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Gilmore R, Chen J, Dembinski R, Reissis Y, Milek D, Cadena L, Habibi M. Cost minimization in breast conserving surgery: a comparative study of radiofrequency spectroscopy and full cavity shave margins. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:66. [PMID: 37716980 PMCID: PMC10504787 DOI: 10.1186/s12962-023-00477-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 09/09/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND In an effort to minimize positive margins and subsequent re-excision after breast conserving surgery (BCS), many providers and facilities have implemented either a Full Cavity Shave (FCS) approach or adding the MarginProbe Radiofrequency Spectroscopy System. OBJECTIVE We sought to create a functioning Pro-Forma for use by facilities and payers to evaluate and compare the cost savings of implementing FCS or MarginProbe based on personalized variable inputs. METHODS A decision tree demonstrating three possible surgical pathways, BCS, BCS + FCS, and BCS + MarginProbe was developed with clinical inputs for re-excision rate, mastectomy as 2nd surgery, rate of reconstruction, and rate of 3rd surgery derived by a literature review. A surgical pathway cost formula was created using the decision tree and financial inputs derived by utilizing the nation's largest database of privately billed health insurance claims and Medicare claims data (fairhealth.org). Using the surgical pathway formula and financial inputs, a customizable Pro-Forma was created for immediate cost savings analysis of BCS + FCS and BCS + Marginprobe using variable inputs. Costs are from the perspective of third-party payers. RESULTS Utilizing MarginProbe to reduce re-excisions for positive margins can be associated with better cost-savings than FCS due to the increased pathology processing costs by using an FCS approach. The reduction in re-excision provided by both FCS and MarginProbe offset their increased expense to various degrees with cost savings of each method improving as baseline re-excisions rates increase, until ultimately each may become cost-neutral or cost-prohibitive when compared to BCS alone. Our data suggest that in the privately insured population, MarginProbe provides a cost-savings over BCS alone when baseline re-excision rates are over 20% and that FCS becomes cost-saving when baseline re-excision rates are over 29%. For Medicare patients, MarginProbe provides a cost-savings when baseline re-excision rates exceed 34%, and FCS becomes cost-saving for re-excision rates over 52%. Our Pro-Forma allows an individual provider or institution to evaluate the cost savings of the FCS approach and/or utilization of the MarginProbe device such that the additional cost or cost-savings of utilizing one or both of these methods can be quickly calculated based on their facility's volume and baseline re-excision rate. CONCLUSIONS Our data suggest that utilizing either an FCS approach or the MarginProbe radiofrequency spectroscopy system may be a cost-saving solution to reducing the rate of re-excisions depending on a facility or practice's surgical volume and baseline re-excision rate. The degree to which each of these interventions provides an added cost or cost-savings to healthcare payers can be evaluated by utilizing the Pro-Forma outlined herein with customizable variable inputs.
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Affiliation(s)
- Richard Gilmore
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Jennifer Chen
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Robert Dembinski
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Yannis Reissis
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - David Milek
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Lisa Cadena
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Mehran Habibi
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA.
- Department of Surgery, Northwell Health, Zucker School of Medicine, New York, United States.
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Fernandez-Pacheco M, Ortmann O, Ignatov A, Inwald EC. Does cavity margin shaving reduce residual tumor and re-excision rates? A systematic review. Arch Gynecol Obstet 2023; 307:1295-1309. [PMID: 35593951 PMCID: PMC10023760 DOI: 10.1007/s00404-022-06512-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/06/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Cavity shaving (CS) is a surgical technique used in the treatment of breast cancer (BC). It may reduce margin positivity in histologic assessment and consequently reduces re- excision rates in breast conserving surgery (BCS). The evidence for this assumption is described in the present review. METHODS A systematic review of relevant literature in English from January 1999 to April 2019 was conducted. The analysis included studies on CS and its effects on re-excision rates and margin positivity. We searched PubMed databases for relevant publications. In total, 22 studies were included in the present review. RESULTS The benefit from CS on re-excision rates and histologic margin positivity was variable. Out of 22 studies, 17 reported a reduction in both re-excision rates and histologic margin positivity in margin shaved patients. Four studies could not find a significant reduction of second surgeries and residual tumor rates. One study suggested that CS after BCS was superior to single BCS only in subgroup analysis in IDC tumors. CONCLUSION CS is a surgical technique that was shown to reduce re-excision and margin positivity rates in most of the studies. Furthermore, it can be a useful tool to assess specimen margins and detect multifocality.
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Affiliation(s)
- M Fernandez-Pacheco
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany.
| | - O Ortmann
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - A Ignatov
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - E C Inwald
- Department of Gynaecology and Obstetrics, University Medical Center Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
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Joel C, Ciampa M, O'Hara T, Bandera BC, Mangieri CW. Effect of three-dimensional intraoperative imaging on surgical outcomes with breast conservation therapy. Am J Surg 2022; 225:1009-1012. [PMID: 36621358 DOI: 10.1016/j.amjsurg.2022.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/04/2022] [Accepted: 12/26/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Breast conservation therapy (BCT) is frequently performed for breast cancer and associated with a significant risk for positive margins. Intraoperative three-dimensional (3-D) tomosynthesis potentially could limit the risk of positive margins. METHODS Retrospective review of an institutional breast cancer registry. Evaluated BCT cases for a two year time period prior to and after the introduction of intraoperative 3-D tomosynthesis. Primary outcome was the effect of 3-D tomosynthesis on margin positivity rates. Secondary measures were the impact of 3-D tomosynthesis on additional margin procurements at the index surgery and operative time. RESULTS A total of 228 cases were evaluated with 106 cases utilizing 3-D tomosynthesis and 122 cases with standard imaging. No significant difference in margin positivity rates between the cohorts at 23.9% versus 15.8% for 3-D tomosynthesis and standard imaging respectively (OR 1.53, CI 0.772-3.032, P = 0.221). 3-D tomosynthesis was associated with increased margin procurement rates (OR 2.34, 95%CI 1.303-4.190, P = 0.004) and longer operative times (P < 0.001). CONCLUSION Intraoperative 3-D tomosynthesis was not found to limit margin positivity rates or improve the performance of the procedure.
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Affiliation(s)
- Constance Joel
- Department of General Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA
| | - Maeghan Ciampa
- Department of General Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA
| | - Thomas O'Hara
- Department of General Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA
| | - Bradley C Bandera
- Department of General Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA
| | - Christopher W Mangieri
- Department of General Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA.
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Association of Surgical Margin Status with Oncologic Outcome in Patients Treated with Breast-Conserving Surgery. Curr Oncol 2022; 29:9271-9283. [PMID: 36547140 PMCID: PMC9777347 DOI: 10.3390/curroncol29120726] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/18/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
We aimed to compare the prognosis of patients with close resection margins after breast-conserving surgery (BCS) with that of patients with negative margins and identified predictors of residual disease. A total of 542 patients with breast cancer who underwent BCS between 2003 and 2019 were selected and divided into the close margin (114 patients) and negative margin (428 patients) groups. The median follow-up period was 72 (interquartile range, 42-113) months. Most patients received radiation therapy (RTx) and systemic therapy according to their stage and molecular subtype. The 10-year locoregional recurrence-free survival rates of the close and negative margin groups were 88.2% and 95.5%, respectively (p = 0.001). Multivariable analysis showed that adjuvant RTx and margin status after definitive surgery were significantly associated with locoregional recurrence. Of the 57 patients who underwent re-excision, 34 (59.6%) had residual disease. Multivariable analysis revealed that a histological type of positive or close margins and multifocality were independent predictive factors for residual disease. Although the current guidelines suggest that no ink on tumor is an adequate margin after BCS, a close resection margin may be associated with locoregional failure. The treatment strategy for close resection margins after BCS should be based on individual clinicopathological features.
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Mohamedahmed AYY, Zaman S, Srinivasan A, Peterknecht E, Saeed S Mohammed S, AlBendary M, Alnzaer AA, Elsamani K. Do we need to routinely perform cavity shaving with breast-conserving surgery for breast cancer? A systematic review and meta-analysis. Surg Oncol 2020; 36:7-14. [PMID: 33271465 DOI: 10.1016/j.suronc.2020.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/30/2020] [Accepted: 11/15/2020] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate comparative outcomes of breast-conserving surgery (BCS) of breast cancer with and without cavity shaving. METHODS A systematic search of multiple electronic data sources was conducted, and all randomised controlled trials (RCTs) comparing BCS with or without cavity shaving for breast cancer were included. Positive margin rate, second operation rate, operative time, post-operative haematoma, cosmetic appearance and budget cost were the evaluated outcome parameters for the meta-analysis. RESULTS Six RCTs reporting a total number of 971 patients; 495 of these underwent BCS plus shaving (BCS + S), and 473 underwent BCS alone were included. BCS + S showed significantly lower positive margin rate (Risk Ratio [RR] 0.40, P = 0.00001) and second operation rate (RR 0.38, P = 0.00001). BCS + S demonstrated longer operative time than BCS (79 ± 4 min vs 67 ± 3 min, Mean Difference 12.14, P = 0.002), and there was no significant difference in the risk of post-operative haematoma (RR 0.33, P = 0.20). CONCLUSION BCS + S is superior to BCS in terms of positive margins rate and second operation rate. Operative time is longer when cavity shaving is performed.
