Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy

Effect of re-excision on local recurrence in patients with involved or close margins after upfront breast-conserving surgery: a systematic review and meta-analysis

BACKGROUND

Involved margins after breast-conserving surgery are associated with increased risk of local recurrence. A systematic search and meta-analysis was conducted to investigate the still-unclear role of re-excision in reducing this risk.

METHODS

A systematic search of the English-language literature up to May 31, 2024, was performed using PubMed and Embase databases. Studies that met the following criteria were included in the meta-analysis: available full data, patients with breast cancer, involved or close margins after breast-conserving surgery, and comparison of local recurrence rates between patients who underwent re-excision and those who did not. Odds ratios (ORs) and 95% confidence intervals (CI) were calculated using the random effects model. Bias risk was assessed with Begg-Mazumdar and Egger tests.

RESULTS

Eight papers and 13 datasets were included in the analysis. Studies differed by sample selection: inclusion of patients with close margins and of both patients with invasive cancer and carcinoma in situ. Of the total 3728 patients, 1897 underwent re-excision and 1831 did not. The mean OR of local recurrence after re-excision was 1.034 (95% CI 0.656-1.629), with a p-value of 0.885. The mean OR of local recurrence after re-excision in patients with DCIS was 2.065 (95% CI 0.96 - 4.442), with a p-value of 0.063, and in patients with 10-years follow-up the mean OR was 1.47 (95% CI 0.75 - 2.86) with a p-value of 0.26.

CONCLUSION

The local recurrence rate in this study did not differ between patients with involved or close margins after breast-conserving surgery who had or did not have additional surgery. The absence of local control effect remained in those with longer follow-up. A trend toward an increased risk of local recurrence was observed in patients with carcinoma in situ who underwent re-excision; however, this finding did not reach statistical significance. Thus, we recommend against routine re-excision and suggest it should be carried out only in selected cases, after thorough discussion of a multidisciplinary team.

The effect of pre-operative MRI on the in-breast tumor recurrence rate of patients with breast cancer: a meta-analysis

PURPOSE

The impact of preoperative MRI on breast cancer recurrence and long-term outcomes remains undefined. Therefore, this study aims at determining the influence of preoperative MRI on in-breast tumor recurrence rates in cases of surgical treatment for breast cancer.

METHODS

A systematic review and meta-analysis were performed. Literature searches of PubMed, Scopus, and Google Scholar were conducted for studies up to February 2024. Two authors assessed the quality of the eligible studies and extracted their data.

RESULTS

The meta-analysis included 14 studies (2 RCTs, 12 cohort studies) with 12,889 patients with 5,451 undergoing preoperative MRI. Pooled hazard ratio for in-breast tumor recurrence was 0.95, using fixed effects and 0.94 using random effects models with 95% confidence intervals of 0.80-1.14 and 0.77-1.14, respectively. A trend towards lower recurrence rates in the MRI group was seen, but the reduction was not statistically significant.

CONCLUSION

This meta-analysis found no significant reduction in in-breast tumor recurrence rates associated with preoperative MRI use in breast cancer patients, consistent with previous findings.

Evaluation of Hologic LOCalizer™ RFID Tags for Preoperative Localization of Breast Lesions: A Single-Center Experience

Background: The increasing detection of non-palpable breast lesions necessitates accurate preoperative localization to ensure complete excision while preserving healthy tissue and optimizing cosmetic outcomes. Traditional wire-guided localization (WL) has been the gold standard; however, it has several drawbacks, including patient discomfort and scheduling challenges. This study evaluates the accuracy and feasibility of radiofrequency identification (RFID) tag localization using the Hologic LOCalizer™ system as an alternative technique. Methods: This retrospective study included 258 consecutive patients who underwent image-guided RFID tag localization from March 2021 to February 2023 from a single-center London breast unit. The primary outcome measured was the accuracy of RFID tag placement, defined as within 10 mm of the target lesion on post-clip mammograms. Secondary outcomes included type and size of lesions, re-excision rates, review of post-operative specimen radiographs, and patient demographics. Results: A total of 297 RFID tags were placed, with 95.6% accurately positioned within the target range. The median target size was 29 mm, with the most common abnormalities being mass lesions (64%). Among the 13 inaccurately placed RFID tags (4.4%), all were identified preoperatively, with two requiring additional wire placements. RFID tags were successfully identified in 92% of specimen radiographs, and 8% of patients required re-excision due to positive or close margins. Notably, patients with multiple RFID tags showed a higher incidence of re-excision. Conclusions: The LOCalizer™ RFID system demonstrated a high accuracy rate for preoperative localization of breast lesions, presenting a viable alternative to WL. This technique improves surgical scheduling flexibility and enhances patient comfort. Comparative studies with other wire-free localization technologies, such as magnetic seeds and radar reflectors, are needed to determine the optimal approach for clinical practice.

Reimagining Deintensification for Low-Risk Breast Cancer

As outcomes for low-risk breast cancer continue to improve, research and clinical paradigms are increasingly focused on appropriate deintensification with the goal of improving the therapeutic ratio of breast cancer treatment. These deintensification approaches span across disciplines including breast surgery, radiation therapy, and systemic therapy. With regard to breast surgery, studies have continued to push deintensification when it comes to surgical margins with breast conservation, reducing re-excision rates, whereas deintensification of axillary surgery has reduced the rates of axillary lymph node dissection and increasingly the need for any axillary surgery, including sentinel lymph node biopsy for low-risk patients. With regard to radiation therapy, studies have allowed for a drastic reduction in treatment duration, whereas approaches that reduce the target of treatment have led to a change from from treatment daily for 5-7 weeks to many low-risk patients completing treatment in just five treatments. With regard to systemic therapy, use of genomic assays and tumor biology has led to reduced utilization of cytotoxic chemotherapy, with studies also allowing for dose reduction of endocrine therapy for patients with ductal carcinoma in situ. Moving forward, greater focus should be placed on interdisciplinary deintensification approaches such as the consideration of radiation therapy alone as compared with endocrine therapy alone for low-risk breast cancers.

Secondary Resections and Survival After Breast-Conserving Surgery in Breast Cancer Patients: A Cancer Registry-Based Cohort Study

Breast cancer remains the most common malignancy in women, and breast-conserving surgery (BCS) with adjuvant radiotherapy is a standard treatment for early-stage disease. This study assessed the impact of positive surgical margins and secondary surgeries on local recurrence rates and patient outcomes. In this retrospective tumor registry-based study, 24,450 women were eligible for analysis. Of them, 18,082 underwent primary BCS only, 4836 underwent re-excision by BCS, and 1532 underwent re-excision by mastectomy following primary BCS. Our findings indicate that even though re-excision procedures were associated with higher local recurrence rates (HR 1.19; 95% CI 1.08-1.33), they did not significantly affect long-term survival (HR 0.98; 95% CI 0.87-1.10). This underscores the need for meticulous surgical practices to achieve clean margins initially, and suggests that the choice of surgical intervention should consider individual tumor characteristics and patient preferences to optimize oncological and aesthetic outcomes.

Immunohistochemical Evaluation of Cathepsin B, L, and S Expression in Breast Cancer Patients

PURPOSE

Cysteine cathepsins are proteases that play a role in normal cellular physiology and neoplastic transformation. Elevated expression and enzymatic activity of cathepsins in breast cancer (BCa) indicates their potential as a target for tumor imaging. In particular cathepsin B (CTSB), L (CTSL), and S (CTSS) are used as targets for near-infrared (NIR) fluorescence imaging (FI), a technique that allows real-time intraoperative tumor visualization and resection margin assessment. Therefore, this immunohistochemical study explores CTSB, CTSL, and CTSS expression levels in a large breast cancer patient cohort, to investigate in which BCa patients the use of cathepsin-targeted NIR FI may have added value.

PROCEDURES

Protein expression was analyzed in tumor tissue microarrays (TMA) of BCa patients using immunohistochemistry and quantified as a total immunostaining score (TIS), ranging from 0-12. In total, the tissues of 557 BCa patients were included in the TMA.

RESULTS

CTSB, CTSL, and CTSS were successfully scored in respectively 340, 373 and 252 tumors. All tumors showed CTSB, CTSL, and/or CTSS expression to some extent (TIS > 0). CTSB, CTSL, and CTSS expression was scored as high (TIS > 6) in respectively 28%, 80%, and 18% of tumors. In 89% of the tumors scored for all three cathepsins, the expression level of one or more of these proteases was scored as high (TIS > 6). Tumors showed significantly higher cathepsin expression levels with advancing Bloom-Richardson grade (p < 0.05). Cathepsin expression was highest in estrogen receptor (ER)-negative, human epidermal growth factor receptor 2(HER2)-positive and triple-negative (TN) tumors. There was no significant difference in cathepsin expression between tumors that were treated with neoadjuvant systemic therapy and tumors that were not.

