmed using postoperative histopathology that takes several days. Thus, there is a need for a real-time, accurate, automated guidance tool that can be used during tumour resection intraoperatively to assure complete tumour removal in a single procedure. In this paper, we evaluate feasibility of a 3-dimensional scanner that relies on Raman Spectroscopy to assess the entire margins of a resected specimen within clinically feasible time. We initially tested this device on a phantom sample that simulated positive tumour margins. This device first scans the margins of the sample and then depicts the margin status in relation to an automatically reconstructed image of the phantom sample. The device was further investigated on breast tissues excised from prophylactic mastectomy specimens. Our findings demonstrate immense potential of this device for automated breast tumour margin assessment to minimise repeat invasive surgeries.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Benchtop and Animal Validation of a Projective Imaging System for Potential Use in Intraoperative Surgical Guidance

We propose a projective navigation system for fluorescence imaging and image display in a natural mode of visual perception. The system consists of an excitation light source, a monochromatic charge coupled device (CCD) camera, a host computer, a projector, a proximity sensor and a Complementary metal-oxide-semiconductor (CMOS) camera. With perspective transformation and calibration, our surgical navigation system is able to achieve an overall imaging speed higher than 60 frames per second, with a latency of 330 ms, a spatial sensitivity better than 0.5 mm in both vertical and horizontal directions, and a projection bias less than 1 mm. The technical feasibility of image-guided surgery is demonstrated in both agar-agar gel phantoms and an ex vivo chicken breast model embedding Indocyanine Green (ICG). The biological utility of the system is demonstrated in vivo in a classic model of ICG hepatic metabolism. Our benchtop, ex vivo and in vivo experiments demonstrate the clinical potential for intraoperative delineation of disease margin and image-guided resection surgery.

Is a higher boost dose of radiation necessary after breast-conserving therapy for patients with breast cancer with final close or positive margins?

To determine rates of loco-regional recurrence (LRR), distant failure and overall survival for patients with breast cancer treated with breast-conserving therapy (BCT) with a close or positive surgical margin (C/PM) treated with standard dose boost radiation compared with a higher boost of radiation. We retrospectively studied 1476 patients with T1-T3 invasive breast cancer treated with BCT between 1992 and 2009. Median age was 57 years. Patients were divided into three groups: Group I included 1197 patients (81 %) with negative margins who received a standard boost (median 60 Gy) total dose to the lumpectomy cavity; Group II included 116 patients (8 %) with C/PM who received a standard boost (median 60 Gy); and Group III included 163 patients (11 %) with C/PM who received a higher boost (median 68 Gy). Biological subtypes (e.g., ER, PR, HER2/neu) were available for 858 patients (58 %) and were also assessed for any relationship to LRR rate. The Kaplan-Meier, Cox-regression, and log-rank tests were used to estimate rates of LRR and the significance of risk factors. Median follow-up was 8.6 years. The overall 5- and 10-year cumulative incidences of LRR were 2.1 % (95 % CI 0.8-2.1 %) and 4.5 % (95 % CI 3.4-6.0 %), respectively. The 5- and 10-year cumulative incidences of LRR for Group I (negative margins + standard boost) were 1.9 and 4.4 %; for Group II (C/PM + standard boost) were 3.9 and 7.0 %; and for Group III (C/PM + higher boost) were 2.9 and 3.8 %, respectively. No statistically significant differences in LRR rates were found among the three groups (p = 0.4). Similar results were obtained for distant failure (p = 0.3) and overall survival (p = 0.4). On multivariate analysis, tumor grade (p = 0.03), systemic-therapy (p = 0.005), node positivity (p = 0.05), young age (p = 0.001), and biological subtype (p = 0.04) were statistically significantly associated with higher LRR. Higher boost dose and margin positivity were not significant. Our data suggest that the 10-year risk of local recurrence for patients with close or positive margins receiving a standard boost was 7 % compared to 3.8 % for those receiving a higher boost; however, this difference was not significant. A higher boost dose did not significantly improve local control, nor did margins impact LRR risk in our cohort of patients.