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Affiliation(s)
- Ali Yasen Y Mohamedahmed
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.
| | - Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Ananth Srinivasan
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Elizabeth Peterknecht
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Mohamed AlBendary
- Department of Anaesthesia, Sudan Medical Specialisation Board, Khartoum, Sudan
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Pahmeyer C, Schablack A, Ratiu D, Thangarajah F, Ludwig S, Gruettner B, Mallmann P, Malter W, Warm M, Eichler C. Occurrence of Residual Cancer Within Re-excisions After Subcutaneous Mastectomy of Invasive Breast Cancer and Ductal Carcinoma In Situ - A Retrospective Analysis. In Vivo 2020; 34:2015-2019. [PMID: 32606175 DOI: 10.21873/invivo.12000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND/AIM Surgical margin status remains an important determinant for recurrence of invasive breast cancer and ductal carcinoma in situ. We compared the number of positive margins in initial histology with rates of residual tumor in re-excision specimens. Furthermore, we analysed cost-effectiveness of re-excisions. PATIENTS AND METHODS 101 patients treated with secondary surgery were included. The first group underwent breast conserving surgery and secondary mastectomy. The second group was primarily treated with subcutaneous mastectomy followed by secondary surgery. RESULTS Within the first group, 22.7% did not show residual tumor in the re-excision specimen. Of the second group, 54.3% had no residual tumor. Consequentially 45.7% needed a re-excision to achieve R0 status. Cost-effectiveness was determined as secondary endpoint. If a patient needs a secondary mastectomy the hospital gains 602,65€ in comparison to a primary breast conserving operation. CONCLUSION In every second patient who had first received a subcutaneous mastectomy, no tumor could be detected in the secondary operation despite a previous R1 status.
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Affiliation(s)
- Caroline Pahmeyer
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Anika Schablack
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Dominik Ratiu
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Fabinshy Thangarajah
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Sebastian Ludwig
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Berthold Gruettner
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Peter Mallmann
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Wolfram Malter
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
| | - Mathias Warm
- Breast Cancer Center, Municipal Hospital Holweide, Cologne, Germany
| | - Christian Eichler
- Department of Gynecology and Obstetrics, University of Cologne, Cologne, Germany
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7
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O'Connell L, Walsh S, Evoy D, O'Doherty A, Quinn C, Rothwell J, Geraghty J, McDermott EW, Prichard R. The approach to an isolated close anterior margin in breast conserving surgery. Ann R Coll Surg Engl 2019; 101:268-272. [PMID: 30855173 DOI: 10.1308/rcsann.2019.0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Although close radial margins after breast-conserving surgery routinely undergo re-excision, appropriate management of patients with close anterior margins remains a topic of controversy. An increasing body of literature suggests that re-excision of close anterior margins yields low rates of residual malignancy and may only be necessary in selected patients. The aim of this study was to examine the management of close anterior margins after breast conserving surgery in a single institution and to analyse the rate of residual disease in re-excised anterior margins. METHODS All patients having breast conserving surgery at St Vincent's University Hospital from January 2008 to December 2012 were reviewed retrospectively. Data collected included patient demographics, tumour characteristics, margin positivity, re-excision rates and definitive histology of the re-excision specimens. A close margin was defined as les than 2 mm. RESULTS A total of 930 patients were included with an average age of 65 years (range 29-94 years). Of these, 121 (13%) had a close anterior margin. Further re-excison of the anterior margin was carried out in 37 patients (30.6%) and a further 16 (13.2%) proceeded to mastectomy. Residual disease was found in 18.5% (7/36) of those who underwent re-excision and 7/16 (43.75%) of those who underwent mastectomy. Overall, 11.57% (14/121) of patients with close anterior margins were subsequently found to have residual disease. CONCLUSION The low yield of residual disease in re-excised anterior margins specimens supports the concept that routine re-excision of close anterior margins is not necessary. Further research is required to definitively assess its influence on the risk of local recurrence.
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Affiliation(s)
- L O'Connell
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
| | - S Walsh
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
| | - D Evoy
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
| | - A O'Doherty
- Department of Radiology, St Vincent's University Hospital , Dublin , Ireland
| | - C Quinn
- Department of Pathology, St Vincent's University Hospital , Dublin , Ireland
| | - J Rothwell
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
| | - J Geraghty
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
| | - E W McDermott
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
| | - R Prichard
- Department of Breast, Endocrine and General Surgery, St Vincent's University Hospital , Dublin , Ireland
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Lai HW, Huang RH, Wu YT, Chen CJ, Chen ST, Lin YJ, Chen DR, Lee CW, Wu HK, Lin HY, Kuo SJ. Clinicopathologic factors related to surgical margin involvement, reoperation, and residual cancer in primary operable breast cancer – An analysis of 2050 patients. Eur J Surg Oncol 2018; 44:1725-1735. [DOI: 10.1016/j.ejso.2018.07.056] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 07/04/2018] [Accepted: 07/23/2018] [Indexed: 12/23/2022] Open
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Kahlert S, Kolben TM, Schmoeckel E, Czogalla B, Hester A, Degenhardt T, Kempf C, Mahner S, Harbeck N, Kolben T. Prognostic impact of residual disease in simultaneous additional excision specimens after one-step breast conserving therapy with negative final margin status in primary breast cancer. Eur J Surg Oncol 2018; 44:1318-1323. [PMID: 30041974 DOI: 10.1016/j.ejso.2018.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/06/2018] [Accepted: 06/18/2018] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The purpose of this study was the evaluation of risk factors for local recurrence after breast conserving surgery (BCS) with special focus on the impact of residual disease in specimens of simultaneous additional excisions (AE) from the tumor cavity on patients' outcome in patients with negative final margin status after one-step BCS. METHODS This study was designed as a single center retrospective cohort study. Patients with primary non-metastatic breast cancer treated by one-step BCS with pathologically confirmed negative resection status between 1990 and 2006 were included. Ipsilateral breast tumor recurrence (IBTR) and overall survival (OS) were evaluated by Kaplan-Meier-estimates. A multivariate Cox proportional hazards regression model was used to identify potential independent prognostic factors associated with the risk of IBTR. RESULTS A total of 1081 patients were included in this analysis. Simultaneous additional excisions were performed in 79.4% of patients (tumor positive: 12.2%). Median follow-up after primary diagnosis was 124 months. The IBTR rate after 15 years was significantly higher in the group with tumor positive AE (no AE (10.2%) vs. AE tumor positive (27.5%) p = 0.002; AE tumor negative (14.0%) vs. AE tumor positive (27.5%) p = 0.008). The OS rate did not differ significantly between groups. Multivariate analysis revealed residual cancer in AE being associated with a significantly increased relative risk of IBTR of 2.0 (p = 0.014). CONCLUSION In the current analysis residual disease in simultaneous additional excisions was associated with an increased risk for IBTR despite negative final margin status. This should be considered in the overall therapeutic concept.
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Affiliation(s)
- Steffen Kahlert
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Theresa M Kolben
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Elisa Schmoeckel
- Department of Pathology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Bastian Czogalla
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Anna Hester
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Tom Degenhardt
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Cordula Kempf
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Sven Mahner
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Nadia Harbeck
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany
| | - Thomas Kolben
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, 15, 81377 Munich, Germany.
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Findlay-Shirras LJ, Outbih O, Muzyka CN, Galloway K, Hebbard PC, Nashed M. Predictors of Residual Disease After Breast Conservation Surgery. Ann Surg Oncol 2018; 25:1936-1942. [PMID: 29748884 DOI: 10.1245/s10434-018-6454-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Breast-conserving therapy is the standard of care for early-stage breast cancer. In the era of multimodality therapy, the debate on the value of revision surgery for compromised margins continues, and high re-excision rates persist despite updated guidelines. Our study sought to identify the local re-excision rate for compromised margins after lumpectomy, and identify predictors of residual disease at re-excision. METHODS This population-based retrospective cohort study included women with breast cancer who underwent a lumpectomy between 2009 and 2012 in Manitoba, with close (≤ 2 mm) or positive margins that led to re-excision. Patient demographics and tumor characteristics were identified through provincial cancer registries and chart reviews. For patients with invasive cancer, the six anatomical margins were reported for margin status, width, and pathology type at the margin. RESULTS Of the 2494 patients identified, 556 women underwent re-excision, yielding a re-excision rate of 22.29%. Of our 311 patients with invasive cancer who underwent re-excision, 62.7% had residual disease identified on revision. On univariable analysis, the size and grade of the invasive component, nodal stage, and the number of positive margins were associated with residual disease on re-excision (p < 0.05). With the exception of nodal stage, the same variables remained statistically significant on multivariable analysis. CONCLUSIONS Our results suggest that even in the absence of 'no ink on tumor', the cancer size and grade in lumpectomy specimens are high-risk factors for residual disease, and this subgroup of patients may benefit from re-excision. Long-term follow-up of this cohort is required to determine their risk of recurrence after adjuvant treatment.