CONCLUSIONS

The expression of at least one of the cysteine cathepsins B, L and S in all breast tumor tissues tested suggests that cathepsin-activatable imaging agents with broad reactivity for these three proteases will likely be effective in the vast majority of breast cancer patients, regardless of molecular subtype and treatment status. Patients with high grade ER-negative, HER2-positive, or TN tumors might show higher imaging signals.

Oncological outcomes of selective axillary dissection with 4% carbon marking

INTRODUCTION

The use of axillary marking prior to Neoadjuvant Systemic Therapy (NST) is a controversial matter regarding patients with positive Lymph Nodes (LN). Several methods were tested to make possible the decrease of false negative rate in comparison to sentinel lymph node adding more accuracy to the results. This study aims to evaluate the oncological outcomes in patients who had undergone selective axillary dissection with 4% carbon marking before TSN.

METHODS

A prospective study was performed with cT1-T4, cN1-N2 breast cancer patients classified as suspected LNs undergoing concomitant 4% carbon marking. After TSN, targeted LNs were identified and resected associated to the sentinel lymph node (SLN) biopsy. The oncological outcomes pointed out were overall survival (OS), causespecific survival (CSS), distant disease-free survival (DDFS), axillary recurrence (AR) and local recurrence (LR).

RESULTS

A total of 168 patients were evaluated for a median period of 49 months. The axillary emptying was reached in 89 (50.6%) cases. Five of 168 patients (2.9%) had axillary recurrence (AR). There was a significant link between axillary emptying and AR (0 vs. 6% p = 0.012). The DDFS was 140/168 (83.3%), OS 158/168 (94%) and CSS 158/163 (96.9%).

CONCLUSION

The use of carbon marking in selective axillary dissection is a reliable low-cost method with simple execution. Among the oncological outcomes AR may not be considered for post downstaging axillary evaluation analysis since it is a rare event and not necessarily related to OS or DDFS.

Ex vivo fluorescence-guided resection margin assessment in breast cancer surgery using a topically applied, cathepsin-activatable imaging agent

Up to 40 % of breast cancer patients have a tumor-positive resection margin (TPRM) - defined as cancer cells at the surface of the resected specimen - after breast-conserving surgery (BCS), necessitating re-resection or boost radiation. To prevent these additional treatments, intraoperative near-infrared (NIR) fluorescence imaging with the topically applied, cathepsin-activatable imaging agent AKRO-6qcICG might be used to detect TPRMs and guide additional resection. Here, to validate its performance, the agent is topically applied to all surfaces of freshly resected breast cancer specimens (n = 11 patients) and to 3-5 mm thick tissue slices of the specimens (n = 26 patients). NIR fluorescence images of the resection surfaces and tissue slices are acquired and correlated to final histopathology. AKRO-6qcICG detects TPRMs with a sensitivity, specificity, PVV, and NPV of 100 %, 67 %, 10 %, and 100 %, respectively. On the tissue slices, the fluorescence signal has a median tumor-to-background ratio of 1.8. These findings indicate that topically applied AKRO-6qcICG can visualize TPRMs ex vivo with a high sensitivity and NPV, with sufficient contrast to adjacent healthy breast tissue.

Revisiting surgical margins for invasive breast cancer patients treated with breast conservation therapy - Evidence for adopting a 1 mm negative width

Clinical trials have demonstrated conclusively the non-inferiority of breast-conserving surgery followed by breast radiation therapy (BCT) compared with mastectomy for the treatment of early-stage invasive breast cancer (BC). The definition of the required surgical margin to ensure adequate removal of the cancer by BCT to obtain an acceptable low local recurrence (LR) rate remains controversial. Meta-analyses published by Houssami et al. in 2010 and 2014 demonstrated significantly lower LR rates for patients with a negative margin compared with those with positive (ink on tumour) or close (defined as ≤1 mm or ≤2 mm) margins. Neither meta-analysis addressed whether 'no ink on tumour' was adequate to define a negative margin because of a lack of data. Nevertheless, in 2014, the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) with advice from pathologists reviewed these data together and published guidelines recommending that a margin of 'no ink on tumour' was sufficient to define a clear margin in BCT. Subsequently, clinical practice has varied with some national and international bodies endorsing 'no ink on tumour', whilst others have recommended a ≥1 mm margin as acceptable margins for BCT. A more recent meta-analysis conducted by Bundred and colleagues in 2022 did have sufficient data to compare 'no ink on tumour' and 1 mm and concluded that 1 mm rather than 'no ink on tumour', should be used as a minimum negative margin, and recommended that international guidelines be revised. The current review presents a balanced assessment of the evidence relating margin width and local recurrence after BCT. This review concludes that guidelines should consider re-defining a negative margin as ≥1 mm rather than 'no ink on tumour' in the context of BCT, recognising there will be variation to tailor therapy for any individual patient situation to ensure optimal patient care.

Surgical outcomes and prognosis of HER2+ invasive breast cancer patients with a DCIS component treated with breast-conserving surgery after neoadjuvant systemic therapy

INTRODUCTION

In up to 72 % of HER2+ invasive breast cancer (IBC), a ductal carcinoma in situ (DCIS) component is present. The presence of DCIS is associated with increased positive surgical margins after breast-conserving surgery (BCS). The aim of this study was to assess surgical margins, recurrence and survival in a nationwide cohort of HER2+ IBC with versus without a DCIS component, treated with neoadjuvant systemic therapy (NST) and BCS.

MATERIALS AND METHODS

Women diagnosed with HER2+ IBC treated with NST and BCS, between 2010 and 2019, were selected from the Netherlands Cancer Registry and linked to the Dutch Nationwide Pathology Databank. Kaplan-Meier and Cox regression analyses were performed to determine locoregional recurrence rate (LRR) and overall survival (OS) and associated clinicopathological variables. Surgical outcomes and prognosis were compared between IBC only and IBC+DCIS.

RESULTS

A total of 3056 patients were included: 1832 with IBC and 1224 with IBC+DCIS. Patients with IBC+DCIS had significantly more often positive surgical margins compared to IBC (12.8 % versus 4.9 %, p < 0.001). Five-year LRR was significantly higher in patients with IBC+DCIS compared to IBC (6.8 % versus 3.6 %, p < 0.001), but the presence of DCIS itself was not significantly associated with LRR after adjusting for confounders in multivariable analysis. Five-year OS did not differ between IBC+DCIS and IBC (94.9 % versus 95.7 %, p = 0.293).

CONCLUSION

The presence of DCIS is associated with higher rates of positive surgical margins, but not with LRR and lower OS when adjusted for confounders. Further research is necessary to adequately select IBC+DCIS patients for BCS after NST.

A New Approach to Breast Specimen Orientation: Avoiding Pitfalls with the Specimen Plate Concept

Accurate specimen marking is crucial during breast cancer surgery to avoid misorientation, which can lead to inadequate re-excision and tumor recurrence. We studied the marking methods at various breast cancer centers to create a tool that would prevent specimen misorientation. An online questionnaire was used to survey marking procedures at major breast cancer centers in Hungary, and a tool was developed using a troubleshooting method. Twelve out of twenty units responded (60%). Nine use an institutionally standardized marking system. Less than half of the surgical teams found specimen mammograms to be unambiguous. In more than 70% of departments, pathologists were uncertain about breast specimen orientation. Ambiguous marking methods caused orientation errors in half of the cases, while unclear marking directions caused the rest. Most pathologists (85%) and surgeons (75%) believed that coronal plane specimen mammography would help solve the problem. A plastic specimen plate has been developed to anchor breast tissue to a coronal breast scheme as seen in mammography images, providing clear localization information throughout the surgical process. There is a lack of standardization in breast specimen orientation and marking in Hungary. An optimized orientation toolkit is being developed to ensure consistent interpretation of specimen mammograms by surgeons and pathologists.

The value of oestrogen receptor, progesterone receptor and keratins 5 and 14 immunohistochemistry in the evaluation of epithelial proliferations at cauterised margins in breast-conserving surgery specimens

In breast conservative surgery, it is sometimes difficult to decide whether the cauterised tissue at the inked margin represents normal / hyperplastic or neoplastic tissue. We retrospectively assessed the value of ER, PR, CK5 and CK14 IHC in clarifying the nature of cauterised tissues at the margins concerning 34 lesions of 23 patients. 27 cases belonged to lesions that could not be adequately classified on the basis of the HE stains. Two thirds of them could be classified as non-neoplastic or neoplastic and two thirds of the remaining could be favourised as neoplastic or non-neoplastic, with 3/27 cases remaining uncertain. All 4 IHC reactions were helpful in classifying the lesions in almost half of the cases. However, 3 or 4 immunostains were supportive of the classification in 19/27. The most useful stains were the keratins, generally demonstrating a matching pattern of cell labelling with CK5 and CK14. ER and PR were somewhat less useful in classifying uncertain lesions. Considering all the 27 questionable lesions, IHC with ER, PR, CK5 and CK14 clarified the lesions at the cauterised margins in 23 cases. Taken all these considerations into account, CK5, CK14, PR and ER IHC may help in distinguishing between cautery damaged neoplastic and non-neoplastic tissues. All four IHC may yield the best support for decision making, but CK5 and/or CK14 may be sufficient in their own. The essential approach is that the results must be interpreted with caution, in the context of the given patient's disease, to avoid misinterpretations.