Clinical features and prognosis of prostate cancer with high-grade prostatic intraepithelial neoplasia

Purpose

To evaluate the clinical features and biochemical recurrence (BCR) in prostate cancer (PCa) with high-grade prostatic intraepithelial neoplasia (HGPIN).

Materials and Methods

We retrospectively analyzed the medical records of 893 patients who underwent a radical prostatectomy for PCa between 2011 and 2012 at Asan Medical Center; 752 of these patients who did not receive neoadjuvant or adjuvant therapy and were followed up for more than 1 year were included. The cohort was divided into two groups-patients with and without HGPIN-and their characteristics were compared. The Cox proportional hazards model was used to analyze factors affecting BCR.

Results

In total, 652 study patients (86.7%) had HGPIN. There were no significant differences in preoperative factors between the two groups, including age (p=0.369) and preoperative prostate-specific antigen concentration (p=0.234). Patients with HGPIN had a higher Gleason score (p=0.012), more frequent multiple tumor (p=0.013), and more perineural invasion (p=0.012), but no other postoperative pathologic characteristics were significantly different between the two groups. There were no significant differences in BCR (13.0% vs. 11.5%, p=0.665) and HGPIN was not associated with BCR (p=0.745). In multivariate analysis, only the T stage (p<0.001) was associated with BCR.

Conclusions

PCa patients with HGPIN have a higher Gleason score, more frequent multiple tumors, and more perineural invasion than those without HGPIN. The presence of HGPIN is not an independent predictor of BCR.

Positive Margins After Oncoplastic Surgery for Breast Cancer

BACKGROUND

Oncoplastic techniques applied to breast-conserving surgery (BCS) allow large-volume resections without compromising cosmetic results. Level II oncoplastic techniques are based on mammoplasties. When required, they allow resection of more than 20 % of the breast volume; however, a subgroup of these patients will still have positive margins. The clinical management of positive margins after level II oncoplastic surgery (OPS) is a challenge.

METHODS

All patients who had undergone level II oncoplastic techniques at The Paris Breast Center between 2004 and 2013 were reviewed. The choice of the optimal mammoplasty technique was based on the tumor location and the 'quadrant per quadrant atlas'.

RESULTS

A total of 277 level II oncoplastic techniques were performed on 272 patients. The mean tumor size was 26 mm (range 2-160 mm), with a mean resected weight of 175 g (range 50-1540 g). The rate of positive margins was 11.9 %. Risk factors for positive margins identified in univariate analysis were histologic subgroup, tumor size, T stage and grade. In multivariate analysis, only patients with invasive lobular carcinoma had a significantly higher risk of positive margins. A second operation was required in 33 cases, and a third operation was required in three cases because of positive margins. Final breast conservation rate was 91 %.

CONCLUSIONS

Level II OPS results in a low positive margin rate despite large tumor size. Patients with involved margins can be offered a second BCS if the remaining volume allows this.

Mammographic and Ultrasonographic Findings of Oxidized Regenerated Cellulose in Breast Cancer Surgery: A 5-Year Experience

BACKGROUND

The purpose of this study was to describe the ultrasonographic (US) and mammographic (MX) findings in patients who underwent breast-conserving surgery followed by oxidized regenerated cellulose (ORC) implantation in the surgical cavity and their size variations in follow-up.

MATERIALS AND METHODS

We retrospectively reviewed 417 MX and 743 US images performed between January 2009 and January 2014 for 262 women who underwent breast-conserving surgery. All patients underwent US, only 203 women underwent MX examination.