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Affiliation(s)
| | - Oussama Outbih
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Charlene N Muzyka
- Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Katie Galloway
- Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Pamela C Hebbard
- Section of General Surgery, Department of General Surgery, University of Manitoba, Winnipeg, MB, Canada.,CancerCare Manitoba, Winnipeg, MB, Canada
| | - Maged Nashed
- Radiation Oncology, Department of Radiology, University of Manitoba, Winnipeg, MB, Canada. .,Department of Radiation Oncology, CancerCare Manitoba, Winnipeg, MB, Canada.
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11
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Chagpar AB, Tsangaris TN, Lannin DR. Do All Positive Margins in Breast Cancer Patients Undergoing a Partial Mastectomy Need to Be Resected? J Am Coll Surg 2018. [PMID: 29524664 DOI: 10.1016/j.jamcollsurg.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Positive margins have been reported in 20% to 40% of patients undergoing a partial mastectomy, often resulting in re-excision. How often the re-excision yields additional cancer and whether there are predictors of residual disease remain unknown. STUDY DESIGN Patients who had a positive margin (defined as tumor at ink for patients with invasive disease or within 1 mm for patients with ductal carcinoma in situ) in the SHAVE (A Randomized Controlled Trial of Routine Shave Margins Versus Standard Partial Mastectomy in Breast Cancer Patients) trial before randomization were evaluated to determine the rate of additional disease either in cavity shave margins or at re-excision. Details of the SHAVE trial can be found elsewhere. RESULTS Of the 235 patients in the trial, 82 (34.9%) had a positive margin before randomization; 58 of these patients underwent either cavity shave margins excision or a re-excision of the positive margin(s). Twenty-one (36.2%) patients had residual disease. On bivariate analysis, residual disease was associated with younger patient age (median 51 vs 62 years; p = 0.007), and the presence of high-grade ductal carcinoma in situ (57.1% vs 31.3% for grade 2 and 0% for grade 1; p = 0.025). The following factors were not associated with further disease: patient race; ethnicity; BMI; volume of resection; number of positive margins; extent of ductal carcinoma in situ; and extent, grade, and histologic subtype of invasive cancer. On multivariate analysis, only patient age younger than 60 years remained a significant predictor of residual disease (odds ratio 3.920; 95% CI 1.081 to 14.220; p = 0.038). CONCLUSIONS Positive margins are associated with further disease in more than one-third of patients and, aside from young age, there are no predictors of this. These findings support continued re-excision of positive margins, particularly in patients younger than 60 years of age.
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Affiliation(s)
- Anees B Chagpar
- Department of Surgery, Yale University School of Medicine, New Haven, CT.
| | | | - Donald R Lannin
- Department of Surgery, Yale University School of Medicine, New Haven, CT
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12
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Montoya D, Elias AS, Mosto J, Schejtman D, Varela EB, Paleta C, McLean LH, Sanguinetti M, Bastacini V, Nasute P, Benedek E, Varela M, Chiozza J, McLean I. Positive Margins following Breast Cancer Tumorectomy. Can we Predict the Occurrence of Residual Disease? TUMORI JOURNAL 2018. [DOI: 10.1177/1636.17900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Diana Montoya
- Mastology Service, Hospital Universitario Austral, Buenos Aires, Argentina
| | | | - Julian Mosto
- Anatomical Pathology Service, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Darío Schejtman
- Diagnostic Imaging Service, Hospital Universitario Austral, Buenos Aires, Argentina
| | | | - Claudio Paleta
- Clinical Oncology Service, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Leonardo H McLean
- Mastology Service, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Marta Sanguinetti
- Diagnostic Imaging Service, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Vanina Bastacini
- Diagnostic Imaging Service, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Paola Nasute
- Diagnostic Imaging Service, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Elide Benedek
- Diagnostic Imaging Service, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Mónica Varela
- Clinical Oncology Service, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Jorge Chiozza
- Radiation Therapy Service, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Ignacio McLean
- Mastology Service, Hospital Universitario Austral, Buenos Aires, Argentina
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Yoon TI, Lee JW, Lee SB, Sohn G, Kim J, Chung IY, Kim HJ, Ko BS, Son BH, Gong G, Kim SB, Kim SS, Ahn SD, Chung M, Ahn SH. No Association of Positive Superficial and/or Deep Margins with Local Recurrence in Invasive Breast Cancer Treated with Breast-Conserving Surgery. Cancer Res Treat 2017; 50:275-282. [PMID: 28421725 PMCID: PMC5784642 DOI: 10.4143/crt.2017.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/11/2017] [Indexed: 11/21/2022] Open
Abstract
PURPOSE We evaluated the effect of positive superficial and/or deep margin status on local recurrence (LR) in invasive breast cancer treated with breast-conserving surgery (BCS) followed by radiotherapy. MATERIALS AND METHODS In total, 3,403 stage 1 and 2 invasive breast cancer patients treated with BCS followed by radiotherapy from January 2000 to December 2008 were included in this study. These patients were divided into three groups according to margin status: clear resection margin status for all sections (group 1, n=3,195); positive margin status in superficial and/or deep sections (group 2, n=121); and positive peripheral parenchymal margin regardless of superficial and/or deep margin involvement (group 3, n=87). The LR-free survival between these three groups was compared and the prognostic role of margin status was analyzed. RESULTS Across all groups, age, tumor size, nodal status, and human epidermal growth factor receptor 2 status did not significantly differ. High grade, positive extensive intraductal component, hormone receptor positivity, hormone therapy received, and chemotherapy not received were more prevalent in groups 2 and 3 than in group 1. Five-year LR rates in groups 1, 2, and 3 were 1.9%, 1.7%, and 7.7%, respectively. Multivariate analysis revealed that group 3 was a significant predictor for LR (hazard ratio [HR], 4.78; p < 0.001), but that positive superficial and/or deep margin was not (HR, 0.66; p=0.57). CONCLUSION Superficial and/or deep margin involvement following BCS is not an important predictor for LR.
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Affiliation(s)
- Tae In Yoon
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Jong Won Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sae Byul Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Guiyun Sohn
- Division of Breast and Endocrine Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jisun Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Il Young Chung
- Division of Breast and Endocrine Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Jeong Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Beom Seok Ko
- Division of Breast and Endocrine Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Ho Son
- Division of Breast and Endocrine Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyungyub Gong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Bae Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Do Ahn
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Minsung Chung
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Sei Hyun Ahn
- Division of Breast and Endocrine Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Gorpas D, Koch M, Anastasopoulou M, Klemm U, Ntziachristos V. Benchmarking of fluorescence cameras through the use of a composite phantom. JOURNAL OF BIOMEDICAL OPTICS 2017; 22:16009. [PMID: 28301638 DOI: 10.1117/1.jbo.22.1.016009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 12/23/2016] [Indexed: 05/03/2023]
Abstract
Fluorescence molecular imaging (FMI) has shown potential to detect and delineate cancer during surgery or diagnostic endoscopy. Recent progress on imaging systems has allowed sensitive detection of fluorescent agents even in video rate mode. However, lack of standardization in fluorescence imaging challenges the clinical application of FMI, since the use of different systems may lead to different results from a given study, even when using the same fluorescent agent. In this work, we investigate the use of a composite fluorescence phantom, employed as an FMI standard, to offer a comprehensive method for validation and standardization of the performance of different imaging systems. To exclude user interaction, all phantom features are automatically extracted from the acquired epi-illumination color and fluorescence images, using appropriately constructed templates. These features are then employed to characterize the performance and compare different cameras to each other. The proposed method could serve as a framework toward the calibration and benchmarking of FMI systems, to facilitate their clinical translation.