Intraoperative Evaluation of Breast Tissues During Breast Cancer Operations Using the MasSpec Pen

Importance

Surgery with complete tumor resection remains the main treatment option for patients with breast cancer. Yet, current technologies are limited in providing accurate assessment of breast tissue in vivo, warranting development of new technologies for surgical guidance.

Objective

To evaluate the performance of the MasSpec Pen for accurate intraoperative assessment of breast tissues and surgical margins based on metabolic and lipid information.

Design, Setting, and Participants

In this diagnostic study conducted between February 23, 2017, and August 19, 2021, the mass spectrometry-based device was used to analyze healthy breast and invasive ductal carcinoma (IDC) banked tissue samples from adult patients undergoing breast surgery for ductal carcinomas or nonmalignant conditions. Fresh-frozen tissue samples and touch imprints were analyzed in a laboratory. Intraoperative in vivo and ex vivo breast tissue analyses were performed by surgical staff in operating rooms (ORs) within 2 different hospitals at the Texas Medical Center. Molecular data were used to build statistical classifiers.

Main Outcomes and Measures

Prediction results of tissue analyses from classification models were compared with gross assessment, frozen section analysis, and/or final postoperative pathology to assess accuracy.

Results

All data acquired from the 143 banked tissue samples, including 79 healthy breast and 64 IDC tissues, were included in the statistical analysis. Data presented rich molecular profiles of healthy and IDC banked tissue samples, with significant changes in relative abundances observed for several metabolic species. Statistical classifiers yielded accuracies of 95.6%, 95.5%, and 90.6% for training, validation, and independent test sets, respectively. A total of 25 participants enrolled in the clinical, intraoperative study; all were female, and the median age was 58 years (IQR, 44-66 years). Intraoperative testing of the technology was successfully performed by surgical staff during 25 breast operations. Of 273 intraoperative analyses performed during 25 surgical cases, 147 analyses from 22 cases were subjected to statistical classification. Testing of the classifiers on 147 intraoperative mass spectra yielded 95.9% agreement with postoperative pathology results.

Conclusions and Relevance

The findings of this diagnostic study suggest that the mass spectrometry-based system could be clinically valuable to surgeons and patients by enabling fast molecular-based intraoperative assessment of in vivo and ex vivo breast tissue samples and surgical margins.

Association of clinicopathologic and molecular factors with the occurrence of positive margins in breast cancer

PURPOSE

To explore the association of clinicopathologic and molecular factors with the occurrence of positive margins after first surgery in breast cancer.

METHODS

The clinical and RNA-Seq data for 951 (75 positive and 876 negative margins) primary breast cancer patients from The Cancer Genome Atlas (TCGA) were used. The role of each clinicopathologic factor for margin prediction and also their impact on survival were evaluated using logistic regression, Fisher's exact test, and Cox proportional hazards regression models. In addition, differential expression analysis on a matched dataset (71 positive and 71 negative margins) was performed using Deseq2 and LASSO regression.

RESULTS

Association studies showed that higher stage, larger tumor size (T), positive lymph nodes (N), and presence of distant metastasis (M) significantly contributed (p ≤ 0.05) to positive surgical margins. In case of surgery, lumpectomy was significantly associated with positive margin compared to mastectomy. Moreover, PAM50 Luminal A subtype had higher chance of positive margin resection compared to Basal-like subtype. Survival models demonstrated that positive margin status along with higher stage, higher TNM, and negative hormone receptor status was significant for disease progression. We also found that margin status might be a surrogate of tumor stage. In addition, 29 genes that could be potential positive margin predictors and 8 pathways were identified from molecular data analysis.

CONCLUSION

The occurrence of positive margins after surgery was associated with various clinical factors, similar to the findings reported in earlier studies. In addition, we found that the PAM50 intrinsic subtype Luminal A has more chance of obtaining positive margins compared to Basal type. As the first effort to pursue molecular understanding of the margin status, a gene panel of 29 genes including 17 protein-coding genes was also identified for potential prediction of the margin status which needs to be validated using a larger sample set.

Cavity Shave Margins in Breast Conservative Surgery a Strategy to Reduce Positive Margins and Surgical Time

Background: Resection of additional tissue circumferentially around the cavity left by lumpectomy (cavity shave) was suggested to reduce rates of positive margins and re-excision. Methods: A single center retrospective study which analyzed margins status, re-excision, and surgical time in patients who underwent breast conserving surgery and cavity shave or intraoperative evaluation of resection margins. Results: Between 2021 and 2023, 594 patients were enrolled in the study. In patients subjected to cavity shave, a significant reduction in positive, focally positive, or closer margins was reported 8.9% vs. 18.5% (p = 0.003). No difference was reported in terms of surgical re-excision (p < 0.846) (5% vs. 5.5%). Surgical time was lower in patients subjected to cavity shave (<0.001). The multivariate analysis intraoperative evaluation of sentinel lymph node OR 1.816 and cavity shave OR 2.909 were predictive factors for a shorter surgical time. Excluding patients subjected to intraoperative evaluation of sentinel lymph node and patients with ductal carcinoma in situ, patients that underwent the cavity shave presented a reduced surgical time (67.9 + 3.8 min vs. 81.6 + 2.8 min) (p = 0.006). Conclusions: Cavity shaving after lumpectomy reduced the rate of positive margins and it was associated with a significant reduction in surgical time compared to intraoperative evaluation of resection margins.

Vacuum-assisted excision of small breast cancers under ultrasound guidance

PURPOSE

The purpose of this study was to evaluate if it is possible to completely remove small breast cancer tumours with vacuum-assisted excision (VAE) under ultrasound guidance.

METHODS

Women ≥ 50 years old with a biopsy proven invasive cancer ≤ 10 mm were selected between October 2021 and November 2021 based on referrals and enrolled in this prospective study. The patients underwent VAE within six weeks following biopsy to remove the tumour. After the tumour was excised and the biopsy cavities margins were shaved, a radioactive seed was inserted into the biopsy cavity. The VAE excision cavity and surrounding tissue were surgically excised. Preliminary VAE results were evaluated after ten patients. For the study to proceed at least 80 % of the breast cancer tumours had to be completely removed by VAE.

RESULTS

The tumours median size in mammography was 8.5 mm (6-9 mm) and in ultrasound 6.5 mm (4-9 mm). The shape of the lesion was round in three (30 %), oval in two (20 %) and irregular in five (50 %) patients. None of the tumours were completely removed in the first VAE specimen, meaning that there was invasive cancer or ductal carcinoma in situ (DCIS) in the "shaved margins" and/or the surgical specimen. In five (50 %) cases, the surgical specimen was free of invasive cancer and DCIS.

CONCLUSIONS

None of the small invasive breast cancers were completely excised with VAE under ultrasound guidance, therefore it is not a reliable method to remove small breast cancers.

Diagnostic value of preoperative examination for evaluating margin status in breast cancer

BACKGROUND

A positive resection margin is a major risk factor for local breast cancer recurrence after breast-conserving surgery (BCS). Preoperative imaging examinations are frequently employed to assess the surgical margin.

AIM

To investigate the role and value of preoperative imaging examinations [magnetic resonance imaging (MRI), molybdenum target, and ultrasound] in evaluating margins for BCS.

METHODS

A retrospective study was conducted on 323 breast cancer patients who met the criteria for BCS and consented to the procedure from January 2014 to July 2021. The study gathered preoperative imaging data (MRI, ultrasound, and molybdenum target examination) and intraoperative and postoperative pathological information. Based on their BCS outcomes, patients were categorized into positive and negative margin groups. Subsequently, the patients were randomly split into a training set (226 patients, approximately 70%) and a validation set (97 patients, approximately 30%). The imaging and pathological information was analyzed and summarized using R software. Non-conditional logistic regression and LASSO regression were conducted in the validation set to identify factors that might influence the failure of BCS. A column chart was generated and applied to the validation set to examine the relationship between pathological margin range and prognosis. This study aims to identify the risk factors associated with failure in BCS.