RESULTS

In 170 of 262 patients, US examinations showed abnormal findings. Three main US patterns were identified: (1) complex masses: well-encapsulated ipoisoechoic lesions with circumscribed margins with internal hyperechoic nodules (56%); (2) hypoanechoic lesions without internal hyperechoic nodules (24%); and (3) completely anechoic collections (20%). Moreover, Doppler ultrasound examination was performed on all of the patients. In 95 of 203 patients, MX examinations showed abnormalities. Four main MX patterns were identified: (1) round or oval opacity with circumscribed margins (58%); (2) round or oval opacity with indistinct or ill-defined margins (17%); (3) irregular opacity with indistinct or spiculated margins (9%); and (4) architectural distortion or focal asymmetry (15%). Most of the lesions showed a decrease in size at US and MX follow-up examination and the decrease was statistically significant (P < .01).

CONCLUSION

When applied to the surgical residual cavity, ORC aids to control local hemorrhage and reduce the risk of postoperative infections, but can lead to alterations in surgical scar. Thus, knowledge of the radiological findings might allow avoidance of misdiagnosis of tumor recurrence or unnecessary diagnostic examinations.

Factors associated with the incidence of local recurrences of breast cancer in women who underwent conservative surgery

Conservative surgery is considered the procedure of choice for women who are affected by early stage tumours. The local recurrence of cancer as a consequence of breast tissue conservation is a growing concern. This study aimed to describe the sociodemographic and clinical profiles of women who had local recurrences of breast cancer after conservative surgery and to examine the associations between sociodemographic and clinical variables and the incidence of tumour recurrence in these women. The retrospective cohort included 880 women who were diagnosed with breast cancer and underwent conservative surgery between January 2000 and December 2010. Recurrences occurred in 60 patients, and the mean age of the women at diagnosis was 48.8 years. Predictive factors for local recurrence were young age (<39 years) (P = 0.028 and OR = 10.93), surgical margin involvement (P = 0.001 and OR = 3.66), and Her-2 overexpression (P = 0.045 and OR = 1.94). The establishment of sociodemographic and clinical characteristics might help to select optimum treatments, which is a crucial challenge for public health in Brazil, especially with regard to reductions of surgery and hospitalisation expenditures in the Unified Health System (Sistema Único de Saúde—SUS).

Is intraoperative frozen section analysis of reexcision specimens of value in preventing reoperation in breast-conserving therapy?

OBJECTIVES

A prior study at our institution showed a marked reduction in reoperation for margin reexcision following the development of an intraoperative frozen section evaluation of margins (FSM) practice on lumpectomy specimens from patients undergoing breast-conserving therapy (BCT). This study aimed to examine the frequency of FSM utilization, FSM pathology performance, and outcomes for BCT patients undergoing margin reexcision only.

METHODS

Consecutive reexcision-only specimens were reviewed from a 40-month period following the development of the FSM practice. Clinicopathologic features and patient outcomes were assessed.

RESULTS

FSM was performed in 46 (30.7%) of 150 reexcision-only operations. Of the 46 operations with FSM, there were 28 (60.9%) true-negative, 12 (26.1%) true-positive, six (13.0%) false-negative, and no false-positive cases. There was no difference in further reexcision, total operations, or conversion to mastectomy among patients with and without FSM. Need for further reexcision was significantly associated with tumor multifocality (P = .008).

CONCLUSIONS

Despite overall good pathology performance for FSM in reexcision-only specimens, use of FSM did not affect patient outcome. Rather, underlying disease biology appeared most significant in predicting whether adequate surgical margins could be attained.

The oncoplastic reduction approach to breast conservation therapy: benefits for margin control

BACKGROUND

Reduction mammaplasty during lumpectomy allows more generous resection and minimizes potential for poor cosmesis as compared with breast conservation therapy alone.

OBJECTIVES

The authors assessed the benefits of oncoplastic reduction for margin status in patients with breast cancer by conducting a retrospective review of cases of tumor resection alone vs tumor resection with oncoplastic reduction.

