Practical consensus recommendations for tumor margins and breast conservative surgery

Diagnostic accuracy and challenges of intraoperative frozen section evaluation for axillary sentinel lymph node biopsy and breast margins

AIMS

Our study aims to audit and evaluate the accuracy and pitfalls of intraoperative evaluation of frozen sentinel lymph nodes (IOE-FSLN) and resection margins (IOE-FSM) compared to final findings in paraffin sections.

METHODS

A total of 264 cases underwent intraoperative evaluation, encompassing 688 sentinel lymph nodes (SLNs) and 1186 surgical margins. Frozen section (FS) diagnoses were compared with corresponding permanent sections of FS (PFS). Sensitivity, specificity, false-negative rate, false-positive rate, and concordance rates were assessed. Cases with discrepancies underwent a detailed histological review.

RESULTS

The study predominantly comprised cases of invasive breast carcinoma (IBC) (74%). For FSLN reporting, sensitivity was 88.1%, specificity 100%, and FS-PFS concordance 99.0%. FSM reporting showed sensitivity of 85.0%, specificity 99.9%, and concordance 98.4%. Sampling errors accounted for 86% (FSLN) and 88% (FSM) of discrepancies, with interpretive errors present in 1/7 FSLN and in 2/17 FSM cases. The shave margin method demonstrated a higher false-negative rate in FSM reporting. The rate of final positive margins was reduced from 21.3% to 11.4% when IOE-FSM was utilized.

CONCLUSION

IOE-FSLN and IOE-FSM showed high reliability in guiding intraoperative decisions for axillary lymph node dissection and achieving free surgical margins in one-stage surgeries. However, limitations include challenges in distinguishing metastatic carcinoma from benign mimics in FSLN and diagnosing certain features such as IBC with post-treatment changes, invasive lobular carcinoma in FSLN and FSM; IBC rich in tumour-infiltrating lymphocytes, low-grade (DCIS/IBC in FSM) without immunohistochemical studies.

Outcomes From Real-World Data on Intraoperative Electronic Radiotherapy for the Treatment of Early-Stage Breast Cancer: Long-Term Recurrence and Survival Outcomes From a Single Center

Purpose: This study is aimed at investigating the 10-year outcomes of intraoperative radiotherapy (IORT) in Mexican women with early breast cancer (EBC) treated at the Centro Medico ABC, Mexico City. Methods: A cohort study included women with early-stage invasive ductal carcinoma aged ≥ 45 years without prior oncologic treatment, tumor size ≤ 3.5 cm, cN0M0, positive hormone receptors, margins ≥ 2 mm, negative sentinel lymph nodes, and no extensive lymphovascular invasion. IORT was administered at 20 Gy for 20-30 min after a lumpectomy. Follow-up extended over 10 years and included clinical examinations every 6 months for the first 18 months, followed by annual mammograms and conventional examinations. Patients out of the criteria were excluded from this study because they were referred for additional surgery and/or whole-breast radiation therapy. Results: The study involved 238 patients with an average age of 61.1 years. The mean tumor size was 12 mm, and the percentages of lymphatic invasion, positive hormone receptors, and HER2/neu overexpression were 12.6%, 90.8%, and 2.1%, respectively. The median follow-up was 66.6 months (range: 1-126 months), and the overall survival and mastectomy-free rate reached 95.7% and 90%, respectively. Thirteen patients showed side effects; four recurrences were recorded, of which 50% were out-field relapses. The 5-year Kaplan-Meier probability of local relapses, mastectomy-free, and overall survival reached 97.5%, 100%, and 98%, respectively. Conclusions: This is the first 10-year report about the effect of IORT on Mexican women with EBC in the early stages. Strict adherence to the selection criteria in this study resulted in low rates of side effects, mortality, and local recurrences, demonstrating that IORT is an effective treatment alternative for patients with EBC. Studies with a longer follow-up period should be performed, as recurrences can occur in the long term.

Oncoplastic Breast-Conserving Surgery in African Women: A Systematic Review

PURPOSE

Breast cancer is the most frequently diagnosed cancer in women worldwide. Surgery is a major treatment modality for breast cancer, and over the years, breast-conserving surgeries with breast radiation have shown similar outcomes with mastectomy. Not much is known about the frequency and outcome of breast-conserving surgery in Africa. This systematic review provides a comprehensive summary of the evidence evaluating cosmetic and oncologic outcomes after oncoplastic breast-conserving surgery (OBCS) for breast cancer in African women.

METHODS

This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases were systematically searched for studies on African women undergoing OBCS. The oncologic and cosmetic outcomes, as well as the localization and reconstruction techniques, were evaluated. Descriptive statistics were used to summarize the frequency and proportions of the extracted variables.