RESULTS

The multivariate non-conditional logistic regression analysis demonstrated that various factors raise the risk of positive margins following BCS. These factors comprise non-mass enhancement (NME) on dynamic contrast-enhanced MRI, multiple focal vascular signs around the lesion on MRI, tumor size exceeding 2 cm, type III time-signal intensity curve, indistinct margins on molybdenum target examination, unclear margins on ultrasound examination, and estrogen receptor (ER) positivity in immunohistochemistry. LASSO regression was additionally employed in this study to identify four predictive factors for the model: ER, molybdenum target tumor type (MT Xmd Shape), maximum intensity projection imaging feature, and lesion type on MRI. The model constructed with these predictive factors exhibited strong consistency with the real-world scenario in both the training set and validation set. Particularly, the outcomes of the column chart model accurately predicted the likelihood of positive margins in BCS.

CONCLUSION

The proposed column chart model effectively predicts the success of BCS for breast cancer. The model utilizes preoperative ultrasound, molybdenum target, MRI, and core needle biopsy pathology evaluation results, all of which align with the real-world scenario. Hence, our model can offer dependable guidance for clinical decision-making concerning BCS.

Diagnostic value of preoperative examination for evaluating margin status in breast cancer

BACKGROUND

A positive resection margin is a major risk factor for local breast cancer recurrence after breast-conserving surgery (BCS). Preoperative imaging examinations are frequently employed to assess the surgical margin.

AIM

To investigate the role and value of preoperative imaging examinations [magnetic resonance imaging (MRI), molybdenum target, and ultrasound] in evaluating margins for BCS.

METHODS

A retrospective study was conducted on 323 breast cancer patients who met the criteria for BCS and consented to the procedure from January 2014 to July 2021. The study gathered preoperative imaging data (MRI, ultrasound, and molybdenum target examination) and intraoperative and postoperative pathological information. Based on their BCS outcomes, patients were categorized into positive and negative margin groups. Subsequently, the patients were randomly split into a training set (226 patients, approximately 70%) and a validation set (97 patients, approximately 30%). The imaging and pathological information was analyzed and summarized using R software. Non-conditional logistic regression and LASSO regression were conducted in the validation set to identify factors that might influence the failure of BCS. A column chart was generated and applied to the validation set to examine the relationship between pathological margin range and prognosis. This study aims to identify the risk factors associated with failure in BCS.

RESULTS

The multivariate non-conditional logistic regression analysis demonstrated that various factors raise the risk of positive margins following BCS. These factors comprise non-mass enhancement (NME) on dynamic contrast-enhanced MRI, multiple focal vascular signs around the lesion on MRI, tumor size exceeding 2 cm, type III time-signal intensity curve, indistinct margins on molybdenum target examination, unclear margins on ultrasound examination, and estrogen receptor (ER) positivity in immunohistochemistry. LASSO regression was additionally employed in this study to identify four predictive factors for the model: ER, molybdenum target tumor type (MT Xmd Shape), maximum intensity projection imaging feature, and lesion type on MRI. The model constructed with these predictive factors exhibited strong consistency with the real-world scenario in both the training set and validation set. Particularly, the outcomes of the column chart model accurately predicted the likelihood of positive margins in BCS.

CONCLUSION

The proposed column chart model effectively predicts the success of BCS for breast cancer. The model utilizes preoperative ultrasound, molybdenum target, MRI, and core needle biopsy pathology evaluation results, all of which align with the real-world scenario. Hence, our model can offer dependable guidance for clinical decision-making concerning BCS.

Point-of-care devices based on fluorescence imaging and spectroscopy for tumor margin detection during breast cancer surgery: Towards breast conservation treatment

OBJECTIVE

Fluorescence-based methods are highly specific and sensitive and have potential in breast cancer detection. Simultaneous fluorescence imaging and spectroscopy during intraoperative procedures of breast cancer have great advantages in detection of tumor margin as well as in classification of tumor to healthy tissues. Intra-operative real-time confirmation of breast cancer tumor margin is the aim of surgeons, and therefore, there is an urgent need for such techniques and devices which fulfill the surgeon's priorities.

METHODS

In this article, we propose the development of fluorescence-based smartphone imaging and spectroscopic point-of-care multi-modal devices for detection of invasive ductal carcinoma in tumor margin during removal of tumor. These multimodal devices are portable, cost-effective, noninvasive, and user-friendly. Molecular level sensitivity of fluorescence process shows different behavior in normal, cancerous and marginal tissues. We observed significant spectral changes, such as, red-shift, full-width half maximum (FWHM), and increased intensity as we go towards tumor center from normal tissue. High contrast in fluorescence images and spectra are also recorded for cancer tissues compared to healthy tissues. Preliminary results for the initial trial of the devices are reported in this article.

RESULTS

A total 44 spectra from 11 patients of invasive ductal carcinoma (11 spectra for invasive ductal carcinoma and rest are normal and negative margins) are used. Principle component analysis is used for the classification of invasive ductal carcinoma with an accuracy of 93%, specificity of 75% and sensitivity of 92.8%. We obtained an average 6.17 ± 1.66 nm red shift for IDC with respect to normal tissue. The red shift and maximum fluorescence intensity indicates p < 0.01. These results described here are supported by histopathological examination of the same sample.

CONCLUSION

In the present manuscript, simultaneous fluorescence-based imaging and spectroscopy is accomplished for the classification of IDC tissues and breast cancer margin detection.

Rates of reoperation after breast conserving cancer surgery in Western Australia before and after publication of the SSO-ASTRO margins guideline

BACKGROUND

A 2014 SSO-ASTRO guideline on surgical margins aimed to reduce unnecessary reoperation after breast conserving surgery (BCS). We investigate whether publication of the guideline was associated with a reduction in reoperation in Western Australia (WA).

METHODS

In this retrospective, population-based cohort study, cases of newly-diagnosed breast cancer were identified from the WA Cancer Registry. Linkage to the Hospital Morbidity Data Collection identified index BCS for invasive cancer between January 2009 and June 2018 (N = 8059) and reoperation within 90 days. Pre-guideline (2009-2013) and post-guideline (2014-2018) reoperation proportions were compared, and temporal trends were estimated with generalised linear regression.

RESULTS

The pre-guideline reoperation proportion was 25.8% compared with 21.7% post-guideline (difference -4.0% [95% CI -5.9, -2.2, p < 0.001], odds ratio [OR] 0.80 [95% CI 0.72, 0.89, p < 0.001]). Absolute reductions were similar for repeat BCS (16.3% versus 14.6%; difference -1.8% [95% CI -3.4, -0.2, p = 0.03]) and conversion to mastectomy (9.4% versus 7.2%; difference -2.2% [95% CI -3.4, -1.0, p < 0.001]). Over the study period, there was an annual absolute change in reoperation of -0.8% (95% CI -1.2, -0.5, p < 0.001). Accounting for this linear trend, the difference in reoperation between time periods was -0.5% (95% CI -4.3, 3.3; p = 0.81), reflecting a non-significant reduction in conversion to mastectomy.

CONCLUSIONS

Comparisons of pre- versus post-guideline time periods in WA showed reductions in reoperation that were similar to international estimates; however, an annual decline in reoperation predated the guideline. Analyses that do not account for temporal trends are likely to overestimate changes in reoperation associated with the guideline.

Automated breast ultrasound (ABUS) for intraoperative margin control on surgical specimens in breast conserving surgery

PURPOSE

As breast-conserving surgery (BCS) has become the standard for treatment of early breast cancer, the need for new technologies to improve intraoperative margin assessment has become clear. Close or positive margins during BCS lead to additional surgeries, treatment delay, additional stress for patients and increasing healthcare cost. Automated three-dimensional breast ultrasound (ABUS) systems are meant to overcome the shortcomings of hand-held ultrasound (HHUS). In this study, we investigate the feasibility of ABUS to conduct ultrasound on surgical specimens in breast conserving therapy.

METHODS

In this monocentric, non-interventional study, specimens of 40 women were examined via ABUS. A construction with isotonic saline solution, gel pads and ABUS membranes was invented by our team to produce images of breast cancer specimens using ABUS. Evaluation of the ABUS images was carried out by two independent physicians trained on ABUS evaluation.

RESULTS

ABUS was conducted on 40 specimens. 90% of the generated images were of high quality. Measured tumor sizes with ABUS were bigger than measured tumor size with HHUS (mean tumor size 22.9 vs. 18.1 mm, CI 2.38-7.35, p < 0.05). The mean difference between the ABUS tumor size and the pathological tumor size was 1.8 mm (CI - 0.84-4.53, p = 0.17). The mean difference between the HHUS tumor size and the pathological tumor size was 3.2 mm (CI - 5.35 to - 1.03, p = 0.005).

