Secondary operations are frequently required to complete the surgical phase of therapy in the era of breast conservation and sentinel lymph node biopsy

A Single institution's randomized double-armed prospective study of lumpectomy margins with adjunctive use of the MarginProbe in nonpalpable breast cancers

Breast conservation surgery (BCS) aims to excise all cancerous tissue while minimizing the amount of healthy breast tissue removed. Up to 30% of patients undergoing BCS require a second operation for re-excision to obtain negative margins. Previous studies reported a lower re-excision rate with intraoperative use of the MarginProbe device (Dune Medical Devices). This device utilizes radiofrequency spectroscopy to detect differences between cancerous and normal tissue. From July 2009 to January 2010, our institution enrolled 46 patients electing for BCS in a prospective double-arm randomized controlled trial and had a significantly lower re-excision rate than that reported in the multicenter trial. Intraoperatively, after performing conventional lumpectomy with excision of any additional shavings deemed necessary based on palpation and visual inspection alone, patients were then randomized. In the device arm, the surgeon used the MarginProbe to interrogate the lumpectomy specimen, taking additional shavings from the cavity surfaces corresponding to the parts of the specimen read as positive by the device. In the control arm, only standard intraoperative assessments were performed. All specimens were evaluated by pathologists who were blinded to the study arm. In this population, 72% had invasive ductal carcinoma (IDC), 20% had ductal carcinoma in situ (DCIS), and 8% had invasive lobular carcinoma (ILC). Average age was 64 years old. The average size of the specimen was 5.6 cm, the average volume was 37.8 cm³ , and the average weight was 32.7 g. The mean size of DCIS was 1.4 cm. For invasive specimens, 32 were T1 and 7 were T2. Prior to randomization, 43 patients were thought to have positive or close margins and therefore underwent additional shavings. Twenty-three patients were randomized to the device arm and 23 to the control arm. In the device arm, 14 (60%) patients had IDC, 7 (30%) had DCIS, and 2 (8%) had ILC, vs the control arm where 19 (82%) patients had IDC, 2 (8%) had DCIS, and 2 (8%) had ILC. Eight (35%) patients in the control group vs 1 (4%) in the device group underwent re-excision for margin involvement (P < .05). The use of the MarginProbe device at our institution significantly improved the ability of our surgeons to obtain clear margins during initial BCS. Our results show a lower re-excision rate (4%) than those published in the multicenter trial (19.8%). We postulate that in the face of more patients having DCIS in our device group (30%), our surgeons responded by taking thicker shavings when the MarginProbe device reported margin involvement during the initial lumpectomy, resulting in greater success achieving clear final margins on the shaved tissue and a significantly lower re-excision rate than previously reported with the MarginProbe device.

Success rates of re-excision after positive margins for invasive lobular carcinoma of the breast

Rates of positive margins after surgical resection of invasive lobular carcinoma (ILC) are high (ranging from 18 to 60%), yet the efficacy of re-excision lumpReceptor subtypeectomy for clearing positive margins is unknown. Concerns about the diffuse nature of ILC may drive increased rates of completion mastectomy to treat positive margins, thus lowering breast conservation rates. We therefore determined the success rate of re-excision lumpectomy in women with ILC and positive margins after surgical resection. We identified 314 cases of stage I-III ILC treated with breast conserving surgery (BCS) at the University of California, San Francisco. Surgical procedures, pathology reports, and outcomes were analyzed using univariate and multivariate statistics and Cox-proportional hazards models. We evaluated outcomes before and after the year 2014, when new margin management consensus guidelines were published. Positive initial margins occurred in 118 (37.6%) cases. Of these, 62 (52.5%) underwent re-excision lumpectomy, which cleared the margin in 74.2%. On multivariate analysis, node negativity was significantly associated with successful re-excision (odds ratio [OR] 3.99, 95% CI 1.15-13.81, p = 0.029). After 2014, we saw fewer initial positive margins (42.7% versus 25.5%, p = 0.009), second surgeries (54.6% versus 20.2%, p < 0.001), and completion mastectomies (27.7% versus 4.5%, p < 0.001). In this large cohort of women with ILC, re-excision lumpectomy was highly successful at clearing positive margins. Additionally, positive margins and completion mastectomy rates significantly decreased over time. These findings highlight improvements in management of ILC, and suggest that completion mastectomy may not be required for those with positive margins after initial BCS.

Utilization of iron (III)-doped nanoshells for in vivo marking of nonpalpable tumors using a VX2 rabbit model

BACKGROUND

We aimed to evaluate the potential for ultrasound (US) visible biodegradable nanoshells (NS) as an alternative to wire-guided localization for nonpalpable tumors in vivo.

METHODS

VX2 tumor was injected in bilateral thighs of 22 New Zealand rabbits and after 5 to 10 days, 1 tumor was marked with a wire as a control and the contralateral tumor was injected with 1 mL of 500 nm gas-filled silica NS under Doppler US. Tumors were excised after 24 hours. Chi-square was used for significance, P = .05.

RESULTS

One rabbit was excluded on postoperative day 1 due to equipment failure, no ill effects were observed from the NS. The NS were used to localize and resect 100% of marked tissue, 4/21 wires were displaced (P < .05).