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Affiliation(s)
- Dimitris Gorpas
- Technical University Munich, Chair for Biological Imaging, Arcisstrasse 21, Munich D-80333, GermanybHelmholtz Zentrum München, Institute for Biological and Medical Imaging, Ingolstädter Landstrasse 1, Neuherberg D-85764, Germany
| | - Maximilian Koch
- Technical University Munich, Chair for Biological Imaging, Arcisstrasse 21, Munich D-80333, GermanybHelmholtz Zentrum München, Institute for Biological and Medical Imaging, Ingolstädter Landstrasse 1, Neuherberg D-85764, Germany
| | - Maria Anastasopoulou
- Technical University Munich, Chair for Biological Imaging, Arcisstrasse 21, Munich D-80333, GermanybHelmholtz Zentrum München, Institute for Biological and Medical Imaging, Ingolstädter Landstrasse 1, Neuherberg D-85764, Germany
| | - Uwe Klemm
- Helmholtz Zentrum München, Institute for Biological and Medical Imaging, Ingolstädter Landstrasse 1, Neuherberg D-85764, Germany
| | - Vasilis Ntziachristos
- Technical University Munich, Chair for Biological Imaging, Arcisstrasse 21, Munich D-80333, GermanybHelmholtz Zentrum München, Institute for Biological and Medical Imaging, Ingolstädter Landstrasse 1, Neuherberg D-85764, Germany
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Lai HW, Chen CJ, Lin YJ, Chen SL, Wu HK, Wu YT, Kuo SJ, Chen ST, Chen DR. Does Breast Magnetic Resonance Imaging Combined With Conventional Imaging Modalities Decrease the Rates of Surgical Margin Involvement and Reoperation?: A Case-Control Comparative Analysis. Medicine (Baltimore) 2016; 95:e3810. [PMID: 27258520 PMCID: PMC4900728 DOI: 10.1097/md.0000000000003810] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The objective of this study was to assess whether preoperative breast magnetic resonance imaging (MRI) combined with conventional breast imaging techniques decreases the rates of margin involvement and reexcision.Data on patients who underwent surgery for primary operable breast cancer were obtained from the Changhua Christian Hospital (CCH) breast cancer database. The rate of surgical margin involvement and the rate of reoperation were compared between patients who underwent conventional breast imaging modalities (Group A: mammography and sonography) and those who received breast MRI in addition to conventional imaging (Group B: mammography, sonography, and MRI).A total of 1468 patients were enrolled in this study. Among the 733 patients in Group A, 377 (51.4%) received breast-conserving surgery (BCS) and 356 (48.6%) received mastectomy. Among the 735 patients in Group B, 348 (47.3%) received BCS and 387 (52.7%) received mastectomy. There were no significant differences in operative method between patients who received conventional imaging alone and those that received MRI and conventional imaging (P = 0.13). The rate of detection of pathological multifocal/multicentric breast cancer was markedly higher in patients who received preoperative MRI than in those who underwent conventional imaging alone (14.3% vs 8.6%, P < 0.01). The overall rate of surgical margin involvement was significantly lower in patients who received MRI (5.0%) than in those who received conventional imaging alone (9.0%) (P < 0.01). However, a significant reduction in rate of surgical margin positivity was only observed in patients who received BCS (Group A, 14.6%; Group B, 6.6%, P < 0.01). The overall BCS reoperation rates were 11.7% in the conventional imaging group and 3.2% in the combined MRI group (P < 0.01). There were no significant differences in rate of residual cancer in specimens obtained during reoperation between the 2 preoperative imaging groups (Group A, 50%; Group B, 81.8%, P = 0.09). In multivariate analysis, multifocal/multicentric breast cancer (odds ratio = 2.38, P = 0.02) and without MRI use (odds ratio = 2.35, P < 0.01) were the major predisposing factors to margin involvement in patients received BCS.Preoperative breast MRI combined with conventional breast imaging results in a lower rate of surgical margin involvement and reoperations in patients who receive BCS.
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Affiliation(s)
- Hung-Wen Lai
- From the Endoscopic & Oncoplastic Breast Surgery Center (H-WL, S-LC, S-TC, D-RC), Comprehensive Breast Cancer Center (H-WL, S-LC, S-JK, S-TC, D-RC), Division of General Surgery, Department of Surgery (H-WL, S-JK, S-TC, D-RC), Department of Surgical Pathology (C-JC), Tumor Center (Y-JL), Department of Radiology, Changhua Christian Hospital, Changhua (H-KW), School of Medicine, National Yang Ming University, Taipei (H-WL), School of Medicine, Chung Shan Medical University, Taichung (C-JC), Department of Medical Technology, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli (C-JC), and Department of Surgery, Ministry of Healthy and Welfare Sinying Hospital, Tainan, Taiwan (Y-TW)
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O'Kelly Priddy CM, Forte VA, Lang JE. The importance of surgical margins in breast cancer. J Surg Oncol 2015; 113:256-63. [PMID: 26394558 DOI: 10.1002/jso.24047] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 09/08/2015] [Indexed: 12/22/2022]
Abstract
Achieving negative margins with "no tumor on ink" is an appropriate goal in breast conserving therapy (BCT). Wider margins do not decrease recurrence rates, and re-excision in patients with microscopic positive margins is warranted. Several strategies exist to increase rates of negative margins, including techniques to improve tumor localization, intraoperative assessment of margins and oncoplastic techniques. Negative margins should be the goal of BCT, as this will improve both local control and long-term survival.
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Affiliation(s)
- Colleen M O'Kelly Priddy
- Department of Surgery, Section of Breast Soft Tissue Surgery, USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Victoria A Forte
- Department of Medicine, Division of Medical Oncology, USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Julie E Lang
- Department of Surgery, Section of Breast Soft Tissue Surgery, USC Norris Comprehensive Cancer Center, Los Angeles, California
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Garvey EM, Senior DA, Pockaj BA, Wasif N, Dueck AC, McCullough AE, Ocal IT, Gray RJ. Rates of residual disease with close but negative margins in breast cancer surgery. Breast 2015; 24:413-7. [DOI: 10.1016/j.breast.2015.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 01/11/2015] [Accepted: 03/15/2015] [Indexed: 01/03/2023] Open
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Clough KB, Gouveia PF, Benyahi D, Massey EJD, Russ E, Sarfati I, Nos C. Positive Margins After Oncoplastic Surgery for Breast Cancer. Ann Surg Oncol 2015; 22:4247-53. [PMID: 25893409 DOI: 10.1245/s10434-015-4514-3] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Oncoplastic techniques applied to breast-conserving surgery (BCS) allow large-volume resections without compromising cosmetic results. Level II oncoplastic techniques are based on mammoplasties. When required, they allow resection of more than 20 % of the breast volume; however, a subgroup of these patients will still have positive margins. The clinical management of positive margins after level II oncoplastic surgery (OPS) is a challenge. METHODS All patients who had undergone level II oncoplastic techniques at The Paris Breast Center between 2004 and 2013 were reviewed. The choice of the optimal mammoplasty technique was based on the tumor location and the 'quadrant per quadrant atlas'. RESULTS A total of 277 level II oncoplastic techniques were performed on 272 patients. The mean tumor size was 26 mm (range 2-160 mm), with a mean resected weight of 175 g (range 50-1540 g). The rate of positive margins was 11.9 %. Risk factors for positive margins identified in univariate analysis were histologic subgroup, tumor size, T stage and grade. In multivariate analysis, only patients with invasive lobular carcinoma had a significantly higher risk of positive margins. A second operation was required in 33 cases, and a third operation was required in three cases because of positive margins. Final breast conservation rate was 91 %. CONCLUSIONS Level II OPS results in a low positive margin rate despite large tumor size. Patients with involved margins can be offered a second BCS if the remaining volume allows this.
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Affiliation(s)
| | | | | | | | | | | | - Claude Nos
- L'Institut du Sein - Paris Breast Center, Paris, France
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The Oncologic Safety and Practicality of Breast Conservation Surgery in Large Breast Tumors 5 Centimeters or More. Clin Breast Cancer 2015; 15:e47-53. [DOI: 10.1016/j.clbc.2014.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/31/2014] [Accepted: 06/17/2014] [Indexed: 11/23/2022]
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20
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Extent of margin involvement, lymphovascular invasion, and extensive intraductal component predict for residual disease after wide local excision for breast cancer. Clin Breast Cancer 2014; 15:219-26. [PMID: 25576998 DOI: 10.1016/j.clbc.2014.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 12/08/2014] [Accepted: 12/16/2014] [Indexed: 11/21/2022]
Abstract
UNLABELLED In the present study, we identified predictors of residual disease after an inadequate wide local excision. Residual tumor was more likely when tumor was present at the inked margin, when more than a single radial margin was affected, and in tumors associated with lymphovascular invasion and an extensive intraductal component. BACKGROUND Positive margins after wide local excision (WLE) increase the probability of residual disease, and additional surgery is often recommended. However, residual tumor will be found in only two thirds of cases, suggesting that additional surgery can be avoided in many instances. In the present study, we sought to establish the frequency of residual tumor when the surgical margins are inadequate and to identify factors that predict for residual tumor. MATERIALS AND METHODS A retrospective review was performed of 720 consecutive patients who had undergone WLE for ductal carcinoma in situ and nonmetastatic breast cancer at a single unit from January 1, 2004 to December 31, 2010. RESULTS At least a single radial margin was affected (either involved or close, defined as tumor < 1 mm from the margin) in 244 patients who had undergone WLE, and either the anterior or posterior margin was affected in another 103 patients. Reoperation was performed in 215 patients with affected radial margins and 9 others with affected anterior or posterior margins. Residual disease was found in 98 of 224 patients (43.8%) and was more likely when tumor was present at the inked margin, when > 1 radial margin was affected, and when lymphovascular invasion (LVI) or an extensive intraductal component (EIC) was present. The association with tumor size was of borderline significance. No association was found with tumor histologic type or patient age. CONCLUSION Additional evaluation is needed to determine whether additional surgery can be safely omitted in women with tumors without LVI or EIC when a single radial margin has been deemed to be close.