CONCLUSION

ABUS seems to be a suitable method to conduct specimen ultrasound. Further studies are required to evaluate the accuracy of ABUS for intraoperative margin assessment and possible implementation in clinical work routine.

De-Escalating the Management of In Situ and Invasive Breast Cancer

Simple Summary

De-escalation of breast cancer treatment reduces morbidity and toxicity for patients. De-escalation is safe if cancer outcomes, such as recurrence and survival, remain unaffected compared to more radical regimens. This review provides an overview on treatment de-escalation for ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments have facilitated de-escalation of treatment over time.

Abstract

It is necessary to identify appropriate areas of de-escalation in breast cancer treatment to minimize morbidity and maximize patients’ quality of life. Less radical treatment modalities, or even no treatment, have been reconsidered if they offer the same oncologic outcomes as standard therapies. Identifying which patients benefit from de-escalation requires particular care, as standard therapies will continue to offer adequate cancer outcomes. We provide an overview of the literature on the de-escalation of treatment of ductal carcinoma in situ (DCIS), local treatment of breast cancer, and surgery after neoadjuvant systemic therapy. De-escalation of breast cancer treatment is a key area of investigation that will continue to remain a priority. Improvements in understanding the natural history and biology of breast cancer, imaging modalities, and adjuvant treatments will expand this even further. Future efforts will continue to challenge us to consider the true role of various treatment modalities.

Breast-conserving surgery versus mastectomy for older women with triple-negative breast cancer: population-based study

Purpose: To assess whether the poor prognosis of triple-negative breast cancer (TNBC) necessitates a more aggressive surgical approach. Methods: We examined the association of: breast-conserving surgery (BCS); BCS plus radiotherapy; mastectomy; and mastectomy plus radiotherapy with overall and breast cancer-specific survival of stage I-III TNBC patients aged 66 years and older. We used unweighted and inverse probability of treatment weighted Cox proportional hazards regression and the Fine and Gray sub-distribution model. Results: Among 4333 women, individuals who were selected for BCS, mastectomy or mastectomy plus radiotherapy had lower adjusted overall and breast cancer-specific survival compared with women who had BCS plus radiotherapy. Conclusion: In this population-based study, women with TNBC treated with BCS plus radiotherapy have a better prognosis than those treated with BCS, mastectomy or mastectomy plus radiotherapy. Given the poor prognosis of TNBC and selection bias inherent in observational studies, these findings should be confirmed in further studies such as randomized clinical trials.

Formulation of a Thermosensitive Imaging Hydrogel for Topical Application and Rapid Visualization of Tumor Margins in the Surgical Cavity

Simple Summary

We have developed a formulation for an innovative, quenched, cathepsin-targeted, fluorescent molecular probe to enhance resection quality for several solid-tumor cancers. Unlike other formulations for imaging probes or tracers in development and entering the clinic, which require systemic administration hours before the procedure, this current formulation is applied topically into the surgical cavity immediately after a standard of care resection. Within minutes of application, the probe activates in the presence of residual cancer in the surgical wound and provides a strong fluorescent signal that precisely delineates any remaining cancer, enabling a more complete resection. Utilization of this imaging gel formulation for topical application to detect breast cancer in the surgical cavity during surgery has the potential to reduce re-excisions, with consequent savings in healthcare costs and enhancement in patient quality of life.

Abstract

Background: Tumor-positive surgical margins during primary breast cancer (BCa) surgery are associated with a two-fold increase in the risk of local recurrence when compared with tumor-negative margins. Pathological microscopic evaluation of the samples only assesses about 1/10 of 1% of the entire volume of the removed BCa specimens, leading to margin under-sampling and potential local recurrence in patients with pathologically clean margins, i.e., false negative margins. In the case of tumor-positive margins, patients need to undergo re-excision and/or radiation therapy, resulting in increases in complications, morbidity, and healthcare costs. Development of a simple real-time imaging technique to identify residual BCa in the surgical cavity rapidly and precisely could significantly improve the quality of care. Methods: A small-molecule, fluorescently quenched protease-substrate probe, AKRO-QC-ICG, was tested as part of a thermosensitive imaging gel formulated for topical application and imaging of the BCa surgical cavity. Results: More than forty formulations of gel mixtures were investigated to enable easy fluid application and subsequent solidification once applied, preventing dripping and pooling in the surgical cavity. The final formulation was tested using human BCa orthotopic implants in nude and NSG patient-derived xenografts (PDX) mice. This formulation of Pluronic F-127/DMSO/AKRO-QC-ICG imaging gel was found to be a good solvent for the probe, with a desirable thermo-reversible solid–gel transition and mechanical strength for distribution of AKRO-QC-ICG on the surfaces of tissue. It demonstrated excellent ability to detect BCa tissue after 10 min exposure, with a high signal-to-noise ratio both in mouse xenografts and freshly excised human lumpectomy tissue. The in vivo efficacy of the AKRO-QC-ICG imaging gel to detect BCa revealed the levels of sensitivity/specificity = 0.92/1 in 12 nude mice, which was corroborated with the sensitivity/specificity = 0.94/1 in 10 PDX mice. Conclusions: Utilization of Pluronic F-127/DMSO/AKRO-QC-ICG imaging gel for topical application to detect BCa in the surgical cavity during surgery has the potential to reduce re-excisions, with consequent savings in healthcare costs and enhancement in patient quality of life.

Development of an intraoperative breast cancer margin assessment method using quantitative fluorescence measurements

Breast-conserving surgery has become the preferred treatment method for breast cancer. Surgical margin assessment is performed during surgery, as it can reduce local recurrence in the preserved breast. Development of reliable and lower-cost ex vivo cancer detection methods would offer several benefits for patient care. Here, a practical and quantitative evaluation method for the ex vivo fluorescent diagnosis of breast lesions was developed and confirmed through a three-step clinical study. Gamma-glutamyl-hydroxymethyl rhodamine green (gGlu-HMRG) has been reported to generate fluorescence in breast lesions. Using this probe, we constructed a reliable and reproducible procedure for the quantitative evaluation of fluorescence levels. We evaluated the reliability of the method by considering reproducibility, temperature sensitivity, and the effects of other clinicopathological factors. The results suggest that the fluorescence increase of gGlu-HMRG is a good indicator of the malignancy of breast lesions. However, the distributions overlapped. A 5 min reaction with this probe could be used to distinguish at least part of the normal breast tissue. This method did not affect the final pathological examination. In summary, our results indicate that the methods developed in this study may serve as a feasible intraoperative negative-margin assessment tool during breast-conserving surgery.

Racial Disparities in Survival of Breast Cancer Patients After Surgery

Introduction

The racial disparities of opportunity to receive the appropriate intervention and lower insurance coverage may result in survival disparities in different races. This study aims to provide a perspective on racial disparities in the survival of breast cancer patients after surgery.

Methods

Through data from the Surveillance, Epidemiology, and End Results (SEER) program, this study estimated the survival of breast cancer patients of different races from 1998 to 2017. Inverse probability weighting (IPW) was utilized to adjust the imbalanced clinicopathological features of patients of different races.

Results

This study analyzed 214,965 breast cancer patients after surgery. Among them, 130,746 patients received BCS, and the remaining 84,219 breast cancer patients underwent mastectomy. Although Asian or Pacific Islander (API) patients after surgery showed higher survival benefit than that of white patients in the primary data, after adjusting for age at diagnosis, luminal subtype, grade, T stage, and N stage in different races, white individuals had the longest period of survival was higher than that of the minority groups in BCS group [breast cancer-specific survival (BCSS): HR_Whitevs.API = 0.402, HR_{Whitevs.Black} = 0.132; P < 0.001; overall survival (OS): HR_Whitevs.API = 0.689, HR_{Whitevs.Black} = 0.254; all P < 0.001] and mastectomy group (BCSS: HR_Whitevs.API = 0.325, HR_{Whitevs.Black} = 0.128; P < 0.001; OS: HR_Whitevs.API = 0.481, HR_{Whitevs.Black} = 0.206; all P < 0.001)

Conclusions

We first identified that the survival benefit of the minority group after surgery was lower than that of white individuals, regardless of tumor chrematistics and surgery types.

Lympho-vascular invasion impacts the prognosis in breast-conserving surgery: a systematic review and meta-analysis

BACKGROUND

It is estimated that breast cancer (BC) incidence, especially that of early-stage breast cancer cases continues to rise due to increased universal screening. Breast-conserving surgery (BCS) is the main intervention for early-stage BC. Lympho-vascular invasion (LVI) is reported to influence breast cancer prognosis but its prognostic value in breast-conserving treatment is controversial.