CONCLUSIONS

We have shown that preoperatively injected US visible silica NS can be successfully used to mark nonpalpable tumors in vivo more consistently than WL.

Association between underestimation of tumour size by imaging and incomplete excision in breast-conserving surgery for breast cancer

Background

Completeness of excision is the most important factor influencing local recurrence after breast-conserving surgery (BCS). The aim of this case–control study was to determine factors influencing incomplete excision in patients undergoing BCS.

Methods

Women with invasive breast cancer treated by BCS between 1 June 2008 and 31 December 2009 were identified from a prospectively collected database in the Edinburgh Breast Unit. The maximum size of the tumour, measured microscopically, was compared with the size estimated before operation by mammography and ultrasound imaging. A multivariable analysis was performed to investigate factors associated with incomplete excision.

Results

The cohort comprised 311 women, of whom 193 (62·1 per cent) had a complete (CE group) and 118 (40·7 per cent) an incomplete (IE group) excision. Mammography underestimated tumour size in 75·0 per cent of the IE group compared with 40·7 per cent of the CE group (P &lt; 0·001). Ultrasound imaging underestimated tumour size in 82·5 per cent of the IE group compared with 56·5 per cent of the CE group (P &lt; 0·001). The risk of an incomplete excision was greater when mammography or ultrasonography underestimated pathological size: odds ratio (OR) 4·38 (95 per cent c.i. 2·59 to 7·41; P &lt; 0·001) for mammography, and OR 3·64 (2·03 to 6·54; P &lt; 0·001) for ultrasound imaging. For every 1-mm underestimation of size by mammography and ultrasonography, the relative odds of incomplete excision rose by 10 and 14 per cent respectively.

Conclusion

Underestimation of tumour size by current imaging techniques is a major factor associated with incomplete excision in women undergoing BCS.

Magnetic Resonance Imaging-Guided Breast Interventions: Role in Biopsy Targeting and Lumpectomies

Contrast-enhanced breast MR imaging is increasingly being used to diagnose breast cancer and to perform biopsy procedures. The American Cancer Society has advised women at high risk for breast cancer to have breast MR imaging screening as an adjunct to screening mammography. This article places special emphasis on biopsy and operative planning involving MR imaging and reviews use of breast MR imaging in monitoring response to neoadjuvant chemotherapy. Described are peer-reviewed data on currently accepted MR imaging-guided procedures for addressing benign and malignant breast diseases, including intraoperative imaging.

Preoperative chemotherapy for T2 breast cancer is associated with improved surgical outcome

BACKGROUND

The aim of this study is to compare the clinical outcome in T2 breast cancer patients who underwent preoperative chemotherapy (PC) and who did not. The study also tried to define a subgroup of patients, who are more beneficial after PC in terms of lower re-excision rates, better cosmetic results and local recurrence free survival.

MATERIALS AND METHODS

251 consecutive patients treated for nonmetastatic T2 invasive breast cancer were analyzed retrospectively. Of those; 141 underwent primary surgery (PS) followed by chemotherapy, whereas 110 were treated with combination of PC and surgery.

RESULTS

The patients who were treated with PC had a significantly higher incidence of negative margins and lower rate of re-excision (5% vs. 16%, p = 0.02). Of all patients attempted breast conserving surgery (BCS), patients in the PC group were more likely to undergo BCS as their definitive operation compared to patients with PS group (BCS rates; PC group: 99% vs. PS group: 92%, p = 0.05). Multifocal disease (OR: 7, 95% Cl, 2.7-18.4, p = 0.0001) and PC (OR = 0.2; 95% CI, 0.06-0.72, p = 0.01) were factors associated with margin positivity in patients treated with BCS. There was no statistically significant difference in 5 year local-recurrence free survival rates between 2 groups.

CONCLUSIONS

Our study shows that PC significantly decreases the re-excision in patients undergoing BCS with primary T2 breast tumors. This data suggests that any patient with a tumor greater than 2 cm might be considered for PC to increase BCS success with final negative margins.

Application of desorption electrospray ionization mass spectrometry imaging in breast cancer margin analysis

Distinguishing tumor from normal glandular breast tissue is an important step in breast-conserving surgery. Because this distinction can be challenging in the operative setting, up to 40% of patients require an additional operation when traditional approaches are used. Here, we present a proof-of-concept study to determine the feasibility of using desorption electrospray ionization mass spectrometry imaging (DESI-MSI) for identifying and differentiating tumor from normal breast tissue. We show that tumor margins can be identified using the spatial distributions and varying intensities of different lipids. Several fatty acids, including oleic acid, were more abundant in the cancerous tissue than in normal tissues. The cancer margins delineated by the molecular images from DESI-MSI were consistent with those margins obtained from histological staining. Our findings prove the feasibility of classifying cancerous and normal breast tissues using ambient ionization MSI. The results suggest that an MS-based method could be developed for the rapid intraoperative detection of residual cancer tissue during breast-conserving surgery.

A randomized prospective study of lumpectomy margin assessment with use of MarginProbe in patients with nonpalpable breast malignancies

Background

The presence of tumor cells at the margins of breast lumpectomy specimens is associated with an increased risk of ipsilateral tumor recurrence. Twenty to 30 % of patients undergoing breast-conserving surgery require second procedures to achieve negative margins. This study evaluated the adjunctive use of the MarginProbe device (Dune Medical Devices Ltd, Caesarea, Israel) in providing real-time intraoperative assessment of lumpectomy margins.