METHODS

Patients with breast cancer who underwent lumpectomy performed by a single oncologic surgeon between 2009 and 2013 were included. Patients were stratified into 2 groups based on surgical procedure: tumor resection with oncoplastic reduction (group 1) vs tumor resection alone (group 2). Patient demographics including risk factors, diagnosis, cancer stage, and procedure type were recorded. Tumor size, specimen weight, width of narrowest margin, and receptor status were determined. Outcome variables included margin positivity (≤1 mm), need for re-excision, and conversion to completion mastectomy.

RESULTS

A total of 222 breasts from 207 patients were included in the study: 83 in group 1 and 139 in group 2. The patients in group 1 had a lower incidence of positive margins and wider free surgical margins, required re-excision less often, and went on to completion mastectomy less often. Patients in group 1 were younger and had cancer that was more advanced. When controlling for these variables on multivariate regression analysis, the oncoplastic technique was independently associated with fewer positive margins and fewer instances of re-excision.

CONCLUSIONS

The oncoplastic reduction technique achieves wider free margins and less often necessitates re-excision or subsequent mastectomy. The long-term oncologic effect of this approach deserves further study.

LEVEL OF EVIDENCE

4.

Designing a wearable navigation system for image-guided cancer resection surgery

A wearable surgical navigation system is developed for intraoperative imaging of surgical margin in cancer resection surgery. The system consists of an excitation light source, a monochromatic CCD camera, a host computer, and a wearable headset unit in either of the following two modes: head-mounted display (HMD) and Google glass. In the HMD mode, a CMOS camera is installed on a personal cinema system to capture the surgical scene in real-time and transmit the image to the host computer through a USB port. In the Google glass mode, a wireless connection is established between the glass and the host computer for image acquisition and data transport tasks. A software program is written in Python to call OpenCV functions for image calibration, co-registration, fusion, and display with augmented reality. The imaging performance of the surgical navigation system is characterized in a tumor simulating phantom. Image-guided surgical resection is demonstrated in an ex vivo tissue model. Surgical margins identified by the wearable navigation system are co-incident with those acquired by a standard small animal imaging system, indicating the technical feasibility for intraoperative surgical margin detection. The proposed surgical navigation system combines the sensitivity and specificity of a fluorescence imaging system and the mobility of a wearable goggle. It can be potentially used by a surgeon to identify the residual tumor foci and reduce the risk of recurrent diseases without interfering with the regular resection procedure.

Survey of American and Canadian general surgeons' perceptions of margin status and practice patterns for breast conserving surgery

Although breast conservation surgery (BCS) is commonly performed, several aspects of the procedure remain controversial. We undertook a cross-sectional survey to compare Canadian (CDN) and American (AM) general surgeons' reported BCS practice patterns to better understand the cross-border differences in early-stage breast cancer surgery care. A modified Dillman Method survey was mailed to 1,447 AM and 1,443 CDN surgeons. Factors evaluated included preoperative assessment, margin definition, surgical techniques, and re-excision practices. The response rate was 26% and 51% for AM and CDN surgeons, respectively. There was variation in use of preoperative core biopsies. American surgeons required wider margins for invasive cancer and ductal carcinoma in situ, and more often recommend re-excision for invasive cancer with 1 and 2 mm margins (p < 0.05). There was also variability in surgical techniques used for intraoperative margin assessment. Wide variation in BCS practice was observed, with some of this variability related to surgeon country.

Concomitant high-grade prostatic intraepithelial neoplasia is associated with good prognosis factors and oncologic outcome after radical prostatectomy

OBJECTIVES

To assess correlations between concomitant high-grade prostatic intraepithelial neoplasia (HGPIN), pathological features and oncologic outcomes after radical prostatectomy (RP).

MATERIAL AND METHODS

We prospectively collected a single-institution database of 2,351 patients who underwent RP between 1998 and 2011.