METHODS

A search was conducted on the Cochrane library, PubMed, Web of Science, and EMBASE from inception to December 1st, 2021, without language restrictions, to identify studies that explored the prognosis of lympho-vascular invasion in breast-conserving surgery. Reviews of each study were conducted, and data extracted. The meta-analysis was performed with StataSE 16. Study quality assessment was evaluated using the Newcastle-Ottawa Scale.

RESULTS

Overall, 15 studies with 21,704 patients deemed eligible for this study. Event-free survival (EFS), disease-free survival (DFS), overall survival (OS), distant metastases (DM), loco-regional recurrence (LRR), local recurrence (LR), breast recurrence (BR), disease specific survival (DSS), and breast cancer specific survival (BCSS), were extracted from each study. We found that LVI leads to poor OS (HR = 1.46, 95% CI: 1.17-1.83), DM (HR = 2.08, 95% CI: 1.66-2.60) and LR (HR = 2.00, 95% CI: 1.54-2.61).

CONCLUSIONS

We confirmed that early-stage BC patients with LVI-positive have poorer OS, DFS, LRR, BCSS, DM and LR following receiving BCS than those LVI-negative patients. Mastectomy, in combination with radical systemic therapies could be considered, especially in those requiring second surgery. How to change the impact of LVI on the local recurrence rate and long-term survival in patients who undergo BCS may be a valuable research direction in the future.

Predictive value of ductal carcinoma in situ with invasive breast cancer in core needle biopsies for final pathologic size of intraductal elements

Preoperative evaluations of the size of ductal carcinoma in situ (DCIS) extension in invasive breast cancer (IBC) are problematic and markers of the actual size of DCIS remain elusive. This study aimed to quantify DCIS on core needle biopsy (CNB) and investigated its association with degree of DCIS extension on paired resection specimens, instead of with presence or absence of an extensive intraductal component or margin status as in earlier studies. This series examined 150 IBCs diagnosed from paired CNB and resection specimens. The DCIS/invasion ratio was calculated using the sum of each element size from CNB. In resection specimens, cases in which the greatest dimension of DCIS extension was longer than the greatest dimension of invasive size were defined as extended DCIS (Ext-DCIS). DCIS/invasion ratio level correlated positively with the degree of Ext-DCIS (P = 0.003). Using receiver operating characteristic curve analysis, setting cases with the subgroup of DCIS extension with greatest dimension > 2.5 times that of the invasive size in the resection specimen (Ext-DCIS > 2.5) as the positive class provided the best discrimination ability for DCIS/invasion ratio (0.375). In multivariate analysis, DCIS/invasion ratio > 0.375 was significantly associated with Ext-DCIS > 2.5 (P = 0.033). In conclusion, DCIS/invasion ratio > 0.375 in CNB was identified as a predictor of Ext-DCIS > 2.5 in resection specimens, suggesting that an approach combining DCIS/invasion ratio from CNB with preoperative staging may better predict the extent of DCIS and facilitate better surgical planning.

Rapid visualization of mammary gland tumor lesions of dogs using the enzyme-activated fluorogenic probe; γ-glutamyl hydroxymethyl rhodamine green

Since gamma-glutamyl transpeptidase (GGT) is highly and locally expressed in human breast cancer, a GGT-enzymatically activatable fluorescent probe, gamma-glutamyl hydroxymethyl rhodamine green (gGlu-HMRG), has been developed to detect the human breast cancer area with high performance. In this study, GGT expression and the efficacy of gGlu-HMRG on visualization were investigated in canine mammary gland tumors (MGT). Seventeen non-fixed fresh-frozen MGT specimens and each peritumoral control tissue were utilized. The GGT mRNA levels were highly observed in the tumor specimens compared with the control. GGT immunostaining was mostly observed on the cell membrane and cytosol of the alveolar and duct mammary epithelium of MGT tissues. These signals were strongly positive in several cases while they were mild to not observed in other cases. When gGlu-HMRG solution was dropped to the non-fixed tissue pieces of MGT or control tissues, the fluorescence intensities (FIs) were measured using Maestro in-vivo imaging device. FIs in MGT tissues were significantly higher than each control tissue 20 min after treatment. Based on Youden index method said that the maximum sensitivity and specificity of FI was 82.4% and 82.4%. These findings suggest that GGT is highly expressed in several MGTs in dogs and gGlu-HMRG could visualize at least a part of MGT tissues in dogs. Nevertheless, it should be needed to assess the false-negative areas more carefully in canine than human cases.

Aesthetic monitoring-based assessment of oncological safety of oncoplastic management of breast cancer: a multi-center research study

BACKGROUND

Oncoplastic Breast surgeries (OBS) in breast cancer have evolved to preserve the cancerous breast rather than its amputation to improve postoperative cosmetic results. The lack of evidence to support the oncological safety and benefits of OBS is questionable. In this study, we evaluate various aspects of oncoplastic surgeries with a focused monitoring of aesthetic results and oncological safety.

METHODS

This was a multi-center observational study focused on the statistics of data collected from cases who underwent oncoplastic surgeries from the cohort of breast cancer candidates at Mansoura University Hospitals/Egypt and King Faisal Medical Complex/KSA from January 2015 to June 2018. All data were analyzed carefully using SPSS v-26.

RESULTS

Eighty cases who underwent different oncoplastic surgeries were included and reviewed for the aesthetic outcome and oncological safety. The recurrence rate was found to be 2.5%. The breast impact treatment scale assessment method was used to analyze the aesthetic outcomes, and average scores were accepted in 90% of patients.

CONCLUSIONS

The oncoplastic breast surgeries are feasible and they had a high rate of oncological safety with the maintenance of good aesthetic outcomes and patient satisfaction.

Clinical usefulness of a novel fluorescence technique for the intraoperative diagnosis of surgical margins in patients with breast cancer

In both 5- and 15-min data, FI was significantly higher in malignant tissues than in benign tissues. The diagnostic accuracy was similar at 5 and 15 min. Therefore, the 5-min FI was enough applying in the further analyses.

Retrospective, Multicenter Analysis Comparing Conventional with Oncoplastic Breast Conserving Surgery: Oncological and Surgical Outcomes in Women with High-Risk Breast Cancer from the OPBC-01/iTOP2 Study

Introduction

Recent data suggest that margins ≥2 mm after breast-conserving surgery may improve local control in invasive breast cancer (BC). By allowing large resection volumes, oncoplastic breast-conserving surgery (OBCII; Clough level II/Tübingen 5-6) may achieve better local control than conventional breast conserving surgery (BCS; Tübingen 1-2) or oncoplastic breast conservation with low resection volumes (OBCI; Clough level I/Tübingen 3-4).

Methods

Data from consecutive high-risk BC patients treated in 15 centers from the Oncoplastic Breast Consortium (OPBC) network, between January 2010 and December 2013, were retrospectively reviewed.

Results

A total of 3,177 women were included, 30% of whom were treated with OBC (OBCI n = 663; OBCII n = 297). The BCS/OBCI group had significantly smaller tumors and smaller resection margins compared with OBCII (pT1: 50% vs. 37%, p = 0.002; proportion with margin <1 mm: 17% vs. 6%, p < 0.001). There were significantly more re-excisions due to R1 (“ink on tumor”) in the BCS/OBCI compared with the OBCII group (11% vs. 7%, p = 0.049). Univariate and multivariable regression analysis adjusted for tumor biology, tumor size, radiotherapy, and systemic treatment demonstrated no differences in local, regional, or distant recurrence-free or overall survival between the two groups.

Conclusions

Large resection volumes in oncoplastic surgery increases the distance from cancer cells to the margin of the specimen and reduces reexcision rates significantly. With OBCII larger tumors are resected with similar local, regional and distant recurrence-free as well as overall survival rates as BCS/OBCI.

Supplementary information

The online version contains supplementary material available at 10.1245/s10434-021-10809-1.

Accuracy of cancer diagnostic probe for intra-surgical checking of cavity side margins in neoadjuvant breast cancer cases: A human model study

BACKGROUND

Background Recently, a real-time system, named cancer diagnostic probe (CDP), has been developed to diagnose the presence of pre-neoplastic/neoplastic cells in breast cavity side margins. Detecting mechanism is real-time determination of the ROS/H₂ O₂ released from cancer or atypical cells, through reverse Warburg effect and hypoxia glycolysis pathways.

AIMS

Here, we designed a human model study based on real-time checking of 387 internal margins (IM) from 39 neoadjuvant breast cancer cases by CDP. MATERIALS & METHODS: Each lesion was checked by entered needle sensor and electrical scores were recorded. The permanent pathology result of each tested lesion was our gold standard to evaluate CDP scoring. CDP results were compared with permanent pathology of tumour side margins (as a conventional margin evaluation procedure).