Methods

This multicenter randomized trial enrolled patients with nonpalpable breast malignancies. The study evaluated MarginProbe use in addition to standard intraoperative methods for margin assessment. After specimen removal and inspection, patients were randomized to device or control arms. In the device arm, MarginProbe was used to examine the main lumpectomy specimens and direct additional excision of positive margins. Intraoperative imaging was used in both arms; no intraoperative pathology assessment was permitted.

Results

In total, 596 patients were enrolled. False-negative rates were 24.8 and 66.1 % and false-positive rates were 53.6 and 16.6 % in the device and control arms, respectively. All positive margins on positive main specimens were resected in 62 % (101 of 163) of cases in the device arm, versus 22 % (33 of 147) in the control arm (p < 0.001). A total of 19.8 % (59 of 298) of patients in the device arm underwent a reexcision procedure compared with 25.8 % (77 of 298) in the control arm (6 % absolute, 23 % relative reduction). The difference in tissue volume removed was not significant.

Conclusions

Adjunctive use of the MarginProbe device during breast-conserving surgery improved surgeons’ ability to identify and resect positive lumpectomy margins in the absence of intraoperative pathology assessment, reducing the number of patients requiring reexcision. MarginProbe may aid performance of breast-conserving surgery by reducing the burden of reexcision procedures for patients and the health care system.

Future directions for monitoring treatment responses in breast cancer

In the prior review, we outlined the current standard of care for monitoring treatment responses in breast cancer and discussed the many challenges associated with these strategies. We described the challenges faced in common clinical settings such as the adjuvant setting, neoadjuvant setting, and the metastatic setting. In this review, we will expand upon future directions meant to overcome several of these current challenges. We will also explore several new and promising methods under investigation to enhance how we monitor treatment responses in breast cancer. Furthermore, we will highlight several new technologies and techniques for monitoring breast cancer treatment in the adjuvant, neoadjuvant and metastatic setting.

Topical dual-stain difference imaging for rapid intra-operative tumor identification in fresh specimens

Assessing tumor margin status during surgery is critical to ensure complete resection of cancer tissue; however, current approaches are ineffective and often result in repeat surgery. We present an optical imaging approach for margin assessment using topical application of two fluorescent stains, one targeted to a tumor biomarker and the other a nontargeted reference, to freshly excised specimens. Computing a normalized difference image from fluorescence images of the targeted and untargeted stains suppresses the confounding effects of nonspecific uptake. Applying this approach in excised breast tumor models produced promising tumor-to-normal tissue contrasts that were significantly higher than single-targeted-stain imaging.

Hospital and surgeon caseload are associated with risk of re-operation following breast-conserving surgery

Breast-conserving surgery (BCS) is increasingly used for breast cancer treatment. One of the disadvantages of BCS is the risk of re-operation, associated with additional costs to the woman, health service and society. Hospital and surgeon caseload have been associated with better outcomes in breast cancer. Whether these are related to re-operation rates is not clear. In women who underwent BCS initially, we aimed to quantify re-operation rates and identify the factors related to the risk of undergoing subsequent (i) re-operation and (ii) total mastectomy (TM). From the National Cancer Registry Ireland, we identified women diagnosed with a first invasive breast cancer during 2002-2008, and who initially had BCS. Poisson regression with robust error variance was used to identify factors significantly associated with (i) re-operation (vs no re-operation) or (ii) re-operation by TM (vs re-operation by BCS). 16,551 women were diagnosed with invasive breast cancer and 8,318 underwent initial BCS. Of these, 17 % had one or more subsequent re-operations and, of these, 62 % had TM. Surgeon and hospital volume significantly predicted subsequent re-operation after adjustment for socio-demographic and clinical variables. Women having surgery in lower-volume hospitals by low-volume surgeons significantly increased the risk of re-operation [incidence rate ratio (IRR) = 1.56; 95 % CI 1.33-1.83] compared to those operated in higher-volume hospitals by a higher-volume surgeon. Risk of subsequent TM was increased by 22 % (95 % CI 1.10-1.35) and 21 % (95 % CI 1.09-1.33), if women were operated by a lower or intermediate-volume surgeon. The fact that factors related to healthcare organisation/service provision are associated with re-operations suggests that it may be possible to reduce the overall re-operation rate. The high frequency of subsequent TM raises questions about strategies for selecting women for initial BCS. Our results may inform the development of information strategies to help ensure that women are aware of risks of re-operation following BCS and hence, make appropriate treatment choices.