RESULTS

The literature search yielded 266 articles but only 26 of these were included in the review. Majority of the studies were from Egypt and South Africa. These studies collectively evaluated 1,896 patients with a mean age of 48.2 years and a mean follow-up period of 36.9 months. The most common histopathology was T2 (71.4%) invasive ductal carcinoma. Hook wire localization was the most common technique used for nonpalpable lesions in 85.3% of patients. Of the studies reporting oncoplastic technique, the latissimus dorsi volume replacement technique was the most reported (15%). Most patients were satisfied with their cosmetic outcome. Seroma was the most common postoperative complication (44.6%). Among studies that reported oncologic outcome data, the crude overall survival and disease-free survival were 93.1% and 89.4%, respectively.

CONCLUSION

This systematic review revealed that the outcome of OBCS in African women compares with that in developed countries.

A quality evaluation of the clinical practice guidelines on breast cancer using the RIGHT checklist

Background

Breast cancer is the most frequent type of cancer in women. The methodological quality of clinical practice guidelines (CPGs) on breast cancer has been shown to be heterogeneous. The aim of our study was to evaluate the quality of breast cancer CPGs published in years 2018-2020, using the Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist.

Methods

We searched Medline (via PubMed), Chinese National Knowledge Infrastructure (CNKI), Wanfang and Chinese Biomedical Literature (CBM) as well as websites of guideline organizations for CPGs on breast cancer published between 2018 and 2020. We used the RIGHT checklist to evaluate the reporting quality of the included guidelines by assessing whether the CPGs adhered to each item of the checklist and calculated the proportions of appropriately reported RIGHT checklist items. We also presented the adherence reporting rates for each guideline and the mean rates for each of the seven domains of the RIGHT checklist.

Results

A total of 45 guidelines were included. Eighteen (40.0%) guidelines had an overall reporting rate below 50% and only three (6.7%) reported more than 80% of the items. The domains “Basic information” and “Background” had the highest reporting rates (75.9% and 62.5%, respectively). The mean reporting rates of the domains “Evidence”, “Recommendation”, “Review and quality assurance”, “Funding and declaration and management of interests” and “Other information” were 42.7%, 53.0%, 33.3%, 45.0%, and 44.4%, respectively.

Conclusions

The reporting quality varied among guidelines for breast cancer, showing the need for improvement in reporting the contents. Guideline developers should pay more attention to reporting the evidence, review and quality assurance, and funding and declaration and management of interests in future.

Does Surgical Margin Width Remain a Challenge for Triple-Negative Breast Cancer? A Retrospective Analysis

Background and Objectives: Local and distant relapse (LR, DR) in breast cancer vary according to its molecular subtypes, with triple-negative breast cancer (TNBC) being the most aggressive. The surgical resection margin width (SRMW) for breast-conserving surgery (BCS) has been intensely debated, especially for the aforementioned subtype. The aim of this study was to examine the impact of SRMW on LR following BCS in TNBC patients. Materials and Methods: We conducted a retrospective study including all patients with TNBC for whom BCS was performed between 2005 and 2014. Results: Final analysis included a total of 92 patients, with a median tumor size of 2.5 cm (range 0-5 cm) and no distant metastasis at the time of diagnosis. A total of 87 patients had received neoadjuvant and/or adjuvant chemotherapy, and all patients had received adjuvant whole-breast radiotherapy. After a median follow-up of 110.7 months (95% CI, 95.23-126.166), there were 5 local recurrences and 8 regional/distant recurrences with an overall LR rate of 5.4%. The risk of LR and DR was similar between groups of patients with several SRMW cut-off values. Conclusions: Our study supports a safe "no ink on tumor" approach for TNBC patients treated with BCS.

Routine cavity shaves following breast conserving surgery; friend or foe?

BACKGROUND

Radial margin status is considered one of the most important prognostic predictor for patients undergoing breast-conserving surgery (BCT), not only related to regional recurrence but also to 5y survival, especially in patients with invasive disease.

AIM

While our primary aim was to evaluate whether doing routine radial cavity shaves following at the time of primary conservative breast surgery will decrease the need for a second operation or not, our secondary aim was to assess time added to the operation to resect and mark the radial shaves, as well as patients' satisfaction with the results.

MATERIAL AND METHODS

We have conducted a case series prospective analysis, including158 patients who underwent breast-conserving surgery looking into the histological status of resection margins and radial shaves, added time taken to take and mark the shaves as well as patients' satisfaction.