RESULTS

1,272 (54.1%) patients had HGPIN on specimens. The mean follow-up was 28 months. Presence of HGPIN was significantly associated with a favorable preoperative risk status and with pathological factors of poor prognosis in RP specimens. Patients without HGPIN had a worse biochemical recurrence-free survival compared with those with HGPIN in RP specimen (log-rank test: p = 0.015). The 3-year RFS rate was 73.9% for the HGPIN group versus 67.2%. The absence of HGPIN was also significantly correlated with the use of androgen deprivation treatment during the follow-up (p < 0.001). In Cox multivariate analysis, taking into account the other prognostic pathological factors, HGPIN was not an independent predictive factor for PSA failure (p = 0.868).

CONCLUSION

HGPIN is associated with factors of good prognosis but fails to show independent significance when classical pathological prognostic factors are taken into account.

Phase I trial of intraoperative detection of tumor margins in patients with HER2-positive carcinoma of the breast following administration of 111In-DTPA-trastuzumab Fab fragments

INTRODUCTION

Our aim was to conduct a Phase I clinical trial to determine the feasibility of intraoperative detection of tumor margins in HER2 positive breast carcinoma using a hand-held γ-probe following administration of (111)In-DTPA-trastuzumab Fab fragments. Accurate delineation of tumor margins is important for preventing local recurrence.

METHODS

Six patients with HER2-positive in situ or invasive ductal carcinoma were administered 74MBq (0.5mg) of (111)In-DTPA-trastuzumab Fab fragments and counts in the tumor, surgical cavity wall and en face margins were measured intraoperatively at 72h post-injection using the Navigator or C-Trak γ-probes. Margins were evaluated histologically. Quantitative whole body planar imaging was performed to estimate radiation absorbed doses using OLINDA/EXM software. SPECT imaging of the thorax was performed to evaluate tumor uptake. The pharmacokinetics of elimination from the blood and plasma were determined over 72h.

RESULTS

There were no acute adverse reactions from (111)In-DTPA-trastuzumab Fab fragments and no changes in hematological or biochemical indices were found over a 3month period. (111)In-DTPA-trastuzumab Fab fragments exhibited a biphasic elimination from the blood and plasma with t1/2α=11.9h and 7.5h, respectively, and t1/2β=26.6 and 20.7h, respectively. The radiopharmaceutical accumulated in the liver, spleen and kidneys. SPECT imaging did not reveal tumor in any patient. The mean effective dose was 0.146mSv/MBq (10.8mSv for 74MBq). Counts in excised tumors were low but were higher than in margins. Margins in two patients harboured tumor but this was not correlated with counts obtained using the γ-probes. Surgical cavity counts were high and likely due to detection of γ-photons outside the surgical field.

CONCLUSION

We conclude that it was not feasible, at least at the administered amount of radioactivity used in this study, to reliably detect the margins of disease in patients with in situ or invasive ductal carcinoma intraoperatively using a hand-held γ-probe and (111)In-DTPA-trastuzumab Fab fragments due to low uptake in the tumor and involved margins.

Intraoperative frozen section analysis of margins in breast conserving surgery significantly decreases reoperative rates: one-year experience at an ambulatory surgical center

Intraoperative frozen section (FS) margin evaluation is not common practice for patients undergoing breast conservation therapy (BCT), but offers a significant reduction in reoperation. In this study, a technique to allow for more effective freezing of breast tissue was developed to perform FS evaluation of lumpectomy margins (FSM) for all patients undergoing BCT at an ambulatory surgery center. FS evaluation of sentinel lymph node biopsy specimens was performed concurrently. One hundred eighty-one study and 188 control patients, with and without FS evaluation, were compared. Reexcision was reduced 34% (from 48.9% to 14.9%) and reoperation was reduced 36% (from 55.3% to 19.3%) with FS evaluation. Most of the decrease in reoperative rate was because of a decrease in the need for margin reexcision. The number of patients requiring 1, 2, or 3 operations to complete therapy was 84, 92, and 12, respectively, in the control group, and 146, 33, and 2, respectively, in the study group. Lobular subtype, multifocal disease, and larger tumor size (≥2 cm) were significantly associated with failure of FSM to prevent reoperation, but reoperation rates were still significantly decreased in this subgroup of patients (from 75.5% to 43.8%) with FSM. This study highlights an innovative yet simple and adaptable FS approach that resulted in a nearly 3-fold reduction in reoperation for patients undergoing BCT.