Imaging-assisted large-format breast pathology: program rationale and development in a nonprofit health system in the United States

Modern breast imaging, including magnetic resonance imaging, provides an increasingly clear depiction of breast cancer extent, often with suboptimal pathologic confirmation. Pathologic findings guide management decisions, and small increments in reported tumor characteristics may rationalize significant changes in therapy and staging. Pathologic techniques to grossly examine resected breast tissue have changed little during this era of improved breast imaging and still rely primarily on the techniques of gross inspection and specimen palpation. Only limited imaging information is typically conveyed to pathologists, typically in the form of wire-localization images from breast-conserving procedures. Conventional techniques of specimen dissection and section submission destroy the three-dimensional integrity of the breast anatomy and tumor distribution. These traditional methods of breast specimen examination impose unnecessary limitations on correlation with imaging studies, measurement of cancer extent, multifocality, and margin distance. Improvements in pathologic diagnosis, reporting, and correlation of breast cancer characteristics can be achieved by integrating breast imagers into the specimen examination process and the use of large-format sections which preserve local anatomy. This paper describes the successful creation of a large-format pathology program to routinely serve all patients in a busy interdisciplinary breast center associated with a community-based nonprofit health system in the United States.

Intraoperative imprint cytology and frozen section pathology for margin assessment in breast conservation surgery: a systematic review

BACKGROUND

Achieving negative surgical margins is critical to minimizing the risk of tumor recurrence in patients undergoing breast conservation surgery (BCS) for a breast malignancy. Our objective was to perform a systematic review comparing reexcision rates, sensitivity and specificity of the intraoperative use of the margin assessment techniques of imprint cytology (IC) and frozen section analysis (FSA), against permanent histopathologic section (PS).

METHODS

The databases PubMed, Web of Knowledge, Cochrane Library and CINAHL Plus were searched for literature published from 1997 to 2011. Original investigations of patients who underwent BCS for breast cancer that evaluated margin assessment with PS and/or IC or FSA were included. Of 182 titles identified, 41 patient cohorts from 37 articles met inclusion criteria: PS (n = 19), IC (n = 7) and FSA (n = 15). Studies were summarized qualitatively using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cohort studies and the Strength of Recommendation Taxonomy (SORT) numerical scale for diagnostic studies.

RESULTS

The final reexcision rates after primary BCS were 35 % for PS, 11 % for IC (p = 0.001 vs. PS) and 10 % for FSA (p < 0.0001 vs. PS). For IC, reexcision rates decreased from 26 to 4 % (p = 0.18) and for FSA, reexcision rates decreased from 27 to 6 % (p < 0.0001). The pooled sensitivity of IC and FSA were 72 and 83 %. The pooled specificity of IC and FSA were 97 and 95 %. The average length of each technique was 13 min for IC and 27 min for FSA.

CONCLUSIONS

Patients who underwent BCS with intraoperative IC or FSA to assess negative surgical margins had significantly fewer secondary surgical procedures for excision of their breast malignancies.

Predictive factors for residual disease in re-excision specimens after breast-conserving surgery

Local recurrence is an issue of concern after breast-conserving therapy and removing the primary tumor with negative surgical margins is the most important determinant of local recurrence. However, some patients with positive margins after initial surgery will have no residual tumor in the re-excision specimen. To avoid unnecessary re-excisions, factors predicting residual disease in re-excision material should be determined. This study aimed to determine the predictive factors for residual disease in the re-excision material in a homogeneous group of patients with positive margins and only invasive ductal carcinoma. Breast cancer patients treated between 2005 and 2008 with breast-conserving surgery and subsequent re-excisions due to positive surgical margins after initial surgery were included in the study. Patients were divided into two groups as those with and without residual disease in the re-excision material. One hundred and four breast cancer patients were included in the study. Forty-seven patients (45.2%) had residual tumor in re-excision specimen. Patient characteristics such as age (p = 0.42) and physical findings (p = 1.0) and specimen volume (p = 0.24), tumor grade (p = 0.33), estrogen (p = 1.0), and progesterone (p = 0.37) receptor status, axillary lymph node metastases (p = 0.16), extensive intraductal component (p = 0.8), and lymphovascular invasion (p = 0.064) were found as insignificant factors for predicting residual tumor. Large tumor size (>3 cm) (p = 0.026), human epidermal growth factor receptor2 (HER2) positivity (p = 0.013), and tumor to specimen volume ratio of >70% (p = 0.002) significantly increased the probability of finding residual disease after re-excision. In multivariate analysis, HER2 positivity (p = 0.046) and tumor to specimen volume ratio of >70% (p = 0.006) independently predicted the presence of residual disease. As a result, in patients with HER2 positive tumors larger than 3 cm, larger volume of breast tissue around the tumor should be removed to decrease the number of re-excisions due to positive surgical margins.

Hollow silica and silica-boron nano/microparticles for contrast-enhanced ultrasound to detect small tumors

Diagnosing tumors at an early stage when they are easily curable and may not require systemic chemotherapy remains a challenge to clinicians. In order to improve early cancer detection, gas filled hollow boron-doped silica particles have been developed, which can be used for ultrasound-guided breast conservation therapy. The particles are synthesized using a polystyrene template and subsequently calcinated to create hollow, rigid nanoporous microspheres. The microshells are filled with perfluoropentane vapor. Studies were performed in phantoms to optimize particle concentration, injection dose, and the ultrasound settings such as pulse frequency and mechanical index. In vitro studies have shown that these particles can be continuously imaged by US up to 48 min and their signal lifetime persisted for 5 days. These particles could potentially be given by intravenous injection and, in conjunction with contrast-enhanced ultrasound, be utilized as a screening tool to detect smaller breast cancers before they are detectible by traditional mammography.