RESULTS

158 female breast cancer patients have been included in our analysis, the mean age was 56 years; total number of lesions was 160. While 89.3% of lesions were palpable, 10.6% were not requiring wire-guided localisation. Mean tumour size was 24 mm SD 7, final histology revealed that 86.8% lesion was invasive ductal carcinoma, 5.6% invasive lobular carcinoma, 1.2% medullary carcinoma. 12.4% had invasive disease as well as DCIS, and 1.8% had DCIS only with no invasive disease. Mean preoperative breast volume was 723 ml, Mean wide local excision specimen weight was 73 g, and mean shave weight was 1.6 g. Total number of radial margins was 640, 81.8% was clear, 14.6% was close, and 3.4% was involved. Total number of shaves was 640 out of which 98.7% was clear 0.7% was close and 0.4% was involved. Out of the 160 lesions, 3.7% required a second procedure to clear margins, out of which 2.5% had re-excision for close or involved single shaves each while 1.2% had mastectomy due to close or involved two shaves each. Average time utilised in resection of radial shaves and marking was 7 min 0.6% of patients developed a haematoma, 1.8% had a Seroma, and 1.2% had wound infection. Mean hospital stay was 1day SD 1.

CONCLUSION

Routine radial cavity shaves not only ensure microscopic clearance, reduce the need for re-excision with no significant added operating time but also has no impact on patients' satisfaction.

Assessment of Internal Carotid Artery Invasion With the Endoscopic Endonasal Approach: Implications of a New Grading System and Security Strategy

BACKGROUND

Internal carotid artery (ICA) injury during the endoscopic endonasal approach (EEA) for ventral cranial base tumors is rare but fatal.

OBJECTIVE

The aim of this study was to investigate the relationship between ventral cranial base tumors and corresponding ICA using quantitative means to improve the safety of surgery.

MATERIAL AND METHODS

In this retrospective study, a total of 46 patients with ventral cranial base tumors undergoing surgery with the EEA were enrolled. Preoperative imaging features and clinical data were recorded. The influencing factors of the gross total resection (GTR) rate were analyzed. A new grading system and security strategy were developed.

RESULTS

Postoperative enhanced magnetic resonance imaging showed a GTR of 61.7%. There was a significant correlation between the GTR rate and tumors surrounding the ICA, the tumor site, the involved ICA segment, and the blood supply (P < 0.05). We included preoperative radiotherapy as supplementary data in the grading system. Each variable involved the letter "S"; (surround, site, segment, blood supply, supplementary data); hence, the system was named the 5S ICA grading scale.

CONCLUSION

We recommend a safety assessment through the 5S ICA grading scale and the ICA grading strategy to obtain the maximum total resection rate while ensuring patient safety.

What is the dosimetric impact of isotropic vs anisotropic safety margins for delineation of the clinical target volume in breast brachytherapy?

PURPOSE

The purpose of the study was to report dosimetric differences for breast brachytherapy plans optimized for clinical target volume (CTV) generated using conventional isotropic expansion of tumor bed volume (TBV) and Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology (GEC-ESTRO) recommendations to expand the TBV anisotropically to achieve a total safety margin of 2 cm (resection margin size + added safety margin).

METHODS

Institutional records of 100 patients who underwent accelerated partial breast irradiation using multicatheter interstitial brachytherapy from May 2015 to March 2020 were reviewed retrospectively. Two sets of CT-based plans were made, one with 1-cm isotropic margins around the tumor bed (CTV_ISO) and the other with anisotropic margins (CTV_GEC). Plans were evaluated and compared using the American Brachytherapy Society and GEC-ESTRO guidelines.

RESULTS

The median TBV was 36.97 cc. The median margin widths were as follows: anterior 1.2, posterior 1.0, superior 1.0, inferior 0.9, medial 1.2, and lateral 1.2 cm. The mean tumor bed coverage index was 0.94; 0.93 [p.066], the CTV coverage index 0.86; 0.84 [p 0.001], the dose homogeneity index (DHI) 0.77; 0.75 [p < 0.001] and the conformity index 0.66; 0.64 [p < 0.001] in CTV_ISO and CTV_GEC plans, respectively. In smaller volume implants (TBV< 35 cc), the DHI was 0.76; 0.75 [p 0.008] and the conformity index was 0.66; 0.62 [p < 0.001], whereas in larger volumes >35 cc, the CTV coverage index was 0.86; 0.84 [p 0.003] and the DHI 0.78; 0.76 [p 0.001] in CTV_ISO and CTV_GEC plans, respectively.

CONCLUSIONS

In this cohort of patients who underwent accelerated partial breast irradiation, plans with anisotropic margins had lower conformity, the impact of which was predominantly seen in smaller implants. Rest of the dosimetric constraints were achieved in both the plans as per the American Brachytherapy Society and GEC-ESTRO guidelines.