RESULTS

Results showed that the sensitivity of CDP in scoring the cavity side margins of those cases is 91%. A total of 18 involved IM which had been detected by CDP were declared as free margins in pathology section of tumour side samples. Just five involved IM were missed by CDP.

DISCUSSIONS

Such sensitivity revealed that metabolism based (here: hypoxia glycolysis) tracing of cancer cells show distinct electrochemical responses between clear and involved cavity side margin evaluation.

CONCLUSION

This human study showed the promising role of CDP to achieve clear margins after BCS of neoadjuvant cases.

Use of wire guided localisation and radio-guided occult lesion localisation for non-palpable breast lesions: A systematic literature review and meta-analysis of current evidence

Breast cancer screening has seen an increase in the detection of non-palpable breast lesions. Wire guided localisation (WGL) and Radio-guided occult lesion localisation (ROLL) are well established modalities of localisation of non-palpable breast lesions in the UK. We aimed to compare the outcomes of WGL and ROLL in this updated meta-analysis. We searched Cochrane Central Register of Controlled Trials (CENTRAL), and LILACS using free text search words as well as relevant MESH-terms. We also searched Medline (02/03/2021), Embase and registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. Outcomes considered were re-excision rates, margin involvement, specimen volume and weight, accurate localisation of lesions and operative time. We assessed the risk of bias in included studies and performed random effects meta-analyses using Review Manager (version 5.3). Heterogeneity was estimated using the I²-statistic. Nine included studies enrolled 1096 patients undergoing localization in breast surgery (534 in WGL and 562 in ROLL). There was a statistically significant benefit in favour of ROLL for non-involved resection margins (OR 0.60; 95% CI, 0.44-0.97); based on seven studies. Nine trials assessed operative time favouring ROLL (OR 1.95; 95% CI, 0.27-3.63). No significant difference in re-excision rates was reported (OR 1.42; 95% CI, 0.83-2.43) based on seven studies. Current evidence favourably supports ROLL, compared to WGL, with respect to margin involvement, localisation and operative time in the treatment of non-palpable breast lesions.

Role of early post-operative breast MRI: how helpful is it in deciding the next step for women who may have residual disease?

Objectives

Positive resection margins following breast conserving surgery are a risk factor for local disease recurrence. Subsequent management of patients is often not straightforward, with post-operative breast MRI increasingly used to aid decision-making. Interpretation of MRI after surgery can prove challenging due to local inflammatory enhancement. We reviewed our experience of post-operative breast MRIs to determine their ability to detect residual disease and to evaluate how they changed initial patient management from re-excision to an alternative.

Methods:

A search of breast MRIs performed from August 2014 to December 2019 was undertaken, to identify those performed post-operatively within 4 months of breast conserving surgery. Electronic patient records and imaging were evaluated to determine additional work-up, pathology and surgical outcomes.

Results:

Of the 2274 breast MRIs during the study period, 44 (2%) were performed post-operatively to evaluate 47 breasts. MRI was normal in 20 cases (43%), suspicious findings at surgical cavity only in 13 (28%), suspicious ipsilateral distant breast findings only in 6 (13%), and both cavity and distant findings in 7 cases (15%). Contralateral abnormalities were identified in 3 cases. Following MRI, mastectomy was performed in 11 cases, re-excision in 25, with 2 subsequent mastectomies, and multidisciplinary team accepted margins in 11 cases, 10 of whom underwent post-operative radiotherapy. MRI altered initial patient management from re-excision to an alternative in 25 cases (45%).

Conclusion:

Post-operative breast MRI, although potentially challenging to interpret, can prove useful in planning the next step in patient management, particularly in its ability to evaluate the whole breast.

Advances in knowledge

Post-operative breast MRI is increasingly requested at multidisciplinary team following breast conserving surgery with positive surgical margins on histology, however interpretation is challenging. The value of these studies lie in assessment of the distant breast rather than the surgical resection cavity and can alter patient management guiding the most appropriate next step for definitive treatment.

Comparative study of surgical and oncological outcomes in oncoplastic versus non oncoplastic breast-conserving surgery for breast cancer treatment

Background: Oncoplastic surgery has been increasingly used in breast cancer treatment and allows the performance of breast-conserving surgery in cases of larger tumors with unfavorable location or tumor-breast disproportion. Purpose: To compare surgical and oncological outcomes of patients undergoing oncoplastic and nononcoplastic breast-conserving surgery. Methods: Retrospective cohort study with convenience sampling of 866 patients who consecutively underwent breast-conserving surgery from 2011 to 2015. Results: The mean follow-up was 50.4 months. Nononcoplastic breast conservation surgery was performed on 768 (88.7%) patients and oncoplastic surgery on 98 (11.3%) patients. Patients in the oncoplastic group were younger (p<0.0001) and most were premenopausal (p<0.0001). Comorbidities such as diabetes (p=0.003) and hypertension (p=0.0001) were less frequent in this population. Invasive carcinoma >2 cm (p<0.0001), multifocality (p=0.004), ductal in situ carcinoma (p=0.0007), clinically positive axilla (p=0.004), and greater weight of surgical specimens (p<0.0001) were more frequent in the oncoplastic group. A second surgery for margin re-excision was more frequently performed in the nononcoplastic group (p=0.027). There was more scar dehiscence in the oncoplastic group (p<0.001), but there was no difference in early major complications (p=0.854), conversion to mastectomy (p=0.92), or local recurrence (p=0.889). Conclusion: Although used for the treatment of larger and multifocal tumors, surgical re-excisions were performed less often in the oncoplastic group, and there was no increase in conversion to mastectomy or local recurrence. In spite of the higher rate of overall complications in the oncoplastic group, major complications were similar in both groups.

Breast-Conserving Therapy in Patients with cT3 Breast Cancer with Good Response to Neoadjuvant Systemic Therapy Results in Excellent Local Control: A Comprehensive Cancer Center Experience

BACKGROUND

Many cT3 breast cancer patients are treated with mastectomy, regardless of response to neoadjuvant systemic therapy (NST). We evaluated local control of cT3 patients undergoing breast-conserving therapy (BCT) based on magnetic resonance imaging (MRI) evaluation post-NST. In addition, we analyzed predictive characteristics for positive margins after breast-conserving surgery (BCS).

METHODS

All cT3 breast cancer patients who underwent BCS after NST between 2002 and 2015 at the Netherlands Cancer Institute were included. Local recurrence-free interval (LRFI) was estimated using the Kaplan-Meier method, and predictors for positive margins were analyzed using univariable analysis and multivariable logistic regression.

RESULTS

Of 114 patients undergoing BCS post-NST, 75 had negative margins, 16 had focally positive margins, and 23 had positive margins. Of those with (focally) positive margins, 12 underwent radiotherapy, 6 underwent re-excision, and 21 underwent mastectomy. Finally, 93/114 patients were treated with BCT (82%), with an LRFI of 95.9% (95% confidence interval [CI] 91.5-100%) after a median follow-up of 7 years. Predictors for positive margins in univariable analysis were hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) subtype, lobular carcinoma, and non-mass enhancement (NME) on pre-NST MRI. MRI response was not correlated to positive margins. In multivariable regression, the odds of positive margins were decreased in patients with HER2-positive (HER2+; odds ratio [OR] 0.27, 95% CI 0.10-0.73; p = 0.01) and TN tumors (OR 0.17, 95% CI 0.03-0.82; p = 0.028). A trend toward positive margins was observed in patients with NME (OR 2.38, 95% CI 0.98-5.77; p = 0.055).

CONCLUSION

BCT could be performed in 82% of cT3 patients in whom BCT appeared feasible on post-NST MRI. Local control in these patients was excellent. In those patients with HR+/HER2- tumors, NME on MRI, or invasive lobular carcinoma, the risk of positive margins should be considered preoperatively.

Sole adjuvant intraoperative breast radiotherapy in Taiwan: a single-center experience

Introduction

Intraoperative radiotherapy (IORT) is more convenient than standard whole breast external beam radiotherapy (EBRT) as a sole adjuvant radiotherapy for breast cancer. The impact of age on breast cancer course and treatment strategy is still under investigation, and the peak age for breast cancer in Taiwan is much younger than that in Western countries. We aimed to review the oncological outcomes of sole IORT compared with standard EBRT in a country with younger breast cancer patients.

Patients and methods

We reviewed patients with invasive breast cancer who received breast-conserving surgery (BCS) from September 2014 to December 2016. The clinicopathologic characteristics and oncological outcomes of eligible patients who received EBRT or IORT as sole adjuvant radiotherapy after BCS were collected and reviewed.