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Angarita FA, Nadler A, Zerhouni S, Escallon J. Perioperative measures to optimize margin clearance in breast conserving surgery. Surg Oncol 2014; 23:81-91. [PMID: 24721660 DOI: 10.1016/j.suronc.2014.03.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 02/28/2014] [Accepted: 03/04/2014] [Indexed: 01/15/2023]
Abstract
Margin status is one of the most important determinants of local recurrence following breast conserving surgery. The fact that up to 60% of patients undergoing breast conserving surgery require re-excision highlights the importance of optimizing margin clearance. In this review we summarize the following perioperative measures that aim to enhance margin clearance: (1) patient risk stratification, specifically risk factors and nomograms, (2) preoperative imaging, (3) intraoperative techniques including wire-guided localization, radioguided surgery, intraoperative ultrasound-guided resection, intraoperative specimen radiography, standardized cavity shaving, and ink-directed focal re-excision; (4) and intraoperative pathology assessment techniques, namely frozen section analysis and imprint cytology. Novel surgical techniques as well as emerging technologies are also reviewed. Effective treatment requires accurate preoperative planning, developing and implementing a consistent definition of margin clearance, and using tools that provide detailed real-time intraoperative information on margin status.
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Affiliation(s)
- Fernando A Angarita
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario M5S 1A1, Canada.
| | - Ashlie Nadler
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario M5S 1A1, Canada.
| | - Siham Zerhouni
- Department of Surgery, University of British Columbia, Vancouver, British Columbia V6T 1Z4, Canada.
| | - Jaime Escallon
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario M5S 1A1, Canada; Department of Surgical Oncology, University of Toronto, Princess Margaret Hospital, Toronto, Ontario M5T 2M9, Canada; Marvelle Koffler Breast Centre, Mount Sinai Hospital, Toronto, Ontario M5G 1X5, Canada.
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Gatek J, Vrana D, Lukesova L, Pospiskova M, Vazan P, Melichar B. Significance of resection margin as a risk factor for local control of early stage breast cancer. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 157:209-13. [DOI: 10.5507/bp.2013.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 09/10/2013] [Indexed: 11/23/2022] Open
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Does the volume of ductal carcinoma in situ impact the positive margin rate in patients undergoing breast conservation for invasive breast cancer? J Surg Res 2013; 184:228-33. [DOI: 10.1016/j.jss.2013.03.071] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 03/17/2013] [Accepted: 03/20/2013] [Indexed: 11/23/2022]
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24
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Los márgenes de resección en la cirugía conservadora del cáncer de mama. Cir Esp 2013; 91:404-12. [DOI: 10.1016/j.ciresp.2013.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 02/07/2013] [Accepted: 02/21/2013] [Indexed: 11/19/2022]
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Grobmyer SR, Cowher MS, Crowe JP. Optimizing clinical management of surgical margins in breast-conserving therapy for breast cancer. Am Soc Clin Oncol Educ Book 2013:66-71. [PMID: 23714459 DOI: 10.14694/edbook_am.2013.33.66] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
There has been, and continues to be, significant controversy over the definition of an "optimal" surgical margin in breast-conserving therapy (BCT). The historic basis of this controversy stems from the original trials documenting the safety of BCT and many conflicting retrospective studies that have sought to define the association between surgical margin width and outcomes over the last 20 years. It is important to understand that margin assessment is an inexact science, and current laboratory approaches to surgical-margin assessment represent only a sampling of the surgical margin. Currently available evidence suggests that decisions regarding surgical margins in BCT should be made in the context of what is known about the biology of breast cancer, as well the interactions of tumor biology, adjuvant treatment for breast cancer, and outcomes. Achieving consensus on management of surgical margins in BCT should be a clinical priority as it offers the opportunity to reduce the burden of breast cancer treatment on patients without compromising cancer-related outcomes.
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Holloway CMB, Scollard DA, Caldwell CB, Ehrlich L, Kahn HJ, Reilly RM. Phase I trial of intraoperative detection of tumor margins in patients with HER2-positive carcinoma of the breast following administration of 111In-DTPA-trastuzumab Fab fragments. Nucl Med Biol 2013; 40:630-7. [PMID: 23618841 DOI: 10.1016/j.nucmedbio.2013.03.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 03/09/2013] [Accepted: 03/11/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Our aim was to conduct a Phase I clinical trial to determine the feasibility of intraoperative detection of tumor margins in HER2 positive breast carcinoma using a hand-held γ-probe following administration of (111)In-DTPA-trastuzumab Fab fragments. Accurate delineation of tumor margins is important for preventing local recurrence. METHODS Six patients with HER2-positive in situ or invasive ductal carcinoma were administered 74MBq (0.5mg) of (111)In-DTPA-trastuzumab Fab fragments and counts in the tumor, surgical cavity wall and en face margins were measured intraoperatively at 72h post-injection using the Navigator or C-Trak γ-probes. Margins were evaluated histologically. Quantitative whole body planar imaging was performed to estimate radiation absorbed doses using OLINDA/EXM software. SPECT imaging of the thorax was performed to evaluate tumor uptake. The pharmacokinetics of elimination from the blood and plasma were determined over 72h. RESULTS There were no acute adverse reactions from (111)In-DTPA-trastuzumab Fab fragments and no changes in hematological or biochemical indices were found over a 3month period. (111)In-DTPA-trastuzumab Fab fragments exhibited a biphasic elimination from the blood and plasma with t1/2α=11.9h and 7.5h, respectively, and t1/2β=26.6 and 20.7h, respectively. The radiopharmaceutical accumulated in the liver, spleen and kidneys. SPECT imaging did not reveal tumor in any patient. The mean effective dose was 0.146mSv/MBq (10.8mSv for 74MBq). Counts in excised tumors were low but were higher than in margins. Margins in two patients harboured tumor but this was not correlated with counts obtained using the γ-probes. Surgical cavity counts were high and likely due to detection of γ-photons outside the surgical field. CONCLUSION We conclude that it was not feasible, at least at the administered amount of radioactivity used in this study, to reliably detect the margins of disease in patients with in situ or invasive ductal carcinoma intraoperatively using a hand-held γ-probe and (111)In-DTPA-trastuzumab Fab fragments due to low uptake in the tumor and involved margins.
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Affiliation(s)
- Claire M B Holloway
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada M4N 3M5.
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Koca B, Kuru B, Yuruker S, Gokgul B, Ozen N. Factors affecting surgical margin positivity in invasive ductal breast cancer patients who underwent breast-conserving surgery after preoperative core biopsy diagnosis. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 84:154-9. [PMID: 23487000 PMCID: PMC3594642 DOI: 10.4174/jkss.2013.84.3.154] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 12/03/2012] [Accepted: 12/18/2012] [Indexed: 11/30/2022]
Abstract
Purpose The aim of our study is to evaluate the factors affecting surgical margin positivity among patients with invasive ductal breast cancer who underwent breast-conserving surgery (BCS) after preoperative diagnostic core biopsy. Methods Two hundred sixteen patients with stage I, II invasive ductal breast carcinoma who had histological diagnosis with preoperative tru-cut biopsy and underwent BCS were included in the present study. Potential factors that affect the positive surgical margin were analyzed. In univariate analysis, the comparisons of the factors affecting the surgical margin positivity were made by chi-square test. Logistic regression test was used to detect the independent factors affecting the surgical margin positivity. Results Positive axillary lymph node (odds ratio [OR], 8.2; 95% confidence interval [CI], 3.01 to 22.12), lymphovascular invasion (LVI; OR, 3.9; 95% CI, 1.62 to 9.24), extensive intraductal component (EIC; OR, 6.1; 95% CI, 2.30 to 16.00), presence of spiculation (OR, 5.1; 95% CI, 2.00 to 13.10) or presence of microcalcification in the mammography (OR, 13.7; 95% CI, 4.04 to 46.71) have been found to be the independent and adverse factors affecting surgical margin positivity. Conclusion Considering decision making for the extent of the excision and for achieving negative surgical margin before BCS, positive axillary lymph node, LVI, EIC, spiculation or microcalcification in mammography are related as predictor factors for positive surgical margin.