[Radiotherapy for breast cancer: which strategy in 2012?]

Postoperative radiotherapy remains essential in breast cancer in 2012. After conserving surgery, it reduces local recurrence risks from 50 to 70%, both for ductal carcinoma in situ and invasive cancers. This was confirmed in several randomized trials and three meta-analyses. The boost increases local control in invasive cancers, but its role should be better defined in ductal carcinoma in situ. Among the latter, there is no clearly identified subgroup for which radiotherapy could be avoided. Local recurrence risk factors are now well-identified both for ductal carcinoma in situ and invasive cancers, with an inclusion, for the latter, of new molecular subgroups. After mastectomy, radiotherapy reduces local recurrence rates from 60 to 70%, especially among patients with axillary nodal involvement, with, in parallel, a 7 to 9% increased survival rate. In order to reduce the waiting list and to avoid under treatment, especially in the elderly, several hypofractionated radiotherapy schemes have been developed for several years. Three randomized trials confirmed similar results to classical radiotherapy. For ten years, several techniques of partial breast irradiation have been developed, with various doses and treated volumes. The optimal indications should be defined according to the new international guidelines.

Adjuvant tamoxifen reduces subsequent breast cancer in women with estrogen receptor-positive ductal carcinoma in situ: a study based on NSABP protocol B-24

PURPOSE

The NSABP (National Surgical Adjuvant Breast and Bowel Project) B-24 study demonstrated significant benefit with adjuvant tamoxifen in patients with ductal carcinoma in situ (DCIS) after lumpectomy and radiation. Patients were enrolled without knowledge of hormone receptor status. The current study retrospectively evaluated the relationship between receptors and response to tamoxifen.

PATIENTS AND METHODS

Estrogen (ER) and progesterone receptors (PgR) were evaluated in 732 patients with DCIS (41% of original study population). An experienced central laboratory determined receptor status in all patient cases with available paraffin blocks (n = 449) by immunohistochemistry (IHC) using comprehensively validated assays. Results for additional patients (n = 283) determined by various methods (primarily IHC) were available from enrolling institutions. Combined results were evaluated for benefit of tamoxifen by receptor status at 10 years and overall follow-up (median, 14.5 years).

RESULTS

ER was positive in 76% of patients. Patients with ER-positive DCIS treated with tamoxifen (v placebo) showed significant decreases in subsequent breast cancer at 10 years (hazard ratio [HR], 0.49; P < .001) and overall follow-up (HR, 0.60; P = .003), which remained significant in multivariable analysis (overall HR, 0.64; P = .003). Results were similar, but less significant, when subsequent ipsilateral and contralateral, invasive and noninvasive, breast cancers were considered separately. No significant benefit was observed in ER-negative DCIS. PgR and either receptor were positive in 66% and 79% of patients, respectively, and in general, neither was more predictive than ER alone.

CONCLUSION

Patients in NSABP B-24 with ER-positive DCIS receiving adjuvant tamoxifen after standard therapy showed significant reductions in subsequent breast cancer. The use of adjuvant tamoxifen should be considered for patients with DCIS.