Preoperative staging with magnetic resonance imaging, with confirmatory biopsy, improves surgical outcomes in women with breast cancer without increasing rates of mastectomy

Needle biopsy to evaluate findings on MRI that could alter surgical planning has been recommended. This study is a retrospective review to evaluate MRI preoperative staging with biopsy confirmation of suspicious findings. A total of 184 women were diagnosed with breast cancer between January 2004 and June 2008. Of these, 79 underwent bilateral MRI before definitive surgery and 105 did not. Suspicious findings on MRI, mammography, or clinical exam underwent additional needle biopsy at the discretion of the surgeon. A retrospective chart review was performed to compare the two groups with respect to rates of reoperative surgery, successful breast conservation, and confirmatory biopsies. Sensitivity and specificity of MRI for preoperative staging is 0.81 and 0.84, respectively. There were no significant differences in demographics or cancer characteristics between the MRI and non-MRI groups. Fewer women who underwent preoperative MRI staging required repeat breast surgery (11% versus 26%, p = .04) or repeat axillary surgery (10% versus 20%, p = .05). There is no difference in the proportion of women who successfully completed conservative therapy and those treated radically (52% versus 53%), but there is a significant increase in women who undergo additional needle biopsy to confirm suspicious findings after initial diagnosis in the MRI group (25% versus 11% p = .04). In this study, mastectomy rates are not increased; suggesting that women who undergo mastectomy following staging would undergo mastectomy following failed conservative therapy if they were not staged. The downside of this improvement is a 14% increase in women who require confirmatory biopsy.

Involved anterior margins after breast conserving surgery: is re-excision required?

BACKGROUND

Complete tumour excision in breast conserving surgery (BCS) is critical for successful outcome; involved circumferential resection margins are associated with increased disease recurrence. However, the importance of an involved anterior margin (IAM) is less clear. The purpose of this study was to review an aggressive approach to IAM and hence assess whether anterior margin re-excision (RE) yields clinical benefit.

METHODS

A review of prospectively collected clinical and pathology data was performed for all patients who underwent BCS between 2006 and 2010 through a single cancer centre. An involved margin was defined as < 1 mm clearance of invasive or in-situ breast cancer.

RESULTS

1667 patients underwent BCS for invasive and/or in-situ disease, of whom 114 underwent RE. A total of 170 involved margins were identified: most commonly the anterior (52 margins) followed by the posterior (39 margins) and inferior (31 margins) margin. Patients with IAM were more likely to have grade 3 invasive disease (p = 0.0323) but less likely to have residual disease found at re-excision (2/49 vs. 32/101 margins, p = 0.0033); there were no differences when in-situ characteristics were compared.

CONCLUSIONS

RE of IAM after BCS rarely yields further disease; multi-disciplinary teams should consider whether further therapy for an IAM is required on a patient by patient basis.

Sonographic tomography for the preoperative staging of breast cancer prior to surgery

INTRODUCTION

This study is a preliminary retrospective analysis of a new imaging technique, sonographic tomography, for the determination of the exact extent of disease prior to definitive surgery for breast cancer.

MATERIALS AND METHODS

Forty-one women were diagnosed with breast cancer had preoperative staging using sonographic tomography, between August 2007 and June 2008. All these women subsequently underwent bilateral contrast-enhanced MRI prior to surgery to determine if there were areas of tumor extension, multifocality, axillary adenopathy, or contralateral disease that would affect their planned surgery. Both imaging techniques were then compared retrospectively for accuracy to pathologic truth.

RESULTS

Sonographic tomography accurately staged breast cancer preoperatively in 68% of cases, while MRI did so in 54% of cases. The resulting improvement in overall accuracy is 14% (2-28%). Sonographic tomography appears non-inferior to contrast enhanced, bilateral breast MRI.

CONCLUSIONS

Further, prospective, study is needed to further evaluate this new imaging technique in preoperative staging prior to definitive surgery.

Conductive interstitial thermal therapy (CITT) inhibits recurrence and metastasis in rabbit VX2 carcinoma model

PURPOSE

To investigate the potential of conductive interstitial thermal therapy (CITT) to inhibit recurrence and metastasis in a partially resected tumour model.

METHOD

Fifteen New Zealand white rabbits were implanted with VX2 tumour intramuscularly in the rear thigh. Once the tumour size reached 20-25 mm in diameter, three animals were randomly selected to serve as controls, while the remaining animals were designated as the study group and treated with CITT. In the CITT group, the partially resected tumour and margins were thermally ablated. In the control group the tumour was partially resected to simulate positive margins. The animals were monitored for up to 12 weeks. At the endpoint, the animals were sacrificed, and whole-body diagnostic necropsy was conducted immediately.

RESULTS

Recurrences and metastatic lesions were observed in iliac and popliteal lymph nodes and abdomens of all control animals. In contrast, the observed rate of recurrence and metastatic lesion was 0% among CITT-treated animals, significantly less than the >or=50% null-hypothesis rate expected upon treatment failure (exact binomial P = 0.0002). Complete histopathological healing was obtained in 2 of 12 rabbits, and residual inflammation remained at the ablation site up to 12 weeks post-ablation in 10 of 12 rabbits. This pattern of necrosis and inflammatory response was not observed in any of the control rabbits.