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Affiliation(s)
- Bulent Koca
- Department of General Surgery, Ondokuz Mayis University School of Medicine, Samsun, Turkey
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Wang SY, Kuntz KM, Tuttle TM, Jacobs DR, Kane RL, Virnig BA. The association of preoperative breast magnetic resonance imaging and multiple breast surgeries among older women with early stage breast cancer. Breast Cancer Res Treat 2013; 138:137-47. [PMID: 23354364 DOI: 10.1007/s10549-013-2420-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 01/15/2013] [Indexed: 11/26/2022]
Abstract
To evaluate the association between preoperative breast magnetic resonance imaging (MRI) utilization and the rate of multiple surgeries, and to investigate the extent of any variation of rates of multiple surgeries among physicians. We identified patients with stage 0, I, or II breast cancer diagnosed between 2002 and 2007 in the Surveillance, Epidemiology, and End Results-Medicare database. Using diagnosis and procedure codes, we defined that the initial treatment episode had ended when a gap in surgery occurred at least 90 days after primary surgery. Surgical procedures of partial mastectomy or mastectomy during the initial treatment period were calculated to identify patients who received multiple surgeries. Multilevel logistic regression models were used to identify patient- and physician-level predictors of multiple surgeries. Of 45,453 women with early stage breast cancer who were treated by 2,595 surgeons during the study period, 9,462 patients (20.8 %) received multiple breast surgeries; of these patients, 8,318 (87.9 %) underwent one additional surgery, 988 (10.4 %) received two additional surgeries, and 156 (1.6 %) received three or more additional surgeries. Among 2,997 (6.6 % of the entire cohort) women who underwent preoperative breast MRI evaluation, 770 received multiple breast surgeries. After we adjusted for patient and tumor characteristics associated with multiple surgeries, we found that the rate of multiple surgeries was not significantly different between the two groups with or without preoperative breast MRI. Furthermore, the median odds ratio of 2.0, corresponding with the median value of the relative odds of receiving multiple surgeries between two randomly chosen physicians after controlling for other confounders, indicated a large individual surgeon effect. Substantial variation was observed in the rates of multiple surgeries in women aged 66 and older with early stage breast cancer. Evidence does not support that preoperative breast MRI reduces the incidence of multiple surgeries.
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Affiliation(s)
- Shi-Yi Wang
- Division of Chronic Disease Epidemiology, Yale School of Public Health, 60 College Street, Room 432, New Haven, CT 06520, USA.
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Eck DL, Koonce SL, Goldberg RF, Bagaria S, Gibson T, Bowers SP, McLaughlin SA. Breast Surgery Outcomes as Quality Measures According to the NSQIP Database. Ann Surg Oncol 2012; 19:3212-7. [DOI: 10.1245/s10434-012-2529-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Indexed: 11/18/2022]
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Jeevan R, Cromwell DA, Trivella M, Lawrence G, Kearins O, Pereira J, Sheppard C, Caddy CM, van der Meulen JHP. Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics. BMJ 2012; 345:e4505. [PMID: 22791786 PMCID: PMC3395735 DOI: 10.1136/bmj.e4505] [Citation(s) in RCA: 224] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To examine whether rate of reoperation after breast conserving surgery is associated with patients' characteristics and investigate whether reoperation rates vary among English NHS trusts. DESIGN Cohort study using patient level data from hospital episode statistics. SETTING English NHS trusts. PARTICIPANTS Adult women who had breast conserving surgery between 1 April 2005 and 31 March 2008. MAIN OUTCOME MEASURE Reoperation rates after primary breast conserving surgery within 3 months, adjusted using logistic regression for tumour type, age, comorbidity, and socioeconomic deprivation. Tumours were grouped by whether a carcinoma in situ component was coded at the time of the primary breast conserving surgery. RESULTS 55,297 women had primary breast conserving surgery in 156 NHS trusts during the three year period. 11,032 (20.0%, 95% confidence interval 19.6% to 20.3%) women had at least one reoperation. 10,212 (18.5%, 18.2% to 18.8%) had one reoperation only; of these, 5943 (10.7%, 10.5% to 11.0%) had another breast conserving procedure and 4269 (7.7%, 7.5% to 7.9%) had a mastectomy. Of the 45,793 women with isolated invasive disease, 8229 (18.0%) had at least one reoperation. In comparison, 2803 (29.5%) of the 9504 women with carcinoma in situ had at least one reoperation (adjusted odds ratio 1.9, 95% confidence interval 1.8 to 2.0). Substantial differences were found in the adjusted reoperation rates among the NHS trusts (10th and 90th centiles 12.2% and 30.2%). CONCLUSION One in five women who had breast conserving surgery in England had a reoperation. Reoperation was nearly twice as likely when the tumour had a carcinoma in situ component coded. Women should be informed of this reoperation risk when deciding on the type of surgical treatment of their breast cancer.
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Affiliation(s)
- R Jeevan
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London WC2A 3PE, UK
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Sabel MS, Jorns JM, Wu A, Myers J, Newman LA, Breslin TM. Development of an intraoperative pathology consultation service at a free-standing ambulatory surgical center: clinical and economic impact for patients undergoing breast cancer surgery. Am J Surg 2012; 204:66-77. [DOI: 10.1016/j.amjsurg.2011.07.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 07/18/2011] [Accepted: 07/18/2011] [Indexed: 11/30/2022]
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Atalay C, Irkkan C. Predictive factors for residual disease in re-excision specimens after breast-conserving surgery. Breast J 2012; 18:339-44. [PMID: 22616572 DOI: 10.1111/j.1524-4741.2012.01249.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Can Atalay
- Department of General Surgery, Ankara Oncology Hospital Department of Pathology, Ankara Oncology Hospital, Ankara, Turkey.
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Gurdal S, Karanlik H, Cabioglu N, Ozcinar B, Yavuz E, Tuzlali S, Ozmen V. Positive or close margins in breast conserving surgery: Is re-excision always necessary? Eur J Surg Oncol 2012; 38:399-406. [DOI: 10.1016/j.ejso.2012.02.182] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 02/11/2012] [Accepted: 02/27/2012] [Indexed: 10/28/2022] Open
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Halevy A, Lavy R, Pappo I, Davidson T, Gold-Deutch R, Jeroukhimov I, Shapira Z, Wassermann I, Sandbank J, Chikman B. Indication for relumpectomy-a useful scoring system in cases of invasive breast cancer. J Surg Oncol 2011; 105:376-80. [DOI: 10.1002/jso.22027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 06/20/2011] [Indexed: 01/04/2023]
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Coopey S, Smith BL, Hanson S, Buckley J, Hughes KS, Gadd M, Specht MC. The Safety of Multiple Re-excisions after Lumpectomy for Breast Cancer. Ann Surg Oncol 2011; 18:3797-801. [DOI: 10.1245/s10434-011-1802-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Indexed: 11/18/2022]
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Review of Third and Fourth Re-Excision for Narrow or Positive Margins of Invasive and Intraductal Carcinoma. Int Surg 2011; 96:18-20. [DOI: 10.9738/1340.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Abstract
The trend in breast surgery has shifted toward breast conservation. We reviewed our third and fourth breast re-excision cases, with an analysis of various factors used in making this decision. A retrospective analysis identified 585 patients who underwent re-excision surgery for positive or close margins of invasive carcinoma or ductal carcinoma in situ (DCIS). Of these patients 75 (13%) and 17 (3%) underwent third and fourth re-excisions, respectively. The indication for a third re-excision was the presence of positive and/or close (≤1 mm) margins for invasive carcinoma or DCIS in 72/75 patients. A third re-excision was done 31 days (range 8–123 days) after the second re-excision. Re-excision of margins was done in 45 (60%) patients, whereas 30 (40%) patients underwent mastectomy. Residual tumor mandated a fourth re-excision in 17 patients, which was done 45 days (range 14–87 days) after the third surgery. Re-excision of margins was done in 6 patients, whereas 11 patients underwent mastectomy. Involved or close margins with DCIS were the most common indication for re-excision, accounting for 61/75 (82%) of third and 16/17 (94%) of fourth re-excisions. Histopathology revealed that 28/75 (37%) of third and 7/17 (41%) of fourth re-excision patients had no residual tumor. In conclusion, the majority of re-excisions was done for margins <1 mm. Lower rates of re-excision were noted in well-differentiated invasive carcinomas. A close or involved DCIS margin was more likely to lead to a third and even a fourth re-excision. The absence of residual tumors in 40% of patients undergoing third and fourth re-excisions calls for a review of margin guidelines for breast re-excision.
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Abstract
As most solid tumors, surgery is often the first step of the multidisciplinary management for breast cancers. Although mastectomy and axillar lymphadenectomy still have indications, conservative treatment and sentinel node detection are commonly used. Thanks to induction chemotherapy and oncoplastic techniques, surgery is conservative in most cases, even for important tumors without overall survival prejudice. There is no consensus about resection margins status but a limit of 2 to 3 mm seems to be reasonable while oncoplastic surgery allows large resection and good cosmetic outcomes. In this overview, we present the state of the art for breast cancer surgery including conservative and radical treatments, axillar lymphadenectomy and sentinel lymph node detection, margins status, oncoplastic techniques.