Results

A total of 170 patients were enrolled with a mean follow-up time of 3.53 ± 0.82 years. The risk of locoregional recurrence was 2.44% for EBRT versus 10.64% for IORT (p = 0.024). IORT was a significant risk factor of locoregional recurrence (p = 0.005). The hazard ratios (HRs) for locoregional recurrence in the IORT group compared with the EBRT group were significantly higher in non-suitable risk group patients (HR = 7.02, p = 0.009) and in patients under 50 years old (HR = 10.42, p = 0.011).

Conclusions

Locoregional recurrence was significantly higher in patients who received IORT than in those who underwent EBRT. IORT should not be used alone in patients under 50 years old who do not belong to a suitable group.

Thermal Ablation as an Alternative for Surgical Resection of Small (≤ 2 cm) Breast Cancers: A Meta-Analysis

Women with early-stage breast cancer have an excellent prognosis with current therapy, but could presumably be treated less invasively, without the need for surgery. The primary goal of this meta-analysis was to examine whether thermal ablation is an effective method to treat early-stage breast cancer. Studies reporting on complete ablation rate after thermal ablation as a treatment of small breast cancers (≤ 2 cm) were included. Methodologic quality of included studies was assessed using MINORS criteria. Complete ablation rates are given as proportions, and meta-regression and subgroup analyses were performed. The overall complete ablation rate in 1266 patients was 86% and was highest after radiofrequency ablation (RFA) (92%). Local recurrence rates varied from 0% to 3%, with a median follow-up of 15 to 61 months. Overall, complication rates were low (5%-18% across techniques) and were highest after high-intensity focused ultrasound ablation and lowest after cryoablation. Cosmetic outcome was good to excellent in at least 85% of patients but was reported infrequently and long-term results of cosmetic outcome after thermal ablation and radiotherapy are still lacking. Thermal ablation techniques treating early-stage breast cancer (≤ 2 cm) are safe and effective based on complete ablation rate and short-term local recurrence rates. Especially, RFA, microwave ablation, and cryoablation are promising techniques as an alternative to surgical resection without jeopardizing current treatment effectiveness or safety. Owing to great heterogeneity in the included studies, a formal recommendation on the best technique is not possible. These findings warrant the design of large randomized controlled trials comparing thermal ablation and breast-conserving surgery in the treatment of T1 breast cancer.

Potential Role of Curcumin and Its Nanoformulations to Treat Various Types of Cancers

Cancer is a major burden of disease globally. Each year, tens of millions of people are diagnosed with cancer worldwide, and more than half of the patients eventually die from it. Significant advances have been noticed in cancer treatment, but the mortality and incidence rates of cancers are still high. Thus, there is a growing research interest in developing more effective and less toxic cancer treatment approaches. Curcumin (CUR), the major active component of turmeric (Curcuma longa L.), has gained great research interest as an antioxidant, anticancer, and anti-inflammatory agent. This natural compound shows its anticancer effect through several pathways including interfering with multiple cellular mechanisms and inhibiting/inducing the generation of multiple cytokines, enzymes, or growth factors including IκB kinase β (IκKβ), tumor necrosis factor-alpha (TNF-α), signal transducer, and activator of transcription 3 (STAT3), cyclooxygenase II (COX-2), protein kinase D1 (PKD1), nuclear factor-kappa B (NF-κB), epidermal growth factor, and mitogen-activated protein kinase (MAPK). Interestingly, the anticancer activity of CUR has been limited primarily due to its poor water solubility, which can lead to low chemical stability, low oral bioavailability, and low cellular uptake. Delivering drugs at a controlled rate, slow delivery, and targeted delivery are other very attractive methods and have been pursued vigorously. Multiple CUR nanoformulations have also been developed so far to ameliorate solubility and bioavailability of CUR and to provide protection to CUR against hydrolysis inactivation. In this review, we have summarized the anticancer activity of CUR against several cancers, for example, gastrointestinal, head and neck, brain, pancreatic, colorectal, breast, and prostate cancers. In addition, we have also focused on the findings obtained from multiple experimental and clinical studies regarding the anticancer effect of CUR in animal models, human subjects, and cancer cell lines.

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.

Ultrasound-Guided Laser Ablation After Excisional Vacuum-Assisted Breast Biopsy for Small Malignant Breast Lesions: Preliminary Results

Background:

The purpose of this preliminary study is to evaluate the feasibility of the excisional ultrasound (US) guided vacuum-assisted breast biopsy (VAE), followed by US-guided Laser Interstitial Thermal Therapy (LITT) in the treatment of unifocal ductal breast carcinomas ≤ 1 cm and estimate the ablation rate analyzing the final histopathological results after subsequent surgical excision.

Methods:

In a single session 11 female patients with unifocal less than a centimeter breast cancer underwent 2 different minimally invasive percutaneous US-guided techniques: a VAE breast biopsy with an 8 G needle to remove the lesion and, immediately after, a LITT ablation in the biopsy site. Four weeks later, all patients underwent radiological follow-up. Afterward, a systematic surgery was performed, the ablation rate was calculated, and iconographic and histological features were correlated.

Results:

Average maximum diameter of the lesions was 7.6 mm (5-10 mm). No patient reported pain or discomfort during procedure. 1/11 patient (9.1%) reported an early minor complication (a small superficial skin burn). After surgical excision, the histopathological evaluation reported in 10/11 cases (90.9%) complete ablation of the target lesion. In only one case (9.1%) residual cancer was detected. The necrotic-hemorrhagic cavities showed a mean maximum diameter of 27.3 mm (20-35 mm).

Conclusions:

Laser ablation performed after excisional biopsy could be considered a valid alternative to surgical excision for the treatment of lesions ≤ 1 cm, if carried out by expert radiologists. The association of these minimally invasive percutaneous methods has proven to be reliable, fast, and safe with an ablation rate of 90.9% and excellent aesthetic results. RM and CESM are potentially able to quantifying treatment results and to follow-up the ablation effects.

Recurrence and survival after standard versus oncoplastic breast-conserving surgery for breast cancer

Background

Oncoplastic techniques in breast-conserving surgery (BCS) are used increasingly for larger tumours. This large cohort study aimed to assess oncological outcomes after oncoplastic BCS (OPS) versus standard BCS.

Methods

Data for all women who had BCS in three centres in Stockholm during 2010–2016 were extracted from the Swedish National Breast Cancer Register. All patients with T2–3 tumours, all those receiving neoadjuvant treatment, and an additional random sample of women with T1 tumours were selected. Medical charts were reviewed for local recurrences and surgical technique according to the Hoffman–Wallwiener classification. Date and cause of death were retrieved from the Swedish Cause of Death Register.

Results

The final cohort of 4178 breast cancers in 4135 patients was categorized into three groups according to surgical technique: 3720 for standard BCS, 243 simple OPS, and 215 complex OPS. Median duration of follow up was 64 (range 24–110) months. Node-positive and large tumours were more common in OPS than in standard BCS (P < 0.001). There were 61 local recurrences: 57 (1.5 per cent), 1 (0.4 per cent) and 3 (1.4 per cent) in the standard BCS, simple OPS and complex OPS groups respectively (P = 0.368). Overall, 297 patients died, with an unadjusted 5-year overall survival rate of 94.7, 93.1 and 92.6 per cent respectively (P = 0.350). Some 102 deaths were from breast cancer, with unadjusted 5-year cancer-specific survival rates of 97.9, 98.3 and 95.0 per cent respectively (P = 0.056).

Discussion

Oncoplastic BCS is a safe surgical option, even for larger node-positive tumours, with low recurrence and excellent survival rates.

Biophotonic technologies for assessment of breast tumor surgical margins-A review

Breast conserving surgery (BCS) offering similar surgical outcomes as mastectomy while retaining breast cosmesis is becoming increasingly popular for the management of early stage breast cancers. However, its association with reoperation rates of 20% to 40% following incomplete tumor removal warrants the need for a fast and accurate intraoperative surgical margin assessment tool that offers cellular, structural and molecular information of the whole specimen surface to a clinically relevant depth. Biophotonic technologies are evolving to qualify as such an intraoperative tool for clinical assessment of breast cancer surgical margins at the microscopic and macroscopic scale. Herein, we review the current research in the application of biophotonic technologies such as photoacoustic imaging, Raman spectroscopy, multimodal multiphoton imaging, diffuse optical imaging and fluorescence imaging using medically approved dyes for breast cancer detection and/or tumor subtype differentiation toward intraoperative assessment of surgical margins in BCS specimens, and possible challenges in their route to clinical translation.

Practical consensus recommendations for tumor margins and breast conservative surgery

My suggestion: There is no difference in survival of breast cancer patients treated with either mastectomy or with breast conservation therapy combined with external beam radiotherapy. A positive margin (s) is an important factor contributing to the increased risk of local recurrence. However, in published literature, there is a lack of consensus on the definition of acceptable margin (s). As a result decision process about need for re-excision after positive margins remains uncrear.