CONCLUSIONS

The CITT device effectively ablated partially resected VX2 carcinoma in a rabbit model, and inhibited recurrence and metastasis in this model. CITT evoked an inflammatory response that may be linked to the mechanism involved in reduced metastatic spread.

Lateral mammaplasty reconstruction after surgery for breast cancer

BACKGROUND

Up to 60 per cent of cancers develop laterally in the breast and breast-conserving surgery frequently produces superolateral nipple-areolar complex (NAC) distortion aggravated by postoperative irradiation. Correction is technically demanding and the outcomes are variable. Lateral mammaplasty may allow wider excision margins and prevent such deformities.

METHODS

This was a review of 86 consecutive patients who had lateral mammaplasty: combined wide tumour excision with NAC repositioning on a reliable dermoglandular pedicle. Simultaneous axillary surgery was performed via a separate or combined incision. Aesthetic outcomes were assessed.

RESULTS

The median age of the women was 54 (range 29-75) years; 55 (64 per cent) had palpable tumours and 73 (85 per cent) underwent simultaneous axillary surgery. Median radiological and histological tumour sizes were 29.8 and 33.6 mm, respectively, and median weight of excised tumour was 150 g. Two patients required haematoma evacuation. Eleven women required revisional surgery for involved or close margins. Aesthetic outcomes were excellent or good in 93 per cent.

CONCLUSION

Lateral mammaplasty produced clear margins in 87 per cent of women. It is an option when a deformity is anticipated after breast-conserving surgery, and is particularly valuable when neoadjuvant chemotherapy has downgraded a large tumour.

Conductive interstitial thermal therapy device for surgical margin ablation:In vivoverification of a theoretical model

PURPOSE

To demonstrate the efficacy and predictability of a new conductive interstitial thermal therapy (CITT) device to ablate surgical margins.

METHOD

The temperature distributions during thermal ablation of CITT were calculated with finite element modelling in a geometrical representation of perfused tissue. The depth of ablation was derived using the Arrhenius and the Sapareto and Dewey (S&D) models for the temperature range of 90 to 150 degrees C. The female pig animal model was used to test the validity of the mathematical model. Breast tissues were ablated to temperatures in the range of 79-170 degrees C, in vivo. Triphenyltetrazolium chloride viability stain was used to delineate viable tissue from ablated regions and the ablation depths were measured using digital imaging.

RESULTS

The calculations suggest that the CITT can be used to ablate perfused tissues to a 10-15 mm width within 20 minutes. The measured and calculated depths of ablation were statistically equivalent (99% confidence intervals) within +/- 1mm at 170 degrees C. At lower temperatures the equivalence between the model and the observations was within +/- 2 mm.

CONCLUSION

The CITT device can reliably and uniformly ablate a 10-15 mm wide region of soft tissue. Thus, it can be used to secure negative margins following the resection of a primary tumor, which could impede local recurrences in the treatment of local diseases such as early staged, non-metastatic, breast cancer.

Automated microscopy to evaluate surgical specimens via touch prep in breast cancer

BACKGROUND

Breast conservation therapy is the standard treatment for breast cancer; however, 20-50% of operations have a positive margin leading to secondary procedures. The standard of care to evaluate surgical margins is based on permanent section. Imprint cytology (touch prep) has been used to evaluate surgical samples, but conventional techniques require an experienced cytopathologist for correct interpretation. An automated image screening process has been developed to discern cancer cells from normal epithelial cells. This technique is based on cellularity of the imprint specimen and does not require expertise in cytopathology.

METHODS

A rapid immunofluorescent staining technique coupled with automated microscopy was used to classify specimens as cancer vs. noncancer based on the density of epithelial cells captured on touch prep of tumor cross-sections. The results of the automated analysis vs. a manual screen of ten 20x fields were compared to the pathology interpretation on permanent section.

RESULTS

A total of 34 consecutive cases were analyzed: 10 normal cases, and 24 cancer cases. The cross-section specimens for invasive cancer were correctly classified in at least 65% of the cases by using manual microscopy and at least 83% by using automated microscopy. The manual and automated microscopy correlated well for measurements of epithelial cell density (R(2)=0.64); however, the automated microscopy was more accurate.

CONCLUSIONS

This preliminary study using an automated system for intraoperative interpretation does not require a cytopathologist and shows that rapid, low-resolution imaging can correctly identify cancer cells for invasive carcinoma in surgical specimens. Therefore, automated determination of cellularity in touch prep is a promising technique for future margin interpretation of breast conservation therapy.

A prospective, randomized, controlled, multicenter study of a real-time, intraoperative probe for positive margin detection in breast-conserving surgery

BACKGROUND

This randomized, double-arm trial was designed to study the benefit of a novel device (MarginProbe, Dune Medical Devices, Caesarea, Israel) in intraoperative margin assessment for breast-conserving surgery (BCS) and the associated reduction in reoperations.

METHODS

In the device group, the probe was applied to the lumpectomy specimen and additional tissue was excised according to device readings. Study arms were compared by reoperation rates and by correct surgical reaction confirmed by histology.