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Melstrom LG, Melstrom KA, Wang EC, Pilewskie M, Winchester DJ. Ductal carcinoma in situ: size and resection volume predict margin status. Am J Clin Oncol 2010; 33:438-42. [PMID: 20023569 DOI: 10.1097/coc.0b013e3181b9cf31] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES There is strong evidence that breast conservation surgery (BCS) with negative margins for ductal carcinoma in situ (DCIS) is associated with low rates of recurrence. Our goal was to identify factors associated with positive margins in BCS for DCIS. METHODS A retrospective database review identified 823 patients diagnosed with DCIS. The current analysis included 546 of those patients treated with BCS from 2000 to 2006 with complete data regarding tumor and lumpectomy dimensions. Variables analyzed included tumor size, lumpectomy volume, estrogen and progesterone receptor status, histologic subtype, grade, and age at diagnosis. χ analysis and t tests were used to identify factors that may predict positive margins. A multivariate regression model was developed to determine independent variables predictive of positive margin status. RESULTS A total of 33% of specimens had positive margins. Lumpectomy volume, tumor size, nuclear grade (low vs. high), and number of slides positive for DCIS were all significant for positive margin status by bivariate analysis. On multivariate analysis, tumor size (P < 0.001; odds ratio, 2.37; 95% confidence interval, 1.712, 3.296) and resection volume (P = 0.0006; odds ratio, 0.48; 95% confidence interval, 0.318, 0.729) remained significantly associated with positive margin status. Age at diagnosis, histologic subtype, tumor grade, and estrogen and progesterone status all were not associated with margin status. CONCLUSIONS Positive margins after BCS for DCIS are associated with larger lesions and a smaller volume of resection. With 33% of patients having positive margins, these data suggest that a more aggressive initial resection may avoid positive margins and thus lower the risk of recurrence or the need for additional surgery.
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Affiliation(s)
- Laleh G Melstrom
- Department of Surgery, Northwestern University, Chicago, IL, USA
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Gupta A, Subhas G, Dubay L, Silapaswan S, Kolachalam R, Kestenberg W, Ferguson L, Jacobs MJ, Goriel Y, Mittal VK. Review of Re-Excision for Narrow or Positive Margins of Invasive and Intraductal Carcinoma. Am Surg 2010. [DOI: 10.1177/000313481007600729] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The trend in breast surgery has shifted towards breast conservation. Re-excision rates for narrow or positive margins have been variable in published reports. A retrospective analysis of 3246 patients who underwent either a lumpectomy for a palpable mass or a needle localization biopsy between January 2003 and December 2007 was done. Five hundred and eighty-five patients underwent re-excision surgery for margins. The mean patient age was 59-years-old (range 25-93). Needle localization was used to guide initial excision in 372 of 585 patients (64%). Invasive carcinoma was seen in 402 (69%) patients, ductal carcinoma in situ (DCIS) alone in 183 (31%) patients, and 308 (53%) patients had both invasive carcinoma and DCIS. Well-differentiated carcinomas accounted for only 24 per cent of the re-excisions. Four hundred and sixteen patients underwent re-excision of margins, whereas 169 underwent mastectomy as the second surgery. Residual carcinoma was seen in 38 per cent of cases with involved margins, as compared with 24 per cent with <1 mm margins and only 12 per cent cases with >1 mm margins. Residual DCIS was seen in 65 per cent with involved margins, 50 per cent with <2 mm margins, and 35 per cent of cases with 2 to 5 mm margins ( P <0.001, χ2 association). Lesser re-excision was noted in well-differentiated invasive carcinomas. Only 12 per cent of patients with margins greater than 1 mm had residual tumor on re excision, which raises the possibility of nonoperative management in such cases.
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Affiliation(s)
- Aditya Gupta
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | - Gokulakkrishna Subhas
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | - Linda Dubay
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | - Sumet Silapaswan
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | | | - William Kestenberg
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | - Lorenzo Ferguson
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | - Michael J. Jacobs
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | - Yousif Goriel
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
| | - Vijay K. Mittal
- Department of Surgery, Providence Hospital and Medical Centers, Southfield, Michigan
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Zavagno G, Donà M, Orvieto E, Mocellin S, Pasquali S, Goldin E, Lo Mele M, Belardinelli V, Nitti D. Separate cavity margins excision as a complement to conservative breast cancer surgery. Eur J Surg Oncol 2010; 36:632-8. [DOI: 10.1016/j.ejso.2010.05.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 05/10/2010] [Accepted: 05/17/2010] [Indexed: 11/27/2022] Open
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Shafirstein G, Kaufmann Y, Hennings L, Siegel E, Griffin RJ, Novák P, Ferguson S, Moros EG. Conductive interstitial thermal therapy (CITT) inhibits recurrence and metastasis in rabbit VX2 carcinoma model. Int J Hyperthermia 2010; 25:446-54. [PMID: 19657851 DOI: 10.1080/02656730903013618] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
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.
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Affiliation(s)
- Gal Shafirstein
- Department of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA.
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Skripenova S, Layfield LJ. Initial margin status for invasive ductal carcinoma of the breast and subsequent identification of carcinoma in reexcision specimens. Arch Pathol Lab Med 2010; 134:109-14. [PMID: 20073613 DOI: 10.5858/2008-0676-oar1.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Margin status of lumpectomy specimens is related to frequency of local recurrence. Optimal surgical technique requires microscopic margins free of carcinoma by at least 2 mm. Recurrence following lumpectomy is associated with residual carcinoma secondary to inadequate resection. OBJECTIVE To review our series of breast excisions to determine the frequency of residual carcinoma for positive, close, and negative margins. DESIGN We reviewed lumpectomies and excisional biopsies for invasive ductal carcinoma that had subsequent reexcisions. Margin status of specimens was recorded as positive, less than 1 mm, 1 to 2 mm, or greater than 2 mm. RESULTS A total of 123 lumpectomies and excisional biopsies of invasive ductal carcinoma with reexcision were reviewed. Residual invasive carcinoma was found in 44% (17), 25% (6), 28% (8), and 16% (5) of cases with positive, less than 1 mm, 1 to 2 mm, and greater than 2 mm margins, respectively. Residual invasive carcinomas were found in 57% (8), 100% (5), 67% (2), and 100% (2) of mastectomies with positive, less than 1 mm, 1 to 2 mm, and greater than 2 mm margins, respectively, in the initial lumpectomy or excisional biopsy. CONCLUSIONS Frequency of residual invasive carcinoma was related to margin status of the original lumpectomy/biopsy. Even when margins were positive, most reexcisions were free of carcinoma. Residual invasive carcinoma was found in greater than 25% of patients with margins less than 2 mm, supporting reexcision for patients with margins of less than 2 mm. Sixteen percent of cases with margins greater than 2 mm harbored residual invasive carcinoma. Evaluation of margin status was complicated by tissue distortion and fragmentation.
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Affiliation(s)
- Silvia Skripenova
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
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Nguyen FT, Zysk AM, Chaney EJ, Kotynek JG, Oliphant UJ, Bellafiore FJ, Rowland KM, Johnson PA, Boppart SA. Intraoperative evaluation of breast tumor margins with optical coherence tomography. Cancer Res 2009; 69:8790-6. [PMID: 19910294 DOI: 10.1158/0008-5472.can-08-4340] [Citation(s) in RCA: 241] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As breast cancer screening rates increase, smaller and more numerous lesions are being identified earlier, leading to more breast-conserving surgical procedures. Achieving a clean surgical margin represents a technical challenge with important clinical implications. Optical coherence tomography (OCT) is introduced as an intraoperative high-resolution imaging technique that assesses surgical breast tumor margins by providing real-time microscopic images up to 2 mm beneath the tissue surface. In a study of 37 patients split between training and study groups, OCT images covering 1 cm(2) regions were acquired from surgical margins of lumpectomy specimens, registered with ink, and correlated with corresponding histologic sections. A 17-patient training set used to establish standard imaging protocols and OCT evaluation criteria showed that areas of higher scattering tissue with a heterogeneous pattern were indicative of tumor cells and tumor tissue in contrast to lower scattering adipocytes found in normal breast tissue. The remaining 20 patients were enrolled into the feasibility study. Of these lumpectomy specimens, 11 were identified with a positive or close surgical margin and 9 were identified with a negative margin under OCT. Based on histologic findings, 9 true positives, 9 true negatives, 2 false positives, and 0 false negatives were found, yielding a sensitivity of 100% and specificity of 82%. These results show the potential of OCT as a real-time method for intraoperative margin assessment in breast-conserving surgeries.
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Affiliation(s)
- Freddy T Nguyen
- Departments of Chemistry, College of Medicine, and Beckman Institute for Advanced Science & Technology, University of Illinois at Urbana-Champaign, Illinois 61801, USA
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Shafirstein G, Novák P, Moros EG, Siegel E, Hennings L, Kaufmann Y, Ferguson S, Myhill J, Swaney M, Spring P. Conductive interstitial thermal therapy device for surgical margin ablation:In vivoverification of a theoretical model. Int J Hyperthermia 2009; 23:477-92. [PMID: 17852514 DOI: 10.1080/02656730701591476] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
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.