Development of a spatially offset Raman spectroscopy probe for breast tumor surgical margin evaluation

The risk of local recurrence for breast cancers is strongly correlated with the presence of a tumor within 1 to 2 mm of the surgical margin on the excised specimen. Previous experimental and theoretical results suggest that spatially offset Raman spectroscopy (SORS) holds much promise for intraoperative margin analysis. Based on simulation predictions for signal-to-noise ratio differences among varying spatial offsets, a SORS probe with multiple source-detector offsets was designed and tested. It was then employed to acquire spectra from 35 frozen-thawed breast tissue samples in vitro. Spectra from each detector ring were averaged to create a composite spectrum with biochemical information covering the entire range from the tissue surface to ∼2 mm below the surface, and a probabilistic classification scheme was used to classify these composite spectra as "negative" or "positive" margins. This discrimination was performed with 95% sensitivity and 100% specificity, or with 100% positive predictive value and 94% negative predictive value.

Monte Carlo model of spatially offset Raman spectroscopy for breast tumor margin analysis

We have previously demonstrated the discrimination of two layers of soft tissue, specifically normal breast tissue overlying breast tumor, using spatially offset Raman spectroscopy (SORS). In this report, a Monte Carlo code for evaluating SORS in soft tissues has been developed and compared to experimental results. The model was employed to investigate the effects of tissue and probe geometry on SORS measurements and therefore to develop the design strategies of applying SORS for breast tumor surgical margin evaluation. The model was used to predict SORS signals for different tissue geometries difficult to precisely control experimentally, such as varying normal and tumor layer sizes and the addition of a third layer. The results from the model suggest that, using source-detector separations of up to 3.75 mm, SORS can detect sub-millimeter-thick tumors under a 1 mm normal layer, and tumors at least 1 mm thick can be detected under a 2 mm normal layer.

Histopathological prognostic factors in early breast carcinoma: an evaluation of cell proliferation in carcinoma cells

Early breast carcinoma is defined as pathological stage 1 (pT1N0M0) tumour and its incidence has recently increased possibly due to the advent of mammography based mass screening. Overall survival of these patients is in general excellent, but more than 20% of them will eventually develop distant metastasis and die. Therefore, an establishment of prognostic factors could contribute greatly to determining the algorithm for treating these patients after surgery. Histopathological prognostic factors still play pivotal roles in the management of these patients. Among these, Nottingham histological grade is considered the gold standard for determining the clinical outcome of early breast cancer patients if done in optimally processed tissue specimens by well-trained pathologists. Among these histological factors of Nottingham histological grade, mitotic index has been demonstrated to provide the most significant information as to prognosis of these patients. Attempts have been made to assess the status of tumour cell proliferation in practical, reproducible and accurate manners in the past. Among these attempts, immunohistochemical analysis of cell cycle associated nuclear antigens, especially Ki67/MIB1 labelling index in archival materials, has been reported to provide clinically inert and significant information. However, its methodologies, including processing of the specimens, and modes of interpretation should be standardised before this Ki67/MIB1 labelling index can become incorporated into routine clinical practice in the management of early breast carcinoma patients.

Patterns of surgical treatment for women with breast cancer in relation to age

Although treatment recommendations have been advocated for all women with early breast cancer regardless of age, it is generally accepted that different treatments are preferred based on the age of the patient. The aim of this study was to assess the pattern of breast cancer surgery after adjusting for other major prognostic factors in relation to patient age. Data on cancer characteristics and surgical procedures in 31,298 patients with early breast cancer reported to the National Breast Cancer Audit between 1999 and 2006 were used for the study. There was a close association between age and surgical treatment pattern after adjusting for other prognostic factors, including tumor size, histologic grade, number of tumors, lymph node positivity, lymphovascular invasion (LVI), and extensive intraduct component. Breast Conserving Surgery (BCS) was highest among women aged <or=40 years (OR = 1.140; 95% CI: 1.004-1.293) compared to women aged 51-70 years (reference group). BCS was lowest in women aged >70 years (OR = 0.498, 95% CI: 0.455-0.545). Significantly more women aged <or=50 years underwent more than one operation for breast conservation (20.4-24.8%) compared with women aged >50 years (11.4-17.0%). Women aged >70 years were more likely to receive no surgical treatment, 3.5% versus 1.0-1.3% in all other age groups (<or=40, 41-50 51-70 years). There is an association between patient age and the type of breast cancer surgery for women in Australia and New Zealand. Women age <or=40 years are more likely to undergo BCS despite having adverse histologic features and have more than one procedure to achieve breast conservation. Older women (>70 years) more commonly undergo mastectomy and are more likely to receive no surgical treatment.