RESULTS

Three hundred patients were enrolled. Device use was associated with improved correct surgical reaction, defined as additional re-excision in all histologically detected positive margins, with tumor within 1 mm of inked margin. The repeat lumpectomy rate was significantly reduced by 56% in the device arm: 5.6% versus 12.7% in the control arm. There were no differences in excised tissue volume or cosmetic outcome.

CONCLUSIONS

Intraoperative use of the MarginProbe for positive margin detection is safe and effective in BCS and decreases the rate of repeat operations.

Conductive interstitial thermal therapy (CITT) device evaluation in VX2 rabbit model

We have developed a conductive interstitial thermal therapy (CITT) device to precisely and reliably deliver controlled thermal doses to the surgical margins at the cavity site following tumor resection, intraoperatively. The temperature field created by CITT ablation of a perfused tissue was modeled with a finite element package Femlab. The modeling suggested that a maximum probe temperature of 120 degrees C and an ablation time of 20 minutes were required to ablate highly perfused tissue such as the VX2 carcinoma. Deployable pins enable faster and more reliable thermal ablation. The model predictions were tested by thermal ablation of VX2 carcinoma tumors implanted in adult New Zealand rabbits. The size of the ablated region was confirmed with a viability stain, triphenyltetrazolium chloride (TTC). Histopathological examination revealed 3 regions in the ablated area: a carbonized region (1-3 mm); a region that contained thermally fixed cells; and an area of coagulated necrosis cells. Cells in the thermally fixed region stained for PCNA (proliferating cell nuclear antigen) and were bounded by the carbonized layer at the cavity wall, and by necrotic cells that exhibit nuclear fragmentation and cell dissociation, 5 to 10 mm away from the CITT probe. Adjacent tissue outside the target region was spared with a clear demarcation between ablated and normal viable tissue. It is suggested that the CITT device can be used, clinically, to inhibit local recurrence by creating negative surgical margins following the resection of a primary tumor in non-metastatic early staged tumors.

Enhanced Touch Preps Improve the Ease of Interpretation of Intraoperative Breast Cancer Margins

Positive margins and the resulting multiple operations are a major problem for breast conservation therapy. Accurate assessment of intraoperative tumor margins can limit multiple re-excision procedures. Intraoperative touch preparations have been used in the past but can be difficult to interpret without an experienced cytopathologist. The objective of this study is to examine the reliability of enhanced intraoperative touch preps (EIOTP) compared with final pathologic margins. We prospectively performed EIOTP on 20 tumors in women undergoing breast conservation therapy. Six margins and the main tumor were touched onto poly-L-lysine coated slides. The slides were stained with anti MUC1 and anti-E-cadherin antibodies, and Hoechst nuclear stain. A parallel set of slides were stained with hematoxylin and eosin for comparison. The EIOTP results were compared with pathologic interpretation of paraffin embedded permanent sections. A total of 120 margins underwent EIOTP in 20 patients. We found a sensitivity equal to 80 per cent, specificity 100 per cent, positive predictive value 100 per cent, and negative predictive value 99 per cent. EIOTP in conjunction with MUC-1 and E-cadherin by immunofluorescence is a sensitive and highly specific mechanism to identify cancer cells at breast tissue margins. The immunofluorescence stains may help the pathologist to identify cancer cells in fresh breast tissue and limit breast re-excisions in the future.

Role of sentinel lymph node biopsy in high-risk ductal carcinoma in situ patients

BACKGROUND

The role of sentinel lymph node biopsy (SLNB) for ductal carcinoma in situ (DCIS) is poorly defined. However, up to 20% of patients with DCIS will have invasive carcinoma; these patients require staging for axillary metastasis. The aim of this study was to identify patients with a core biopsy diagnosis of DCIS who may benefit from SLNB.

METHODS

In a prospective study, we performed SLNB on patients with a preoperative diagnosis of >2.5 cm of high-grade DCIS or DCIS when mastectomy was indicated.

RESULTS

Sixty-two patients underwent surgery for high-grade DCIS, and 35 of these patients underwent SLNB. Postsurgical excision histology revealed invasive disease in 20 patients, 19 of whom had undergone SLNB. Before the adoption of SLNB in selected DCIS patients, all 20 with occult invasive disease would have required second surgery axillary staging (P < .01, chi-square test).

CONCLUSIONS

SLNB should not be performed routinely for all patients with an initial diagnosis of DCIS. However, selective lymphadenectomy may be a useful clinical adjuvant in selected high-risk DCIS patients.

The role of reexcision for positive margins in optimizing local disease control after breast-conserving surgery for cancer