External validation and modification of nomogram for predicting positive resection margins before breast conserving surgery

PURPOSE

A positive resection margin after breast conserving surgery (BCS) is the most important risk factor for tumor recurrence. In 2012, Seoul National University Hospital (SNUH) breast surgery team developed a nomogram for predicting positive resection margins before BCS to provide individual surgical plans that could reduce local recurrence without increasing re-excision rates. The purpose of this study was to validate this nomogram using an external cohort and to test if addition of surgeon-related factor could improve its use as a predictive model.

METHODS

A total of 419 patients with breast cancer who underwent BCS from January to December 2018 were retrospectively reviewed. Using the SNUH BCS nomogram, risk score for positive resection margins was calculated for 343 patients. The predictive accuracy of the nomogram was assessed, and multivariable logistic regression analyses were performed to evaluate the nomogram's predictive variables.

RESULTS

The positive resection margin rate of the current external validation cohort was 13.5% (46 out of 343), compared to 14.6% (151 out of 1034) of the original study. The discrimination power of the SNUH BCS nomogram as measure by area under the receiver operating characteristics curve (AUC) was 0.656 [95% confidence interval (CI) 0.576-0.735]. This result is lower than expected value of 0.823 [95% CI 0.785-0.862], the AUC of the original study. Multivariable logistic regression analysis showed that, among the five nomogram variables, presence of tumor size discrepancy greater than 0.5 cm between MRI and ultrasonography (OR 2.445, p = 0.019) and presence of ductal carcinoma in situ on needle biopsy (OR 2.066, p = 0.048) were significantly associated with positive resection margins. Finally, the nomogram score was re-calculated by adding each surgeon's resection margin positive rate as odds ratio and the AUC was increased to 0.733.

CONCLUSIONS

Validation of the SNUH BCS nomogram was not successful in the current study as much as its original publication. However, we could improve its predictive power by including surgeon-related factor. Before applying a published nomogram as a preoperative predictive model, we suggest each institution to validate the model and adjust it with surgeon-related factor. Addition of new factors to currently available nomograms holds promise for improving its applicability for breast cancer patients at the actual clinical level.

Postmastectomy radiation therapy in early breast cancer: Utility or futility?

Postmastectomy radiation therapy (PMRT) has been shown to reduce the risk of locoregional recurrence (LRR), in patients with locally advanced breast cancer who are considered of high-risk because of large tumors (>5 cm) or presence of axillary lymph-node involvement, as well as to reduce breast cancer mortality. However, controversy still remains with respect to indication of PMRT in case of early-stages invasive tumors. This review aims to analyze the impact that PMRT has on final results in women with breast tumors in different scenarios that would otherwise be considered as early breast cancer, such as extensive DCIS, tumors without axillary lymph-node involvement or with minimal microscopic nodal-involvement. The existence of risk factors including young age, premenopausal status, and presence of lymphovascular invasion (LVI), high grade or tumor size >2 cm has been associated with an increased risk of LRR in these patients at early-stages and advises to consider PMRT in selected cases.

Comparison between optical coherence tomographic and histopathologic appearances of artifacts caused by common surgical conditions and instrumentation

OBJECTIVE

To document the appearance of artifacts created by commonly encountered surgical conditions and instrumentation on optical coherence tomography (OCT) and to compare these findings with histopathology.

STUDY DESIGN

Ex vivo study.

ANIMALS

Five canine cadavers.

METHODS

Skin, subcutaneous fat, skeletal muscle, and fascia samples were obtained from fresh canine cadavers. Blood pooling, hemostatic crushing, scalpel blade cut, monopolar electrosurgery, bipolar vessel sealing device, and ultrasonic energy surgical artifacts were induced on each tissue type. Each specimen was imaged with OCT and subsequently histologically processed.

RESULTS

Most surgical instrumentation used for tumor excision created a high-scattering region with local architectural disruption. Blood pooling was visible as a high-scattering layer overlying tissue with normal architecture. Only the scalpel blade created a focal, low-scattering area representing a sharply demarcated cut within the tissue distinct from the appearance of other instrumentation.

CONCLUSION

Common surgical instruments and conditions encountered during tumor excision produced high-scattering OCT artifacts in tissues commonly seen at surgical margins.

CLINICAL SIGNIFICANCE

The clinical value of OCT hinges on the ability of personnel to interpret this novel imaging and recognize artifacts. Defining and describing the appearance of common surgical artifacts provides a foundation to create image libraries with known histological and OCT interpretation, ultimately improving the diagnostic accuracy of OCT for assessment of surgical margins.