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Affiliation(s)
- Gal Shafirstein
- Department of Otolaryngology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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Sun L, Wang D, Zubovits JT, Yaffe MJ, Clarke GM. An improved processing method for breast whole-mount serial sections for three-dimensional histopathology imaging. Am J Clin Pathol 2009; 131:383-92. [PMID: 19228644 DOI: 10.1309/ajcpvbzz4ikjhy3u] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
To develop and validate improved processing methods for producing diagnostic-quality, whole-mount serial sections for 3-dimensional imaging of whole-breast histopathologic studies, we subjected 4-mm-thick whole-specimen slices to a 38-hour microwave-assisted protocol. Morphologic features, antigenicity, and tissue shrinkage were evaluated. A schedule using the tissue processor was optimized by evaluating the serial section yield for 3 schedules. The microwave-based processing schedule is adequate for producing diagnostic-quality whole-mount breast serial sections of an area up to 6,000 mm(2) and is compatible with a variety of immunohistochemical stains. A mean +/- SE total tissue shrinkage of 8.4% +/- 0.2% resulted. For the tissue processor, optimal results are obtained using a 59-hour schedule. Total fixation and processing time for whole-mount serial breast sections has been reduced from 21 days to 38 hours, with microwave assistance, and to 59 hours without. No adverse effects of microwaves on morphologic features, antigenicity, or gross tissue dimensions were observed.
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Liu C, Pan H, Li Z, Shi L, Huang T. Histopathological features of invasion of breast invasive ductal carcinoma and safety of breast-conserving surgery. JOURNAL OF HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY. MEDICAL SCIENCES = HUA ZHONG KE JI DA XUE XUE BAO. YI XUE YING DE WEN BAN = HUAZHONG KEJI DAXUE XUEBAO. YIXUE YINGDEWEN BAN 2009; 29:50-2. [PMID: 19224162 DOI: 10.1007/s11596-009-0110-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Indexed: 11/29/2022]
Abstract
In order to investigate the relationship between the extent of tumor invasion and the tumor size, axillary lymph nodes metastasis, Her-2 gene overexpression, and histologic grading in breast invasive ductal carcinoma as well as the optimal extent of excision during the breast-serving surgery, the clinical data of 104 patients with breast invasive ductal carcinoma who had received modified radical mastectomy were analyzed. The correlation analysis on invasive extent, which was evaluated by serial sections at an interval of 0.5 cm from 4 different directions taking the focus as the centre, and the tumor size, axillary lymph nodes metastasis, Her-2 gene overexpression, and histologic grading was processed. There was a significant correlation between invasive extent and tumor size (r=0.766, P<0.01), and lymph nodes metastases (r=0.574, P<0.01), but there was no significant correlation between invasive extent and Her-2 expression (r=0.106, P>0.05), and histologic grading (r=0.228, P>0.05). The 100% negative rate of infiltration in patients without nipple discharge with tumor size <2, 2-3 and >3 cm was obtained at 1.5, 2.0 and 2.5 cm away from the tumor respectively. It is concluded that the performance of breast-serving surgery in patients with breast invasive ductal carcinoma should be evaluated by tumor size in combination with axillary lymph nodes involvement to decide the possibility of breast-serving and the secure excision extent.
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Affiliation(s)
- Chunping Liu
- Department of Breast and Thyroid Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Sabel MS, Rogers K, Griffith K, Jagsi R, Kleer CG, Diehl KA, Breslin TM, Cimmino VM, Chang AE, Newman LA. Residual disease after re-excision lumpectomy for close margins. J Surg Oncol 2009; 99:99-103. [DOI: 10.1002/jso.21215] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kurniawan ED, Wong MH, Windle I, Rose A, Mou A, Buchanan M, Collins JP, Miller JA, Gruen RL, Mann GB. Predictors of surgical margin status in breast-conserving surgery within a breast screening program. Ann Surg Oncol 2008; 15:2542-9. [PMID: 18618180 DOI: 10.1245/s10434-008-0054-4] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2008] [Revised: 05/24/2008] [Accepted: 05/24/2008] [Indexed: 01/29/2023]
Abstract
BACKGROUND Breast-conserving surgery (BCS) requires clear surgical margins to minimize local recurrence. We sought to identify groups of patients at higher risk of involved margins who might benefit from preoperative counselling and/or more generous excision at the first operation. METHODS We reviewed demographic, clinical, radiological and pathological records of all women diagnosed with ductal carcinoma in situ (DCIS) or invasive cancer (IC) through a population-based breast screening program in Melbourne, Australia between 1994 and 2005. RESULTS A total of 2,160 women were diagnosed with DCIS or IC. We excluded 199 who had mastectomy (TM) as initial procedure or had missing data. Three hundred and thirteen had a diagnostic biopsy. Of 1,648 women who had BCS after a preoperative diagnosis of DCIS or IC, 13.5% had involved margins, 16.6% had close (</=1 mm), and 69.8% clear (>1 mm) margins. Of the patients, 281/1,648 (17.1%) underwent re-excision, of whom 93 (33.1%) had residual disease identified. Mammographic microcalcifications (P < 0.0001), absence of a mammographic mass (P = 0.002), presence of DCIS (P < 0.0001), high tumour grade (P < 0.0001), large size (P < 0.0001), multifocal disease (P < 0.0001) and lobular histology (P = 0.005) were associated with involved margins. Microcalcifications (odds ratio [OR] 1.97), large size (OR 4.22) and multifocal disease (OR 2.85) were independently associated with involved margins. Residual disease was associated with involved margins (P < 0.0001), presence of DCIS (P = 0.05) and large tumour size (P = 0.01). CONCLUSION After BCS, patients with mammographic microcalcifications, larger tumour size and multifocal tumours are more likely to have involved margins. Patients with involved margins, large tumour size and/or a DCIS component are more likely to have residual disease on re-excision.
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Affiliation(s)
- Emil D Kurniawan
- Department of Surgery, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, 3050, Australia
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Waljee JF, Hu ES, Ubel PA, Smith DM, Newman LA, Alderman AK. Effect of Esthetic Outcome After Breast-Conserving Surgery on Psychosocial Functioning and Quality of Life. J Clin Oncol 2008; 26:3331-7. [DOI: 10.1200/jco.2007.13.1375] [Citation(s) in RCA: 182] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Although breast-conserving surgery (BCS) is often assumed to result in minimal deformity, many patients report postoperative breast asymmetry. Understanding the effect of asymmetry on psychosocial functioning is essential for patients to make an informed choice for surgery. Patients and Methods All women who underwent BCS at the University of Michigan Medical Center (Ann Arbor, MI) during a 4-year period were surveyed using a mailed questionnaire (N = 714; response rate = 79.5%). Women were queried regarding five aspects of psychosocial functioning: quality of life (QOL), depression, fear of recurrence, stigmatization, and perceived change in health status. Postoperative breast asymmetry was assessed using items from the Breast Cancer Treatment and Outcomes Survey. Multiple regression was used to examine the relationship between breast asymmetry and each outcome, controlling for age, time from surgery in years, race, education level, disease stage, surgical treatment, and the occurrence of postoperative complications. Results Women with pronounced breast asymmetry were significantly more likely to feel stigmatized as a result of their breast cancer treatment (odds ratio [OR] = 4.58; 95% CI, 2.77 to 7.55) and less likely to report unchanged or improved health after treatment (OR = 0.43; 95% CI, 0.27 to 0.66). Minimal breast asymmetry was associated with higher QOL scores (86.3 v 82.4, P < .001). Finally, women with pronounced breast asymmetry were more likely to exhibit depressive symptoms (minimal asymmetry, 16.2%; moderate asymmetry, 18.0%; pronounced asymmetry, 33.7%, Wald test = 16.6; P = .002). Conclusion Pronounced breast asymmetry after BCS is significantly correlated with poor psychosocial functioning. Identifying patients at risk for postoperative asymmetry at the time of consultation may allow for improved referral for supportive counseling, prosthetics, and reconstruction.
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Affiliation(s)
- Jennifer F. Waljee
- From the Sections of General Surgery and Plastic Surgery, Department of Surgery; Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, University of Michigan; and the VA Health Services Research & Development Center of Excellence, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Emily S. Hu
- From the Sections of General Surgery and Plastic Surgery, Department of Surgery; Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, University of Michigan; and the VA Health Services Research & Development Center of Excellence, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Peter A. Ubel
- From the Sections of General Surgery and Plastic Surgery, Department of Surgery; Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, University of Michigan; and the VA Health Services Research & Development Center of Excellence, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Dylan M. Smith
- From the Sections of General Surgery and Plastic Surgery, Department of Surgery; Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, University of Michigan; and the VA Health Services Research & Development Center of Excellence, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Lisa A. Newman
- From the Sections of General Surgery and Plastic Surgery, Department of Surgery; Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, University of Michigan; and the VA Health Services Research & Development Center of Excellence, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Amy K. Alderman
- From the Sections of General Surgery and Plastic Surgery, Department of Surgery; Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, University of Michigan; and the VA Health Services Research & Development Center of Excellence, VA Ann Arbor Healthcare System, Ann Arbor, MI
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