One of the most important factors associated with local recurrence after lumpectomy in breast cancer patients is the status of the surgical margin. Standard surgical practice is to obtain clear margins even if this requires a second surgical procedure. It is assumed that reexcision to achieve clear margins when positive margins are present at initial excision is as effective as complete tumor removal at a single procedure; however, the efficacy of reexcision in this context has not been well studied. A retrospective search of the Henrietta Banting Breast Centre database from 1987 to 1997 identified 1430 patients who underwent lumpectomy for invasive breast cancer: 1225 patients (group A) had negative margins at the initial surgery and 152 patients (group B) underwent one or more reexcisions to achieve negative margins. Fifty-three patients had positive margins at final surgery, but no reexcision was done (group C). Logistic regression was used to identify factors that were predictive of a positive margin; predictors of local recurrence in women whose tumors were completely resected were determined using Cox's proportional hazards model. Patients in groups A, B, and C differed with respect to mean age at diagnosis (58 years, 51 versus, and 56 years, respectively, p < 0.0001), mean tumor size (19 mm, 16 mm, and 26 mm, respectively, p < 0.0001), node positivity (30%, 22%, and 41%, respectively, p = 0.004), and the presence of a ductal carcinoma in situ (DCIS) component (60%, 64%, and 79%, respectively, p = 0.007). The mean follow-up period was similar for the three groups (8 years, 8 years, and 9 years, respectively, p = 0.17). Young age was the only variable predictive of positive margins. Among patients undergoing complete tumor excision, there was a suggestion of a higher 10 year local recurrence rate in reexcision group B, but the difference did not reach statistical significance (11.6% versus 16.6%, p = 0.11). Cox's multivariate regression analyses identified older age, smaller tumor size, receiving radiation therapy, and tamoxifen use as significantly decreasing the rate of local recurrence in patients with negative margins at initial surgery or after reexcision. Our data confirm the results of previous studies indicating that young age is an independent predictor of positive margins after lumpectomy for invasive breast cancer. The only independent predictor of local recurrence in our study cohort was large tumor size. There was a trend toward a higher local recurrence rate if more than one procedure was required to secure clear margins, although this effect was not independent of other factors. Reexcision to clear involved margins is an important surgical intervention for both younger and older women.

Systematic cavity shaves reduces close margins and re-excision rates in breast conserving surgery

The role of cavity shaves in reducing re-excision rates in breast conserving surgery (BCS) remains unclear. We compared rates of close margins and re-excision following cavity shaves based on either intraoperative radiology or systematic cavity shaves. Data was recorded prospectively from 1999 to 2003 for 217 patients undergoing BCS. For the first 106 cases, cavity shaves were performed when intraoperative radiological margins appeared close (<10 mm). The remaining 111 cases had systematic superior and inferior cavity shaves (SSICS). Close margins and re-excision rates were compared between groups. The median weight of excised tissue was less in group two: 82.8 g versus 100.5 g, P=0.001. SSICS reduced close margins by 83% (18/106 versus 8/111), OR 0.17, 95% CI 0.08-0.48, P=0.001. Multivariate analysis showed SSICS also reduced re-excision rates (15 versus 8 cases), OR 0.26, 95% CI 0.09-0.74, P=0.012. SSICS reduces close margins and re-excision rates. This approach has additional cosmetic benefits because less tissue is excised.

The role of sentinel lymph node biopsy in ductal carcinoma in situ

AIM

To review the role of sentinel lymph node (SLN) biopsy in the surgical management of patients with ductal carcinoma in situ (DCIS).

METHODS

A search was conducted of Medline and the National Library of Medicine to identify key articles concerning DCIS, SLN biopsy (SLNB) and axillary dissection. Further relevant articles were obtained from the references cited in the literature.

RESULTS

Up to 20% of patients with a core biopsy diagnosis of DCIS will be later up-staged based on an invasive component identified on the excision specimen. Quality assurance in breast screening programmes requires minimally invasive pre-operative diagnosis and also axillary sampling in the case of documented invasive disease. As an effective and validated procedure, SLNB represents a paradigm shift in the surgical management of the axilla for patients with invasive breast cancer. It remains undefined which, if any, subgroups of patients with DCIS should undergo SLNB.

CONCLUSION

Axillary lymphadenectomy is an overtreatment for patients with DCIS. Performing a SLNB during the initial procedure may avoid a second operation in some DCIS patients who are diagnosed with occult invasive disease at their definitive operation. When predictors of hidden invasive disease are clarified by further study, SLNB may be used in the management of selected high-risk DCIS patients.

Surgical benefits conveyed by biopsy site marking system using ultrasound localization

BACKGROUND

With vacuum-assisted biopsy technology all, or most, of a breast lesion may be removed during the initial biopsy; in such cases a metallic marker is often inserted at the site of the biopsy for future localization. The aim of this study was to evaluate the efficacy and impact of the Gel Mark Ultra biopsy site marking system (SenoRx, Aliso Viejo, CA) on the practice of needle localization breast biopsy.

METHODS

We retrospectively analyzed the experience of 45 general surgeons across the United States in a variety of practice settings using the Gel Mark Ultra clip. Imaging-guided biopsy technique, localization quality, surgeon confidence, and margin status were assessed and compared against the broad data reported in the literature.

RESULTS

A total of 432 records of patients who underwent imaging-guided breast biopsy with placement of Gel Mark Ultra clip were reviewed. Of these, 63 (15%) patients required definitive surgical intervention, for which 41 cases were localized with ultrasound and assessed for margin clearance. Clear margins were achieved in 37 (90%) of the 41 cases. These results are statistically superior (P < .01) to positive margins rates reported in the literature.

CONCLUSIONS

The Gel Mark Ultra biopsy site marking system is a new localization device that provides a safe and effective alternative to traditional localization methods with a significant reduction in the percentage of positive margins, as well as advantages in terms of surgical approach, time, and patient comfort.