Intra-operative touch preparation cytology following lumpectomy for breast cancer: a series of 400 procedures

AIMS

Achieving negative margins is essential in conservative treatment for breast cancer. The conventional method for intra-operative assessment of resection margins is gross or histological examination of frozen sections. We describe and evaluate the contribution of an original intra-operative touch preparation cytology (IOTPC) technique (400 procedures) performed on 396 patients.

MATERIALS AND METHODS

IOTPC consists of touching glass slides to the surfaces of interest after gently pressing the spatially localized specimen taken according to predetermined conditions. The result is conveyed to the surgeon immediately and compared with the conventional histological findings after embedding in paraffin.

RESULTS

The average response time is 10min, which renders the technique compatible with standard operating room procedures and its cost is reasonable. The method has a sensitivity of 88.6%, specificity of 92.2%, positive predictive value of 73.6%, negative predictive value of 97%, and correlation with paraffin section histology of 91.5%. Only 5 true false negatives were found in this series and the technique prevented 11.75% of secondary re-excision procedures for positive margins.

CONCLUSION

IOTPC is a reliable extemporaneous method for assessing surgical margins in conservative treatment for breast cancer and a useful tool for surgeons.

Spatially offset Raman spectroscopy of layered soft tissues

Raman spectroscopy has been widely used for cancer diagnosis, but conventional forms provide limited depth information. Spatially offset Raman spectroscopy (SORS) can solve the depth issue, but it has only been used to detect hard tissues such as bone. We explore the feasibility of using SORS to discriminate two layers of soft tissue. Measurements were taken with individual source and detector fibers at a number of spatial offsets from samples consisting of various thicknesses of normal human breast tissues overlying breast tumors. Results show that SORS can detect tumors beneath normal tissue, marking, to the best of our knowledge, the first application of SORS for discriminating two layers of soft tissue.

The value of diffusion-weighted imaging in assessing the ADC changes of tissues adjacent to breast carcinoma

Background

To define a threshold value of apparent diffusion coefficient (ADC) with which malignant breast lesions can be distinguished from benign lesions, and to evaluate the ADC change of peri-tumor tissue in breast carcinoma by echo planar-diffusion weighted imaging (EPI-DWI).

Methods

57 breast lesions were scanned by routine MRI and EPI-DWI. The ADC values were compared between malignant and benign lesions. The sensitivity and specificity of EPI-DWI and the threshold ADC value were evaluated by Receiver Operating Characteristic curve (ROC). The ADC values of malignant lesion and layered peri-tumor tissues (from innermost layer 1 to outermost layer 4 with 5 mm every layer) in different directions were compared and the ADC values among different layers were compared.

Results

The ADC value of 35 malignant lesions was statistically lower than that of 22 benign lesions (P < 0.05). In ROC curve, the threshold value was 1.24 +/- 0.25*10E-3 mm²/s (b = 500) or 1.20 +/- 0.25*10E-3 mm²/s (b = 1000). The ADC value of malignant lesions was statistically lower than that of peri-tumor tissues in different directions (P < 0.05). For peri-tumor tissues, the ADC values increased gradually from layer 1 to layer 4 and there was a significant difference between the ADC values of layer 1 and layer 2 (P < 0.05); while from layer 2 outwards, there was no statistical difference among different layers.

Conclusion

ADC value was a sensitive and specific parameter that could help to differentiate benign and malignant breast lesions. ADC changes in tissues adjacent to breast carcinoma could be detected by EPI-DWI, which made EPI-DWI a promising method for helping to determine surgical scope of breast carcinoma.